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Archived: Horizon Close Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 18 July 2019

About the service:

Horizon Close is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Its aim is to provide maintenance and rehabilitation programmes for adults with long-term neurological conditions. Accommodation is organised into ten bungalows and is one of six adult social care locations which also has a hospital that is registered separately with CQC. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

The hospital was closed at the time of our inspection due to flood caused by a major water leak in January 2019. Patients from the hospital were transferred at short notice to some of the adult social care (ASC) locations.

People’s experience of using this service:

The provider failed to apply for an extension of the regulated activity to accommodate hospital patients in ASC locations. Although the provider had notified us of the temporary arrangements for hospital patients while refurbishments were taking place. We informed the provider at the time and at inspections that to continue offering accommodation to hospital patient’s they must submit applications to CQC. This was to ensure hospital patients were cared for in a manner that met the regulated activity.

People were not safeguarded from abuse and were placed at some risk of harm.

Medicines were not well managed and the potential for errors was increased.

The service was not well led. The management had not taken action in response to events that had or could cause harm to people. There have been persistent changes of senior managers. There was a lack of regulatory response from the provider.

Rating at last inspection:

The overall rating at the focus inspection dated 7 November 2018 was Requires Improvement. This report was made final on 20 February 2019. The overall rating of this service was changed to Inadequate.

Why we inspected:

This inspection was brought forward due to information of risk or concern about people living in all ASC locations. After the inspections of other ASC locations CQC requested assurances from the provider about the action they would take to improve the service. The responses provided by the provider did not give assurances that the service would improve.

Enforcement:

Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. The action plans provided did not give assurances that the service would improve.

Follow up: This service has been placed in special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in li

Inspection areas

Safe

Inadequate

Updated 18 July 2019

The service was not safe.

Details are in our Safe findings below.

Effective

Requires improvement

Updated 22 December 2018

The service was not effective.

The needs of people were not fully assessed as they moved between services. Discharge care plans were not in place for people moving out to live independently.

Staff had suitable skills and received training to ensure they could meet the needs of the people they cared for.

People’s health needs were assessed and were supported by the GP to stay healthy.

Staff were knowledgeable about people’s abilities to consent to their care and treatment and they were supported to make decisions.

Caring

Good

Updated 22 December 2018

The service was caring.

People told us that staff were kind and caring. The staff spoke about people in a caring and respectful manner.

People told us the staff respected their rights. Members of staff were knowledgeable about building relationships with people and why this was important.

Responsive

Requires improvement

Updated 22 December 2018

The service was not responsive.

Care plans were not always person centred and did not reflect people’s current needs. Care plans were not devised on how to support people with independent living skills.

There was a programme of activities within the Glenside Hospital site which people could join.

Complaints were recorded and investigated.

Well-led

Inadequate

Updated 18 July 2019

The service was not well-led.

Details are in our Well-Led findings below.