Archived: Mayberry Care Services Limited

People’s experience of using this service:

People were not protected from avoidable harm and known risks were not responded to or mitigated. Shortfalls in the service meant people had been exposed to immediate risk of significant harm. The registered manager had not recognised or acted on safeguarding concerns. Lessons were not learnt when incidents occurred and this placed people at risk of ongoing harm.

The provider had not ensured staff had received training in all people’s healthcare needs and as such staff had been providing clinical care tasks without the specific training or oversight. This had put people at serious risk of harm. The provider had not ensured checks were carried out on staff competencies to ensure they were providing safe care. Where concerns about staff practice had been noted through observations of care these had not been addressed by the provider.

People could not be assured that concerns or complaints would be dealt with. There were no robust systems to deal with complaints or for the provider to learn from complaints received. Whilst care plans had been reviewed they had not always involved the person. Care plan reviews had not been effective in identifying where care plans were incomplete.

The provider had not ensured they had robust and effective systems in place to monitor the quality and safety of the service and had failed to recognise the widespread shortfalls in safety. As a result people were exposed to significant levels of harm on an ongoing basis.

More information is in the full report

Rating at last inspection: Good (Report published 1 March 2017)

Why we inspected: We brought the inspection forward due to serious concerns we had received about an unexpected death at the service. Whilst the investigation into the death is on-going we carried out this inspection to check on the safety of the other people receiving care from the service.

Enforcement: As we have rated the service as inadequate, the service will be placed in ‘special measures’. Services in special measures will be kept under review. Following the inspection we took urgent action to impose conditions on the providers registration to restrict admissions to the service. In the meantime the provider submitted an application to deregister and we therefore withdrew any further enforcement. At the time of the publication of this report there are no longer any people using the service which is now closed.

There was a registered manager in place who was present during our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives told us told us that they felt safe using the service. People knew how to report allegations or suspicions of poor practice. Further action was required to clearly detail the risks associated with people’s specific conditions and behaviours.

People who needed support with their medicines were supported appropriately. Staff knew how to dispense medicines safely and there were regular observations of practice and checks by senior staff to make sure this was done properly.

People were supported by staff who had the appropriate skills and knowledge they needed to meet their care needs. Staff received regular training to they maintain their knowledge.

People were supported to eat and drink enough to stay well. Staff knew what foods people enjoyed eating and how to support people who required assistance to receive sufficient nutrition.

People were supported to have their mental and physical healthcare needs met. However records required clearer guidance for staff about how to recognise if a person’s health was at risk of deteriorating and how to keep the person and others safe from harm. The registered manager involved and took advice from relevant health professionals when needed.

People said staff were caring and most had built up close relationships with the members of staff who supported them. The registered manager took action to ensure people were supported by staff they liked, however some people said they had not always been supported by consistent staff.

People were involved in deciding how they wanted their care to be delivered and were supported in line with the Mental Capacity Act 2005. There was clear information and guidance for staff when other people had authority to make decisions on behalf of people who used the service.

People said staff treated them with dignity and respect. There were clear policies and training for staff so they knew how to maintain people’s privacy when providing personal care.

Staff were responsive to people’s needs and delivered care in line with people’s wishes. People were supported to engage in activities they asked to do. People had access to a complaints system and the registered manager responded promptly to concerns.

There was effective leadership from the registered manager and senior members of staff. People and staff told us they were approached for their views of the service.

The registered manager assessed and monitored the quality of care people received. Further action was required to ensure quality monitoring processes were reviewed for trends which could affect the quality of the service.