Archived: Pettsgrove Care Home

We carried out an unannounced comprehensive inspection of this service on 11 and 12 December 2014, at which we found one breach of legal requirements. This was because the provider did not ensure people’s care records were accurate and up to date; had not taken action to ensure the complaints procedure was accessible to people using the service and did not have effective systems for monitoring the quality of care.

After the comprehensive inspection, the registered provider sent us an action plan telling us how they would meet legal requirements and recommendations. We undertook a focused inspection on the 19 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements. We found the provider had started to address the shortfalls, but still needed to demonstrate the service was well-led.

We undertook another comprehensive inspection on16 July 2015 to check that the provider had fully implemented their action plan, to confirm that they met legal requirements and because of safeguarding concerns that had been reported to us which are subject to an on-going investigation.

You can read the report from our last comprehensive and focussed inspection, by selecting the 'all reports' link for ‘Pettsgrove Care Home’ on our website at www.cqc.org.uk’.

Pettsgrove Care Home provides accommodation for up to six people with learning disabilities. At the time of our visit there were four people using the service.

The service did not have a registered manager. 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 in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection, one of the service directors was managing the service pending the appointment of a registered manager.

Whilst there were systems in place to review the quality of the service these were not sufficient to ensure high quality care was provided and that risks to people’s safety and welfare were mitigated. These quality checks had failed to identify shortfalls we saw at this inspection.

People were not protected from the risk of financial abuse because the provider did not ensure there were safeguards in place to protect people’s financial interests. CQC is considering the appropriate regulatory response to resolve the problems we found in respect of this regulation.

There were no sufficient arrangements to deal with emergencies to reduce risks to people. There were no assessments about people’s support needs in respect of evacuation. Similarly, staff were unsure about how to safely support people to leave the building in an emergency.

Although people were supported to eat regular meals, their choices for food were not always supported.

People were supported to access external health and social care professionals. There was evidence that people were referred to specialist services when required.

There were suitable arrangements for the recording, storage, administration and disposal of medicines.

We identified four breaches of the relevant regulations in respect of safeguarding people, safe care and treatment, dignity and respect, and good governance.

We carried out an unannounced comprehensive inspection of this service on 11 and 12 December 2014, at which we found one breach of legal requirements. This is because the provider did not have effective systems for monitoring the quality of care.

After the comprehensive inspection, the registered provider sent us an action plan telling us how they would meet legal requirements and recommendations by 31 July 2015. We undertook a focused inspection on the 19 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Pettsgrove Care Home’ on our website at www.cqc.org.uk’.

Pettsgrove Care Home provides accommodation for up to six people with learning disabilities. At the time of our visit there were four people using the service.

The provider did not have a registered manager. The service had submitted an application to the Care Quality Commission for the registration of a new manager. The director of the service was providing general management support pending the appointment of a new manager. 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 in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection, the service director was managing the service pending the appointment of a registered manager.

At our focused inspection on the 19 June 2015, we found that the provider had followed their action plan and legal requirements had been met.

We found that the provider had taken action to ensure people’s care records were accurate and up to date. The provider had introduced a weekly and monthly audit system that looked at areas of care, including people’s care records. Relevant charts, including weight, food and fluid charts were completed and up to date.

The provider had taken action to ensure the complaints procedure was accessible to people using the service and their relatives or representatives. A copy of the procedure had been sent to relatives. The service had also put in place a pictorial version of the complaints procedure.

We found that the provider had started to address the shortfalls, but still needed more time to demonstrate the service was well-led. We found that action had been taken to ensure the service was well-led. The service had employed a new manager to oversee the implementation of their improvement plan. A new audit system had also been introduced.

This was an unannounced inspection carried out on 11 and 12 December 2014. Pettsgrove Care Home provides accommodation for a maximum of six people with learning disabilities. At the time of our visit there were five people using the service. At our last inspection in January 2014 the service had met all the regulations we looked at.

The service did not have a registered manager. 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 in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection, the service director was managing the service pending the appointment of a

registered manager.

The complaints procedure was not accessible to people using the service and their relatives or representatives. We have given a recommendation about this.

The service worked closely with funding local authorities and other healthcare providers, including the local hospitals and general practitioners. People had access to healthcare professionals when required, such as their GP, hospital consultants, a psychiatrist and a dietician.

People were supported to make choices about their care. Care plans included information about people’s likes and dislikes and a description of daily routines and personal preferences. However, in some cases the care plan folders we reviewed lacked details and there were some inconsistencies in the contents. The discrepancy in the written information may have exposed people to the risk of being given the wrong care and treatment. We have also given a recommendation about this.

Care plans explained how people wished staff to help them meet their needs, encourage their independence, respect their lifestyle and help them meet their goals. However, the provider had not always responded to people’s needs in a timely manner. In one example, one person had not been referred to an appropriate healthcare professional until the intervention of their social worker. In other examples, people had not received health action plans in a timely manner.

The provider did not have an effective quality assurance system. The system did not systematically ensure that staff were able to provide feedback to their managers, which meant their knowledge and experience was not being properly taken into account.

The director and staff were aware of the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). This helped to ensure that people’s rights in relation to this were properly recognised, respected and promoted.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We found that the registered person had not protected people against the risks of inappropriate or unsafe care by means of the effective operation of systems to assess and monitor the quality of services provided. This was in breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.