Archived: Madeley Manor Care Home

Updated 21 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 3, 8 and 30 May 2018 and was unannounced.

The inspection team consisted of three inspectors and an expert by experience who has personal experience of caring for someone who uses this type of care service.

Before the inspection, we checked the information we held about the service and provider. This included the statutory notifications that the provider had sent us. A statutory notification is information about important events which the provider is required to send us by law. We also reviewed information we had received from the public and the local authority. We used this information to help formulate our inspection plan.

We spoke with eleven people who used the service and two visiting relatives. We did this to gain people's views about the care and to check that standards of care were being met. We also spoke with nine members of care staff including the deputy manager, a nurse and a domestic assistant. We spoke with the home manager and the provider to help us to understand how the service was managed.

Some people who used the service were not able to speak to us about their care experiences so we observed how the staff interacted with people in communal areas. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also looked at the care records of nine people who used the service to see if their records were accurate and up to date. We also looked at records relating to the management of the service. These included six staff files, staff rotas, training records and quality assurance records.

Updated 21 June 2018

This inspection took place on 3, 8 and 30 May 2018 and was unannounced.

Madeley Manor 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. Care and support is provided over three floors with communal areas on the ground floor. Madeley Manor Care Home is registered to provider care support for up to 42 people. At the start of this inspection 31 people were using the service.

There was a manager and they were in the process of becoming the ‘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 2008 and associated Regulations about how the service is run.

This was the first inspection under this registration. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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 line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Risks to people's safety, health and wellbeing were not always suitably assessed and managed and plans in place to manage risks were not always followed by staff.

There was not always enough suitably skilled staff, deployed effectively to keep people safe or to meet their needs. Staff were not always trained to provide safe and effective care.

People were not always protected from the risks of avoidable harm and abuse because incidents of possible abuse were not always identified and reported to the local authority as required. Action was not always taken to protect people from further occurrences.

We found that medicines were not managed safely and people were at risk of not receiving their medicines as prescribed.

Systems in place to consistently assess and monitor risks to people and the quality of care provided were not operated effectively. This meant that issues with the safety and quality of the care were not reliably identified and rectified.

People were not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible.

The service looked clean and tidy, however, an infection control audit identified areas that required action and no action had been taken to resolve these.

People and relatives had made complaints that had not been responded to or investigated.

People were not supported to have detailed and personalised plans of care at the end of their life.

People told us they had access to healthcare professionals when they required them, however we found that professional advice was not always followed or incorporated into people’s plans of care.

People enjoyed the food on offer. However, some people were not offered diet choices that promoted their health and wellbeing.

People’s care plans did not contain enough detail for staff to provide consistently and personalised care.

People told us that staff treated them with kindness and compassion. However, people were not always offered the reassurances they needed because staff did not have time to spend with them. People’s privacy and dignity was not always respected and promoted.

People enjoyed the activities provided for them. However, they felt that more could be offered to occupy their time.

We identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.