Naylorsfield and Hartsbourne

Updated 22 March 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Naylorsfield and Hartsbourne is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours' notice of the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with 5 people who used the service about their experience of the care provided. We spoke with 11 members of staff including the registered manager, quality lead, team leaders, registered nurse and support workers. We walked around the building to check if the service was clean, hygienic and a safe place for people to live.

We reviewed a range of records. This included people's care records and medication records. We looked at 5 support plans, 2 staff files in relation to recruitment and a variety of records relating to the management of the service, including policies and procedures.

Updated 22 March 2024

About the service

Naylorsfield and Hartsbourne is a residential care home providing personal and nursing care for up to eight people with learning disabilities, mental health and complex care needs. Five people lived in the home at the time of the inspection.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to their community that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Within the areas looked at during this focused inspection; the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support: People at times did not receive safe care. Not all risks had been assessed and there were gaps within risk management plans for people. When incidents occurred it was not always clear if actions taken by the provider were done so in alignment with the MCA

The physical layout of the building was not homely or domestic in style. It was clear from the roadside people were living within a care setting.

Parts of the service home were unclean, unhygienic, and poorly maintained in particular within people’s bedrooms. Essential improvements were required to the service to make it more homely and fit for purpose. For example, the ovens had not been working properly for some time within one bungalow and within the other bungalow not working at all.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People experienced restrictions in terms of access to food and window restrictions which were not based on people's individual risk. People spent time sitting around with nothing to do. They were not supported to take part in household chores such as cooking or washing and care plans lacked information on how to increase people's independence. The provider had not supported people to take part in activities and pursue their interests in their local area.

Right Care: Staff were kind and respectful in their approach towards people and were knowledgeable about their day-to-day preferences. People were comfortable with staff members; one person told us, "The staff are nice". Staff cared about the people they supported but were frustrated by their inability to deliver person centred care because of financial restrictions which had resulted in people spending large amounts of monies on food in the community which had impacted on their daily routines not being following for some time. This had not been reviewed by the provider or reported to the local authority.

Right Culture: The provider failed to act in a timely manner to ensure everyone within the service had a safe clean environment that promoted their privacy and dignity.

The service was not using governance processes effectively to learn lessons or improve the service. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.

The service was not able to demonstrate they were meeting the underpinning principles of right support, right care, right culture. Staff lacked knowledge of the right support, right care, right culture guidance.

Management oversight was ineffective, and although systems were in place to monitor the quality of care provided by the service, we found concerns their systems had not effectively identified concerns found during the inspection.

The systems in place to audit the quality of the service were not robust or sufficient to alert the provider of the concerns and issues within the service. Audits had not picked up areas which were identified during the inspection. Accidents and incidents were recorded but not monitored to identify how the risks of reoccurrence could be minimised in future. The provider had failed to notify the Care Quality Commission of all reportable incidents as required. Providers are required to notify the CQC of certain incidents without delay.

There was a lack of provider and managerial oversight of the service. There was a failure by the provider to ensure robust governance arrangements were in place to monitor the safety and quality of the service. Shortfalls across the service such as poor risk management, IPC concerns and restrictions to people’s daily living had not been identified prior to our inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 7 April 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

The inspection was prompted in part due to concerns received about the service in terms of restrictions. A decision was made for us to inspect and examine those risks. As a result, we carried out a focused inspection to review the key questions of safe, effective, caring, responsive and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this report.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

Enforcement and Recommendations

At this inspection we have identified breaches in relation to safe care and treatment, person-centred care and the assessment of risks, management’s response to safeguarding concerns, restrictive practices and the application of the mental capacity act, maintaining a safe environment and effective governance of the service.

Please see the action we have told the provider to take at the end of this report.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.