Background to this inspection
Updated
24 April 2015
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 26 January and 11 February 2015 and was unannounced. The inspection team consisted of one inspector on the first day and two inspectors on the second day. Before the inspection we reviewed information we held about the service including notifications. A notification is information about important events which the service is required to send us by law.
We spoke with all of the people living in the service. We spoke with a relative of one person and a friend of another. We also spoke with two visiting opticians. These conversations were to help us understand the experience of all the people who lived in the service. We also spent time observing interactions between staff and people who lived in the service. We spoke with the provider, the registered manager, four care staff, and three of the domestic staff including the cleaner and two cooks.
We looked at care plans and associated records for four people, staff duty and handover records, three staff recruitment files, records of complaints, accidents and incidents, policies and procedures and quality assurance records.
Updated
24 April 2015
This inspection took place on the 26 January and 11 February 2015 and was unannounced. The service provides accommodation for up to 18 older people who may also be living with dementia. There were 12 people living at the service when we visited.
Following an inspection on 17 September 2014 we found five breaches of Regulations and issued compliance actions which we asked the provider to take action on within an agreed timescale. The provider sent us an action plan telling us the action they would take to ensure they met the requirements of the law. They told us they would achieve compliance with the regulations by the end of January 2015.
At this inspection we found the provider had taken steps to make some improvements but these were insufficient to meet the areas of concern and were still not meeting the requirements of the regulations. In addition this inspection has highlighted further breaches of regulations.
At the time of our inspection the service had a manager who had just been registered by CQC. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
People told us they felt safe and tolerated some of the shortfalls in staffing and a lack of activities, because they liked the small homelike atmosphere within the service and found it convenient for them, their friends and relatives. However, we found people’s safety was being compromised in a number of areas.
The arrangements that were in place to safeguard people from the risk of abuse were inadequate as not all incidents which should be reported to the local authority and CQC had been. The management of nutritional and skin integrity risks and for those living with dementia in regard to environmental risks, or those with other health conditions were inadequate. This put people at risk of serious harm.
The provider did not have a system to assess the number of staff needed and there were not enough staff at all times to meet people’s needs. Recruitment procedures did not ensure that all appropriate checks had been carried out or that staff had the appropriate skills to work with people living with dementia. Staff had not received the appropriate level of training to enable them to work confidently and with appropriate understanding of the needs of people living with dementia.
No one living at the service was currently subject to a Deprivation of Liberty Safeguards (DoLS) authorisation, and there was a lack of awareness shown by the registered manager that for some people who did not understand the need for staff to provide interventions in regard to their care and support, a referral to the Deprivation of Liberty safeguards team should have been made. The Care Quality Commission (CQC) monitors the operation of DoLs which applies to care homes and we found that the service was not meeting the requirement of the Deprivation of Liberty safeguards. Mental capacity assessments were not carried out although people who knew people well were involved in their care plans and in making some decisions about their care.
Systems were not in place to ensure that the registered manager and staff had a good understanding of whether people were eating and drinking enough, or steps taken to ensure those who could not be weighed were assessed in some other way. This put them at risk of malnutrition and dehydration.
Staff demonstrated kindness and compassion towards the people they supported, however short staffing led some staff to be less tolerant of those people who required more staff input and monitoring. This was evident in some of the poor practice we saw. There was an over reliance on other people in the service informing staff of the whereabouts of people who needed regular monitoring.
The location of some shared toilet facilities meant people’s privacy and dignity was not always maintained when receiving support in communal areas. Some staff attitudes in response to work stresses also compromised people’s dignity.
The registered manager had developed and updated 10 out of 12 care plans, those updated were individualised and had been developed with the involvement of people and their relatives however some gaps in regard to risks remained and life histories were still being developed with relative’s involvement. Staff did not always follow the care plans so that people could rely on care being delivered in the way they or their relatives had expressed their preferences for. Activity provision was inadequate for everyone but those people who remained in their rooms had very little engagement and mental stimulation and were at risk of becoming isolated.
There was a complaints policy and a system to record and investigate complaints. This was being used for some but not all complaints.
The staff team did not feel well supported through the changes the registered manager was trying to make. Staff meetings were held but staff did not feel these were arranged for the benefit of staff or a forum where they could raise issues important to them. There was a lack of a clear staffing structure in the absence of the registered manager and senior carer with staff unclear who was the shift lead and responsible for decisions within the service.
The provider carried out regular visits to the service and completed visit reports but these were not effective had not identified the shortfalls we have found through inspection and were not being used to drive improvement. The registered manager had implemented a robust medicine audit and also a catering audit and we could see where shortfalls were being highlighted but actions taken to address these were evident in records seen. People were asked for their views about the service but did not receive feedback on what the analysis of surveys had shown and how was used to influence service development.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.