Archived: College Green Rest Home

College Green is a residential care home providing nursing and personal care to 12 people at the time of the inspection. The service is registered to support up to 21 people in one adapted building. The home is located over three floors.

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

People who lived at the home were not always safe. There were significant concerns with health and safety which put people at risk of harm. We found multiple concerns in the environment. There was no record of health and safety checks being completed to ensure people were safe. We raised concerns with the local fire service and the provider responded immediately to address these.

Risks to people were not always appropriately assessed or managed. People were at risk of falls due to poor mobility, but no falls risk assessment had been completed. Staff also identified one person as a choking risk, but no choking risk assessment had been completed and there was no plan to manage this risk.

The service was not well-led. We found widespread and systemic failings throughout the service. Oversight from the management team was inconsistent and roles, responsibilities and accountability arrangements were not clear. Audits were not effective in driving forward improvements within the home. Policies and procedures were not consistently followed to maintain safety. Records were not always accurate, up to date and reflective of people’s needs.

Recruitment processes were not safe. Appropriate checks had not taken place on prospective staff. Full employment histories were not always recorded or corroborated and appropriate refences were not always in place.

There was a lack of guidance for to staff on administering as and when needed medicines (PRN) to people. This meant people were at risk of not receiving medicines when they needed them. Some people were prescribed creams and eye drops which had an expiry date after opening. Opening dates had not been recorded on these meaning they may be used past their expiry date. We made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not always 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. Consent was not always sought in line with legislation and good practice. Dignity and respect were not always considered and promoted. We could not be fully assured autonomy was promoted and people were consulted with.

Most accidents and incidents were recorded, although we found some gaps. Records demonstrated appropriate action had not always been taken after an incident. There were no systems in place to review accidents and incidents to manage risk and prevent reoccurrence.

People’s nutritional and hydration needs were not always recorded appropriately in their plans of care. However, staff were aware of people’s individual needs regarding this and we were assured people were receiving diets appropriate for them.

There was ineffective oversight of training for staff. Not all staff had completed training deemed mandatory by the provider. There was a system in place to monitor training, but this was not effective. Staff told us they received training and felt competent in their roles.

There were enough staff to meet people's needs. However, we raised concerns that there was no system to determine staffing levels to ensure people's needs could always be met.

Relatives were very complimentary about the home and care provided. They told us they felt people were well looked after and they were fully informed of people’s welfare.

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

Rating at last inspection

This service was registered with us on 19/09/2019 and this is the first inspection.

Why we inspected

We undertook this inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about infection control, leadership and poor record keeping. A decision was made for us to inspect and examine those risks under the key questions of safe and well-led.

We inspected and found there concerns with consent, health and safety, and risk assessment and planning, so we widened the scope of the inspection to become a comprehensive inspection which looked at all five key questions.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the assessment, management and mitigation of risk, recruitment processes, consent and governance and oversight 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.