The Care Quality Commission (CQC) has taken legal action to protect the safety and welfare of people by cancelling the registration of a provider of a residential home in Devon.
On Tuesday 17 October CQC was successful in its decision to cancel the registration of Maddalane Care Home because the provider withdrew their appeal against our decision at the Care Standards Tribunal. This means that they will no longer legally provide accommodation and personal care from their premises at St Budeaux, Plymouth, Devon
CQC took this action because it had significant concerns about the service and the risks to people using it.
Since an inspection in August 2016 and two further inspections in December 2016 and in May 2016 where CQC found numerous breaches of the Health and Social Care Act.
CQC asked the provider to take action to manage and administer medicines safely and effectively, and to ensure that people’s nutritional needs were met. Inspectors also found the provider had not always acted in accordance with the Mental Capacity Act, was not always effective in adapting to people’s changing health care needs and did not have robust or effective processes in place to allow improvement in the quality of the service. In addition they had failed to notify the commission of significant events in line with their legal obligations.
Inspectors found for some service users there were significant hours between their last meal and their breakfast. Some service users’ final meal of the day was at 5.30pm, and then they would go to bed around 7pm. On the day of our inspection one person living in the service had been assisted out of bed and given breakfast at 11am.
One person living at the service had seen a Speech and Language Therapist (SALT), but told inspectors they had nearly choked. Inspectors found staff did not know how to support this person safely and documentation was not in place to show how they should be safely supported to eat their meals. At the time of the inspection there was no documented record of the SALT consultation.
Inspectors questioned the provider if staff pre-potted medicines meaning removing them from their blister packs or packaging and placing them into pots ahead of dispensation. This approach is unsafe and does not meet the National Institute for Health and Care Excellence Guideline SC1 for managing medicines in care homes. Initially inspectors were told this did not occur, but by the end of the inspection it was confirmed it did happen. There were also instances where medicines stored within monitored dosage systems (MDS) had been left unattended which meant that people could take medicines which were not meant for them which could place them at risk.
As a result of this, CQC decided action was needed to ensure people were protected.
Deborah Ivanova, Deputy Chief Inspector of Adult Social Care for CQC in the south, said:
“It is apparent Maddalane Care Home let down the people in its care and in some cases put them at risk, so we decided to take the necessary action required to protect the safety and wellbeing of people using the service by moving to cancel the provider’s registration."
“Taking action which leads to the closure of any service is not something that we take lightly, but when we find very poor practice, as we did in this case, we have no alternative but to take action to protect the safety and welfare of people."
“I hope that this sends a strong public message that we are on the side of people who use services and will not hesitate to take tough action if a provider fails to meet the standards for care that everyone has the right to expect.”
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I hope that this sends a strong public message that we are on the side of people who use services and will not hesitate to take tough action
Deborah Ivanova, Deputy Chief Inspector of Adult Social Care in the South