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.Lyme Green Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. This home is not registered to provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 60 people across three separate units, each of which have separate adapted facilities named the Villa Suite, Lymes Suite and Manor Suite. Staff and the people who live at the home refer to each unit as the Villa, Lymes and the Manor and we have done the same throughout this report. At the time of our inspection started there were 49 people living at the home.
This comprehensive inspection of Lyme Green Hall was undertaken following our receipt of a number of concerns raised on behalf of people who used the service. We visited the home unannounced on the 31 October 2017 and carried out five further visits on the 01, 07 and 17 November and 04 and 19 December 2017.
At the last inspection on 16 August 2016, we found the provider was not meeting all the requirements of the regulations. Regulation 18 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Staffing) had been breached because the provider had failed to deploy sufficient numbers of suitably qualified and experienced staff.
Regulation 12 of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment) had also been breached because staff were not following policies and procedures on the administration and recording of medicines.
.
This location requires a registered manager to be in post. A registered manager was in post at the time of our inspection. 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. The registered manager resigned on the third day of our inspection and left without prior notice of her decision to leave.
At this inspection, we found that the provider was in breach of regulations 9, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 18 of the Health and Social Care Act Regulations 2014 and regulation 18 of the Care Quality Commission (Registration) Regulations 2009.
We found that the service was not safe, effective, caring, responsive or well led.
We found that there was an insufficient number of suitably trained and competent staff on duty to meet the needs of the 49 people who lived at the home. We found evidence of poor communication between the registered manager and staff, ineffective and inappropriate care practice, and a lack of knowledge regarding the requirements of the regulations designed to ensure safe and effective care. The registered manager responded ineffectively when we asked for information or highlighted concerns about people’s care and did not demonstrate that they had the necessary competencies to manage the home safely and effectively. Vulnerable people did not always have their needs assessed when their circumstances changed so they remained at risk of their needs not being met. Staff were found to be improvising when assisting people with their mobility in the absence of effective assessment, care planning, training, equipment and skill.
People who were identified as being at high risk of falls were not being reviewed following each fall to mitigate the risks of a reoccurrence. Therefore, the provider was not taking reasonable steps to keep people safe.
At the start of our inspection we found that people were at risk because their medicines were not being recorded, administered and stored in accordance with their doctor’s prescription. Despite receiving assurances from the provider that action would be taken to address these issues we found that vulnerable people remained at risk at the end of our inspection. This was because we found that care staff were unable to administer peoples medicines safely and effectively. There was no medicines policy and any training staff had received had proven to be inadequate.
Vulnerable people remained at risk of abuse because staff failed to take action as soon as they were alerted to alleged or actual abuse, or the risk of abuse.
Recruitment and selection of staff was not always carried out safely which meant vulnerable people were at risk of receiving care from unsuitable people.
The registered person had not taken appropriate action to ensure the fire integrity of the premises and ensure that staff would know what to do in the event of a fire. Fire alarms were not adequately checked. Important documents known as personal emergency evacuation plans, designed to ensure the welfare of people in the event of a fire had not been revised or updated in over five years even though the person’s condition and ability had changed significantly. This rendered the documents useless and placed vulnerable people, staff and members of the fire authority at risk in the event of a fire.
Care plans were not person centred and did not always reflect the personal care needs of the individual. The registered person’s had not ensured that the care and treatment of the people who lived at the home was appropriate and met their needs.
The quality of food was poor and inadequate. The registered persons were not effectively monitoring the dietary intake and weights of people who were deemed at risk of malnutrition. They did not ensure that people were offered a suitably varied and nutritious diet.
Staff support systems including staff training and supervision were found to be lacking or non- existent in some cases. Staff presented with a lack of knowledge about the work they did in some important areas including the safe recording and storage of medication, assisting people with their mobility and the Mental Capacity Act. We also found that managers and staff were not always following the principles of the Mental Capacity Act 2005.
Care staff told us that they had not seen some people’s care plans and that they did not get time to read them. In the absence of effective person centred care planning we found that staff had developed inappropriate care practices that restricted peoples freedom of movement or left them at risk of harm. These included moving a person’s zimmer frame away from them to prevent them from attempting to walk and not allowing a person to sit at the dining table in an attempt to avoid confrontation.
Quality assurance systems were in place but these had failed to identify uncontrolled risks presented to the people who lived at the home. There was evidence of a failure to notify the CQC of serious notifiable incidences and failure to analyse incidents and learn from experience when things had gone wrong.
Recruitment and selection of staff was not always carried out safely which meant vulnerable people were at risk of receiving care from unsuitable people.
During the course of our inspection we raised concerns with the local safeguarding authority because we believed people were at risk of receiving unsafe and ineffective care. The local authority took action to mitigate the risk including deploying their own staff in the home in the absence of suitably qualified staff provided by the registered persons. The local authority carried out assessment on all the people who lived at the home and found that a large proportion of them were inappropriately placed because they presented with needs which the home could not meet.
You can see what action we told the provider to take at the back of the full version of the report. Providers will be asked to share this section with the people who use their service and the staff that work there.
The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the providers registration.