Archived: Londesborough Court Care Home

Updated 8 February 2017

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 registered 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 13, 14 and 29 December 2016 and was unannounced. The inspection team consisted of one adult social care inspector and an expert-by-experience on day one and one adult social care inspector and an inspection manager on day two. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert-by-experience who assisted with this inspection had knowledge and experience relating to older people and people living with dementia. We carried out a further day of inspection on 29 December 2016 to follow up urgent actions we required the registered provider to make following our inspection on 13 and 14 December 2016.

We looked at information we held about the service, which included notifications sent to us since the last inspection. Notifications are when registered providers send us information about certain changes, events or incidents that occur within the service. The registered provider submitted a provider information return (PIR) in December 2015; we had not asked for a more recent PIR prior to this inspection. The PIR is a form that asks the registered provider to give some key information about the service, what the service does well and improvements they plan to make.

As part of the inspection process we contacted the local authority safeguarding adults and commissioning teams to enquire about any recent involvement they had with the service. East Riding of Yorkshire council had undertaken three recent visits to the service as part of their quality assurance reviews and in response to concerns and safeguarding issues raised with them. We were notified that some recommendations from the visit were made and that the service was working with the teams to resolve the issues. Due to health and safety concerns about the service we asked a health and safety enforcement officer to visit the service during our inspection.

At this inspection we spoke with the registered manager, the director of care and six members of staff including care staff and ancillary workers. We spoke in private with four relatives/visitors, eight people who used the service and five health care professionals who were visiting the service. We observed the interaction between people, relatives and staff in the communal areas and during mealtimes.

We walked around the service with the registered manager and spent time looking at records. These included the care records and associated documents for three people who used the service and the recruitment, induction, training and supervision records for three members of staff. We also looked at other records relating to the management of the service including health and safety files, maintenance certificates, staff rotas, staff training plans, infection control records, accident and incident documents and quality assurance files.

Updated 8 February 2017

This inspection took place on 13, 14 and 29 December 2016 and was unannounced. We carried out the third day of inspection on 29 December 2016 to follow up urgent actions we required the registered provider to make following our inspection on 13 and 14 December 2016.

Our last inspection to the service took place on 21 March 2015 and the registered provider was compliant with the regulations in force at that time.

Londesborough Court Care Home provides care and support for up to 30 older people and people living with dementia; the service does not provide nursing care. It is located in the small market town of Market Weighton in East Yorkshire. Accommodation is provided on the ground and first floors; there are 17 single rooms and five shared rooms. Fifteen rooms have their own en-suite toilet and wash hand basin facility and there is a passenger lift to the upper floor. The service has an enclosed courtyard and garden. At the time of this inspection there were 26 people using the service.

The registered provider is required to have a registered manager and the manager in post was registered with the Care Quality Commission (CQC) in July 2016. 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.

During this inspection we found evidence to confirm the registered provider was in breach of regulations pertaining to treating people with dignity and respect. We found staff actions did not always ensure people received respect and were treated in a dignified way.

We found evidence to confirm the registered provider was in breach of regulations pertaining to safeguarding people from abuse and improper treatment. We also found evidence that staff were verbally abusing people using the service. We reported one piece of evidence we found during the inspection to the local authority safeguarding team to investigate due to the nature and seriousness of the incident.

During this inspection we found evidence to confirm the registered provider was in breach of regulations pertaining to staffing. There were insufficient numbers of staff on duty to meet people’s needs and staff were not provided with the skills and knowledge they needed to carry out their roles effectively.

We found evidence to confirm the registered provider was in breach of regulations pertaining to meeting people's nutrition and hydration needs. People were not supported to have adequate nutrition and hydration to maintain good health and reduce the risks of malnutrition.

During this inspection we found evidence to confirm the registered provider was in breach of regulations pertaining to providing safe care and treatment. People who used the service did not receive safe care and treatment and avoidable harm or the risk of harm was not prevented.

We found evidence to confirm the registered provider was in breach of regulations pertaining to providing person-centred care. Care plans were not appropriate and did not meet the needs of the people who used the service or contain accurate information about them.

During this inspection we found evidence to confirm the registered provider was in breach of regulations pertaining to good governance. Effective systems were not in place to monitor assess and mitigate risks to people who used the service or ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Through the inspection process we found numerous failings within the service including evidence of breaches of regulation in respect of the 2014 Regulations. The breach of regulations included; safe care and treatment, dignity and respect, person-centred care, safeguarding service users from abuse, meeting nutrition and hydration needs, staffing and good governance.

We wrote to the registered provider on 16 December 2016 requiring urgent action from them with regard to breaches of Regulations 12 and 18: Safe care and treatment and staffing. The registered provider responded within the given timescales with an action plan which was followed up by the Commission on 29 December 2016. We also received written confirmation from the registered provider on 19 December 2016 of their intention to close the service by the end of January 2017.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the registered provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If insufficient improvement is made within six months so that there is still a rating of inadequate for any key question or for the overall rating, we will take action in line with our enforcement procedures to begin the process of preventing the registered provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 then it will no longer be in special measures.