We carried out an unannounced comprehensive inspection of this service on 11 and 12 November 2014. A number of breaches of legal requirements were found. As a result we undertook a focused inspection on 03, 04 and 05 February to follow up on whether action had been taken to deal with the breaches in regulations.
You can read a summary of our findings from both inspections below.
Comprehensive Inspection of 11 and 12 November 2014
This inspection took place on 11 and 12 November 2014 and was unannounced.
We had previously carried out an unannounced responsive inspection of this service on 5 August 2014, following concerning information we received. We found breaches of the Health and Social Care Act 2008 in relation to people’s care and welfare, respecting and involving people, safeguarding people, staffing and failure to notify CQC of events as required. We took enforcement action in respect of people’s care and welfare and respecting and involving them in their care. Following this inspection in September 2014 the local authority imposed a suspension of new placements at the service which remained in place at the time of the inspection.
There were breaches of the Health and Social Care Act 2008 from a previous inspection on 22 and 23 January 2014 in relation to the management of medicines, monitoring the quality of the service, maintenance and storage of records. For both the inspections of 22 and 23 January and 5 August 2014 the provider was asked for an action plan to tell us how they were going to improve. These were sent to us following both inspections. We carried out this comprehensive inspection to check if the provider had completed their action plans and was now meeting the regulations as well as to provide a rating for the service.
There was a registered manager in post who was registered as manager in June 2014. 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.
At this inspection we found that although improvements had been made in some important areas there were some continued breaches of legal requirements of the Health and Social Care Act 2008. These included medicines, staffing, monitoring the quality of the service and keeping accurate records. Where we have identified continued breaches of the regulation in these areas we will make sure action is taken. We took enforcement action and served warning notices in respect of these continued breaches.
We also found breaches in respect of arrangements for people’s capacity to make decisions and some areas of staff training. You can see what action we told the provider to take at the back of the full version of the report.
There were improvements to the way the service involved people and consulted them about their care. People and their relatives told us they felt safe, staff were kind and caring and that they were consulted more. There were increased opportunities for people to socialise, a programme of activities and the lounge area had been redecorated. There were also improvements to the care provided. People’s care plans had been updated and they had been asked about their preferences, although these were not always accurately recorded. Staff felt the manager had made considerable changes to the culture of the service together with the support of a manager from another service. They told us they had received a lot of training which they felt had improved their skills and knowledge and that care was more person centred than it had been before.
Focused inspection of 03, 04 and 06 February 2015
At our inspection of 11 and12 November 2014 we had found continued breaches in respect of four regulations and took enforcement action. We took enforcement action in relation to how the provider managed medicines, had enough suitable staff, record keeping at the service and how they monitored the quality of the service. We asked the provider to comply fully with these regulations by 31 December 2014.
The provider was also asked for an action plan in respect of two other breaches of regulations for staff training and arrangements for consent and decision making where people lack capacity to do so. We will follow up and report on these at a later date.
We were notified by the provider that the registered manager had been dismissed in January 2015. There was no registered manager in post at the inspection. There was an acting manager in post who had been working at the service since December 2014. The provider also told us that they had appointed a regional quality advisor to help monitor and improve quality across their homes.
At this inspection on 03, 04 and 06 February 2015 we followed up on the breaches of legal requirements, concerning the management of medicines, staffing, records and monitoring the quality of the service which had resulted in enforcement action. We found that although improvements had been made in respect of some aspects of these legal requirements there was evidence of continued breaches of the legal requirements, in medicines, staffing, records and monitoring the quality of the service. We also found breaches of regulations for recruitment and care and welfare. Where we have identified continued breaches of the legal requirements in these areas we will make sure action is taken. We will report on this when this is complete.
There had been some improvements with regard to medicines storage and recording but they were still not managed safely. Systems for the safe management of medicines were not always followed. Checks on staff competency to administer medicines were not in place. A bogus nurse had been able to administer medicines on one occasion and two errors had been made. This had been reported to the relevant authorities although not until the following day. There had also been a delay in seeking of medical advice for people affected by the medicines errors.
Staffing levels were not safe. There was still no system in place to decide on safe staffing levels that took into account the needs of people at the service. Staffing levels did not always comply with the provider’s own staffing levels. There were not always enough suitably qualified and experienced staff available. There was no induction record for nurses to evidence they had the necessary skills to carry out the work. There was also no one suitably trained to oversee aspects of clinical care such as the pressure areas on a daily basis.
Risks to people such as pressure ulcer risks or risk of dehydration or falls were not always accurately monitored or recorded. Records in respect of pressure area care were sometimes missing, muddled or hard to follow and not always accurate. Care plan records did not always accurately reflect people’s needs. There were no recorded checks for those people who were unable to use a call bell and, for one floor with people with high levels of need, no system in place to record checks on their welfare. These were introduced as a result of the feedback at the inspection.
The quality of the service was not monitored effectively. Some areas identified at the inspection on 11 and 12 November in respect of monitoring the quality of the service had been addressed, such as the leak in the roof and the removal of the rubbish in the garden. However there was no clear system in place to regular monitor the quality of the service and the acting manager told us this was being developed. Audits that had been carried out were not fully comprehensive. Where they had identified some issues these had not always been acted on.
People’s fluid and dietary needs were not always identified, or monitored and people’s care plans still did not always reflect their nutritional needs accurately. We found that the provider’s policies had not included verifying the suitability of agency staff before they started work. We were told by the acting manager that the bogus nurse had not had references or police checks completed by the agency. Safe recruitment practices were not always followed.
People’s records and records related to the management of the service such as staff rotas were disorganised and inaccurate making them difficult to follow.