This inspection took place on 8 and 10 January 2019 and was unannounced. Hilgay Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can provide accommodation and personal care for 35 people in one detached building that is adapted for the current use. The home provides support for people living with a range of complex needs, including people living with dementia. There were 18 people living at the home at the time of our inspection. The service had a registered manager. 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 provider of Hilgay Care Home was also the registered manager and they were present throughout the first day of the inspection and part of the second day.
At the last inspection on 23 April 2018 we rated the home as Requires Improvement. This was the third occasion that the home had been rated Requires Improvement. Following the last inspection, we met with the provider to confirm what they would do, and by when, to improve the key questions of is the service safe and well led to at least Good. The provider submitted an action plan which detailed how they planned to make the required improvements.
We received information from the local authority about a number of safeguarding concerns at the home. This indicated potential issues with the management of risks of people falling. We examined these risks as part of this inspection.
At this inspection the registered manager had not maintained improvements seen at the last inspection and standards at the service had deteriorated. We identified serious concerns which put people’s health and well-being at risk.
There were not enough staff to care for people safely. Staff did not all have the training that they needed to be effective in their roles. Some staff had been deployed to work with people during their induction period without having received the training they needed to assist people to move safely.
Risks to some people were not being effectively managed. When people had falls, systems for reviewing their needs were not robust and adjustments were not always made to mitigate risks. Some people needed support to move using equipment. Assessments and care plans did not provide clear guidance for staff in how to support people safely. Some assessments were completed by staff who did not have the necessary training and experience. We raised a safeguarding alert with the local authority following the inspection.
Incidents and accidents were recorded. The registered manager had oversight of these records but had failed to identify patterns and trends. They had not taken all reasonable steps to prevent further occurrences or to mitigate risks to people.
Systems and processes for management at the home were not effective and there was an over reliance on the registered manager. There were not sufficient trained staff willing to administer medicines to people. This had resulted in the registered manager working an unsustainable number of hours over an extended period. Suitable contingency plans were not in place which put people at risk of not receiving their prescribed medicines when the registered manager was unexpectedly away from the service. A safeguarding alert was raised by the deputy manager during the inspection.
The system for managing complaints showed that two complaints had been received since the last inspection. However, people, their relatives and staff told us about a number of other complaints that had been raised but were not recorded. People told us they had no confidence that their concerns were taken seriously and addressed by the registered manager.
There was a lack of strategic management and oversight which meant that there had been a failure to make improvements following the last inspection. The registered manager had failed to ensure that incidents were reviewed and considered in line with the provider’s safeguarding policy.
Records of staff rotas were not always accurate and this meant we could not have confidence that staffing levels were being maintained as described by the registered manager.
There was a widespread lack of confidence in the registered manager. This was expressed by staff, people, their relatives and health and social care professionals. One staff member said, “The manager doesn’t listen, we have all said the staffing levels are too low and nothing changes.”
People and their relatives told us that staff were usually kind and caring. A person told us that some staff were “A bit snappy.” One person told us they thought this was because staff were under pressure.
People were supported to have enough to eat and drink but risks associated with choking were not always identified and acted upon. We asked the deputy manager to assess one person who we observed to be coughing at meal times during both days of the inspection.
Staff checked with people before providing care. Care plans showed that decisions made in people’s best interests were recorded and relatives had been included in the process. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
We found five breaches of the Regulations. 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 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 not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the 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 it will no longer be in special measures.
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.