This unannounced inspection took place on 29 September and 4 October 2016. The home was registered on 13 July 2016 this was the first inspection of this home. The inspection was brought forward because of the number of concerns about the quality of the service provided to people that the CQC had received from the London Borough of Sutton, Sutton Clinical Commissioning Group and on many occasions from relatives of people who use the service and anonymous callers.Belmont House Nursing Home provides accommodation, personal and nursing care for up to 60 older people. There were 19 people using the service when we visited. The home is divided into three units, one on each of the three floors of the home. The ground floor is for people with nursing needs and the first floor accommodates people with dementia. The third floor was not being used at the time of our inspection.
The home had a registered manager but they were no longer in post at the time of the inspection and had not yet deregistered. There was a newly appointed manager who was registered with CQC at another home within the Caring Homes Health Care Group. They had submitted an application to CQC to register as the manager of Belmont House.
A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
We found the provider did not have effective systems to assess, review and manage risks to ensure the safety of people. For example staff were not using the right lancing device to test for blood sugar levels increasing the risks of cross infection. Suction machines were not prepared and set so these could be used in an emergency, to clear a person’s airway if they choked. These issues were addressed when we pointed them out but the provider’s own systems had not identified those issues.
People’s risk assessments and management plans were not always updated when their needs changed. Risk assessment for falls had not been updated after people had had falls. This meant people were not being adequately protected against further risks of falls. The provider had a strategy to manage falls but this was not disseminated within the home so staff were aware of this strategy to reduce the risks of falls. Staff did not fully understand how to operate the sensor mat that was linked to the call bell system so these could be used effectively, to help prevent falls.
The provider did not have suitable arrangements to protect people against the risks that can arise from the unsafe management of medicines. Among the concerns we found, we noted that the quantity of medicines were not always recorded when received into the home or carried forward to provide an audit trail about how medicines were managed. On a few occasions we could not correlate the amount of medicines in stock with what had been received and given; therefore we could not confirm people had received their medicines as prescribed. On at least three occasions on one day staff had signed the MAR sheet that medicines had been given to people but we found the medicines were still in their blister packs.
People had personal emergency evacuation plans (PEEP) in their care records but we found that these had not been reviewed when their needs had changed.
Staff recruitment procedures were not safe. Records did not show a current photograph of the staff member and none of the records we looked at had a current criminal record check. There was no evidence of any assessment of their suitability to work with people who used the service.
People were not supported as well as they could have been by staff who were knowledgeable in understanding their needs because they did not receive appropriate training and support. Records and feedback from staff showed that staff were not receiving regular supervision, particularly when they had all newly started working at the home.
The provider had not followed processes to ensure that any restrictions on people’s liberty were kept to a minimum and to demonstrate that where these restrictions needed to be in place that appropriate risk assessments were undertaken and best interests decisions were made. For example all the doors and lifts to other floors were locked and opened via a key pad system. The number to use to open the doors or lift were not displayed. All the doors to the garden and patio areas were alarmed. This meant that people who were able to could not move around the home freely.
People were not supported by caring staff, who respected their privacy and dignity. For example we heard of two incidents where staff did not respond to call bells at night in a timely manner and people were unable to receive the help they needed. We saw a person being assisted to the toilet in the main corridor and the actions of the staff did not help to maintain the person privacy and dignity.
The bedding we looked at in people’s rooms was of a poor quality and several people told us they were cold in bed. None of the bedrooms we looked at had secondary window coverings, i.e. net curtains or similar, even though the rooms overlooked private housing and other bedroom windows. This lack of secondary window coverings did not help to maintain a person’s privacy and dignity.
The provider had not ensured that people always receive care from staff of a gender of their choosing, even though this information had been recorded in their records.
Care plans had not been updated to take into account peoples changing needs. Staff said they had not received training on reviewing people’s care plans. There was no proper care planning and monitoring around pain management to help alleviate people’s pain.
The programme of activities the home hoped to offer had not started fully during our inspection. In the ground floor lounge the television was on for the majority of both days, the volume was not very loud which may have meant that people could see the screen but not hear the programme. We did not see any activities taking place on the first floor which is mainly for people with dementia. We however saw a party that staff had arranged to celebrate a special occasion for two people at the home.
The provider had a complaints policy and a procedure to respond to people's concerns and complaints. A number of complaints and concerns had been raised about the quality of the service since it opened in July 2016. We saw these had been acknowledged and were still being investigated by senior staff so they could respond appropriately to the complainants.
The provider did not have adequate quality assurance systems. They had expanded the home’s occupancy and did not have systems to check if people’s needs were being met and they were not effectively monitoring and taking action where areas for improvements were identified, to ensure the quality of the service was being sustained.
Food charts, fluid balance charts and turning charts were not completed properly to monitor people’s health. The provider was therefore not maintaining adequate records to show that people were being cared for appropriately. People were therefore not protected against the risks that can arise if appropriate records about their care are not maintained.
The provider had appropriate processes to manage abuse and staff were aware of the action to take if they see or hear about alleged abuse to safeguard people.
The provider had arrangements to support people with their healthcare needs. There was a GP who visited the home weekly and links to health care professionals within the community that staff contacted if they needed advice about how to care and treat people.
During the inspection we saw that people appeared well cared for. They presented well, with clean and appropriate clothes for the weather.
We found seven of breaches of the Health and Social Care act 2008 (Regulated Activities) Regulations 2014. These were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, good governance, staffing and fit and proper persons employed.
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.