Archived: Cleveland Park

Updated 29 December 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

Prior to our inspection, we received information of concern about the care and treatment of people. This related to specific safeguarding concerns, moving and handling procedures and pressure area care. We took this information into account when planning our inspection.

The inspection team consisted of five inspectors, an inspection manager, and a specialist advisor in nutrition. We also sought advice from a CQC pharmacy inspector.

We visited the home on 2, 9, 15, 16 and 22 October 2015. All visits were unannounced except the visit on 16 October 2015.

We spoke with the nominated individual, the regional operations manager, manager, peripatetic manager, two project managers, compliance officer, deputy manager, four nurses, three agency nurses, 15 care workers and the cook. We looked at 19 people’s care records and staff recruitment and training files.

Most people were unable to communicate with us verbally due to the nature of their condition. We therefore used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We also spoke with four relatives.

We conferred with staff from the local authority contracts and safeguarding teams and the local Clinical Commissioning Group throughout our inspection. We also consulted two community matrons, a palliative care nurse and a community psychiatric nurse to obtain their opinions about the home and the care and treatment provided.

Prior to our inspection, we reviewed all the information we held about the home. We did not request a provider information return (PIR) due to the late scheduling of the inspection. A PIR is a form which asks the provider to give some key information about their service, how it is meeting the five domain areas of safe, effective, caring, responsive and well led and what future improvements they plan to make to the service.

Updated 29 December 2015

We visited the home on the 2, 9, 15, 16 and 22 October 2015. All visits were unannounced except the visit on 16 October 2015.

The home was last inspected in August 2015. We found that there was a continuing breach of the regulation relating to the management of medicines. We issued a warning notice and told the provider they needed to take action to improve.

Cleveland Park provides accommodation and personal care for up to 66 older people, some of whom have dementia. There were 52 people living at the home, two of whom were in hospital on the first day of our inspection. There were 47 people living at the home with five individuals in hospital on the last day of our inspection.

The home was divided into four units. There were two units on the ground floor providing mixed accommodation for males and females. There were two specific male and female units on the first floor.

Prior to our inspection, we received information of concern about the care and treatment of people. This related to specific safeguarding concerns, moving and handling procedures and pressure area care. We took this information into account when planning our inspection.

At this inspection we found major shortfalls in all areas of the service and identified that people were at extreme risk of harm. The local authority had placed the home into ‘organisational safeguarding.’ This meant that the local authority was monitoring the whole home since there were concerns that some of the practices within the service were putting vulnerable people at risk. The local authority and the local Clinical Commissioning Group were closely monitoring the home and visiting regularly. They also organised for nursing staff from the local NHS Trust to visit the home to provide staff with advice and support. In addition, senior managers at the home were liaising with health and social care professionals such as tissue viability and palliative care nurses.

At the end of our first visit on 2 October 2015, the provider informed us that they would not accept any further admissions into the home as a result of our initial assessment of serious shortfalls in care delivery. This was followed up with a written agreement from the provider which they adhered to throughout.

A manager was present on the first day of our inspection. He had been in post since May 2014 but was not formally registered with the Care Quality Commission. 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 and associated Regulations about how the service is run. This issue is being followed up and we will report on any action once it is complete. The provider suspended the manager on 2 October 2015 and they resigned on 7 October 2015.

A peripatetic manager [relief manager] was managing the home on the remaining days of our inspection. They were supported by two ‘project managers’ who were overseeing the management of the home and a compliance officer.

Safe recruitment procedures were not always followed. There were no references in one of the staff files we examined. In addition, there were concerns that a member of staff had been working as a nurse without being registered with the Nursing and Midwifery Council [NMC]. The NMC registers all nurses and midwives to make sure they are properly qualified and competent to work in the UK. The provider has referred this issue to the police who are investigating this concern.

Day and night staff expressed concerns about staffing levels. Overall, we found there were limited interactions between staff and people throughout the day. Staff informed us that this was due to staffing levels. One member of staff on night duty raised concerns that there was often only one nurse on duty overnight to oversee the care of people who had nursing needs. During our inspection, staffing levels were increased.

We saw that the provider did not have adequate systems in place to protect people from abuse caused by acts of omission and neglect. We had not been notified of any safeguarding concerns in 2015. The submission of notifications is important to meet the requirements of the law and enable us to monitor any trends or concerns. We wrote to the provider using our regulatory powers to request further information about this issue. Following our letter, the provider submitted five notifications relating to alleged abuse which had occurred since January 2015.

Some of the décor and furnishings were worn and in need of updating. There was a strong odour of stale urine and faeces in the male unit and other areas of the home. We visited one person who was lying in bed. There were faeces on the floor and their bedding. We went back later and the carpet and their bedding had still not been cleaned.

A system to ensure the adequate stock of medicines was not fully in place. Medicines were out of stock on occasions including those for epilepsy and pain relief. The provider informed us that there had been issues with the ordering and supply of certain medicines by some GP practices and the pharmacy. The provider informed us that staff had contacted the GP practices and pharmacy to chase up any outstanding prescriptions. We noted however, that this action was not always recorded. Certain wound care and continence equipment was also out of stock. This meant people were not receiving their medicines and prescribed equipment as they should have, to ensure their needs were met to prevent any deterioration in their condition.

Staff told us that training was provided but explained that most of the training was e-learning. We had concerns with certain staff practices in relation to pressure area care, continence care, nutrition and hydration and privacy and dignity. The peripatetic manager informed us and staff confirmed that individual staff supervision sessions had not been carried out. In addition, there was no evidence that nursing staff had undertaken clinical supervision to ensure that they retained their skills and competence to practise as nurses.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. Care plans did not evidence that a DoLS assessment had been undertaken to ascertain whether the plan would amount to a deprivation of the person’s liberty. We also found there was a lack of documented evidence to demonstrate that care and treatment was sought in line with the Mental Capacity Act 2005. This meant that people’s rights to make particular decisions had not been protected, as unnecessary restrictions may have been placed on them.

We observed that care was not always provided with patience and kindness and staff did not always promote people’s privacy and dignity. We observed staff transferring one person from their armchair to their wheelchair. Their underwear was exposed and staff did not place a blanket over them to promote their dignity.

An activities coordinator was employed to help meet the social needs of people who lived at the home. However, we saw very few planned activities being carried out. Staff explained that, due to staffing levels, they had limited time to spend with people on a one to one basis.

There was no evidence that any audits of the services being provided had been carried out. The peripatetic manager stated that none had been completed. Following our inspection, the provider contacted us and said that these had been completed and were held at head office.

There was no evidence of any surveys and the peripatetic manager told us that these had not been undertaken to obtain the feedback of people who lived at the home or their representatives. The peripatetic manager was unsure whether any complaints or minor concerns had been received since none had been documented. This meant there was no evidence to document what action had been taken in response to any complaints, concerns or feedback to improve the service.

We discovered serious shortfalls in the maintenance of records. We were unable to locate certain documents relating to people’s care and treatment and the management of the service.

Due to the serious shortfalls in all aspects of the service, we wrote to the provider to request an urgent action plan which stated what actions they were going to take to improve. We visited the service again after receipt of their action plan on 22 October 2015. We found that sufficient improvements had not been made to ensure the health, safety and wellbeing of people who lived at the home.

The care was so poor that we judged the home as failing to meet every aspect of the CQC assessment framework.