This inspection took place on 29 and 30 October, 5 and 7 November 2018 and was unannounced. William Wilberforce is a care home without nursing for up to 64 older people, some of whom were living with dementia. There were 59 people living at the service at the time of the inspection. William Wilberforce is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
At our last inspection we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care and good governance. In addition, we identified that the provider was in breach of their (Registration) Regulations 2009. This was because the provider had not submitted notifications of safeguarding incidents to the Care Quality Commission, which they are required to do by law. As a result of our findings, we rated the service overall ‘Requires Improvement.’
Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions, responsive and well-Led to at least good. The provider’s action plan advised that the improvements they intended to make would be in place by 17 December 2018. As this inspection was brought forward, the provider was unable to demonstrate sustainable improvements in these areas. We have taken this into consideration when making our judgements and ratings for this report.
At this inspection we found continued breaches of Regulation 9 Person centred care and Regulation 17 Good Governance. In addition, we found breaches of Regulation 10 Dignity and Respect, Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding service users from abuse and improper treatment, Regulation 14 Meeting hydration and nutritional needs, Regulation 18 Staffing and Regulation 20 Duty of candour. The provider had continued to be in breach of their (Registration) Regulations 2009. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.
There were two registered managers employed by the service. 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.
We were told following the inspection that one registered manager had left the service. At the time of our inspection they had been registered at the service since 21 August 2017. This meant that since our inspection one registered manager was in place who has been registered with the commission since 9 October 2013. This person is also the nominated individual. The nominated individual is an appropriate person nominated by the provider to represent them. The nominated individual is responsible for supervising the management of the regulated activity provided.
The nominated individual advised us they had delegated specific roles to the registered manager that was previously in post. This was because of our previous inspection findings and in order to meet the breaches of regulation. This included auditing care plans to reflect a person-centred approach and submitting retrospective safeguarding notifications to CQC. Since our last inspection the provider had employed additional staff to support with audits and had taken measures to delegate specific roles to other senior staff. These included areas such as; infection prevention and control, falls audits and analysis and Deprivation of Liberty Safeguards (DoLS) applications.
During this inspection we found multiple failings at the service and risks to people had not been mitigated. Some people were not cared for appropriately.
Where risks to people had been identified and monitoring was in place, the written monitoring records did not always reflect the practice of staff. Some risks associated to people’s health conditions had no risk assessments in place to guide staff in supporting them. Measures had not always been put in place to adequately manage risks to people.
Accidents and incidents were not analysed thoroughly and measures were not put in place to mitigate repeat incidents. Staff did not always follow the provider’s procedures for people that were at risk of dehydration and malnutrition and appropriate monitoring and/or guidance was not always in place to support referrals to health professionals. In addition, positional changes for people were not carried out according to the instructions in people’s care plans putting them at risk of skin damage.
The majority of staff were recruited safely but there were insufficient numbers of staff to meet people’s needs effectively. Some people had behaviours that challenged staff and staff were not trained in this area. The provider had identified gaps in staff’s knowledge and training was being booked to support further development in this area.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible. The principles of the Mental Capacity Act (MCA) 2005 were not fully understood by staff and the correct process for making best interest decisions had not been followed.
Medicines were not managed well in every area of the service and we found multiple issues that had not been identified by the provider’s checks.
Staff were described by people as being caring and we saw kindness shown to people by some staff. However, other staff did not always promote people's dignity or meet people's basic care needs in a timely way.
Care plans did not always reflect the care we observed being provided by staff and were generic and task focused. This did not encourage person-centred care practices. When people’s needs had changed care plans had not been updated.
Activities were not meaningful to people living with dementia. There were no stimulating activities for people during the inspection and very few items available to encourage ad-hoc activities for those people walking up and down communal areas. The service had some characteristics of a dementia friendly environment but did not always reflect current good practice guidance.
People and their relatives knew how to make a complaint but on one occasion a relative had raised concerns to staff over several months which were not escalated to senior management to address. These issues were highlighted and addressed as part of this inspection.
There had been a lack of effective leadership and management at the service which had led to a significant deterioration in the quality of the service. This was now being addressed by the registered provider but there were still significant areas of concern. The quality assurance system was not effective. The issues found at the inspection had not always been identified through auditing and monitoring. For example; some medicines audits had not identified errors in warfarin administrations and a lack of effective monitoring of pain relief medicines. Several medicines audits were signed as completed when it was clear actions were still in progress.
Records were at times not reflective of the care people received and updated hours after staff had completed their duties.
Internal investigations into accidents and incidents had not been thoroughly completed and raised concerns in relation to the service being open and transparent. The provider has advised one of these is awaiting further investigation and they will inform us of the outcomes.
The provider had not submitted all safeguarding notifications to the local authority or CQC. This was a continued issue since the last inspection.
Improvements had been made in relation to the dining experience and the chef was aware of how to fortify diets and provided fortified drinks and finger foods for people. However, support when monitoring those people at risk of dehydration and malnutrition was poor. The systems in place did not support best practice and left people vulnerable to harm and neglect.
Servicing and maintenance of the environment had been carried out in a timely manner and infection prevention and control measures were organised, thorough and effective.
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.
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