Review of compliance

Ms Marie McCann Webber House

Region: Location address: South East 3 Station Road Park Gate Southampton Hampshire SO31 7GJ Care home service without nursing June 2012 The service is registered by Ms Marie McCann to provide the regulated activity accommodation for persons who require nursing or personal care. The home can accommodate up to thirteen residents who are generally older and may have dementia.

Type of service: Date of Publication: Overview of the service:

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Summary of our findings for the essential standards of quality and safety
Our current overall judgement Webber House was not meeting one or more essential standards. We have taken enforcement action against the provider to protect the safety and welfare of people who use services.
The summary below describes why we carried out this review, what we found and any action required.

Why we carried out this review

We carried out this review to check whether Webber House had taken action in relation to: Outcome 04 - Care and welfare of people who use services Outcome 07 - Safeguarding people who use services from abuse Outcome 08 - Cleanliness and infection control Outcome 09 - Management of medicines Outcome 13 - Staffing Outcome 14 - Supporting staff Outcome 16 - Assessing and monitoring the quality of service provision Outcome 21 - Records

How we carried out this review

We reviewed all the information we hold about this provider, carried out a visit on 10 April 2012, carried out a visit on 23 April 2012, looked at records of people who use services, talked to staff, reviewed information from stakeholders and talked to people who use services.

What people told us

We spoke with the majority of people during our two visits as we conducted our inspection and moved around the home. We spoke with a person living in the home who said they were well looked after. We spoke with three people who informed us that there was, 'nothing to do' at the home. One said they would have liked to have watched another program but it was too much effort to get to their room. We later discovered that the television in their room did not work though they did have a radio. They also said they liked to read the newspaper but they only had one in the home which they shared. We spoke with a person who had specific dietary needs, to clarify what diet they needed and what food they ate at mealtimes. We also spoke with a visitor who said their relative was very happy and well looked after.
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They liked the home because it was small and homely.

What we found about the standards we reviewed and how well Webber House was meeting them
Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights People living at the home were not protected against the risk of receiving inappropriate or unsafe care. People's needs were not being met as a result and their safety and welfare was not being promoted. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome 07: People should be protected from abuse and staff should respect their human rights People had not been protected against abuse within the home. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome 08: People should be cared for in a clean environment and protected from the risk of infection People were not protected from the risk of infection because appropriate guidance had not been followed and the home was not clean. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome 09: People should be given the medicines they need when they need them, and in a safe way People were probably given their medication appropriately but records did not always show this. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs There were not enough staff to meet people's needs. The provider was not meeting this standard. We judged that this had a major impact on
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people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills People could not be assured that they were safe and their health and welfare needs were being met by competent staff. This was because staff supervision and appraisals were not consistently taking place. While some staff training had taken place it was not possible to establish how their training needs were identified. The provider was not meeting this standard. We judged that this had a moderate impact on people using the service and action was needed for this essential standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome 21: People's personal records, including medical records, should be accurate and kept safe and confidential People were not protected from the risks of unsafe or inappropriate care and treatment. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

Actions we have asked the service to take

We have asked the provider to send us a report within 14 days of them receiving this report, setting out the action they will take. We will check to make sure that this action has been taken. We have taken enforcement action against Ms Marie McCann. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken.

Other information
Please see previous reports for more information about previous reviews.
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What we found for each essential standard of quality and safety we reviewed

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The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety

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Outcome 04: Care and welfare of people who use services

What the outcome says

This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

What we found
Our judgement The provider is non-compliant with Outcome 04: Care and welfare of people who use services. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We spoke with the majority of people during our two visits as we conducted our inspection and moved around the home. We spoke with a person living in the home who said they were well looked after. We spoke with three people who informed us that there was, 'nothing to do' at the home. One said they would have liked to have watched another program but it was too much effort to get to their room. We later discovered that the television in their room did not work though they did have a radio. They also said they liked to read the newspaper but they only had one in the home which they shared. We spoke with a person who had specific dietary needs, to clarify what diet they needed and what food they ate at mealtimes. We also spoke with a visitor who said their relative was very happy and well looked after. They liked the home because it was small and homely. Other evidence When we last inspected the home on 1 December 2011, we identified three people whose care plans we wanted to look at. However, only two of them had one in place. The recording of information was not accurate or complete. There were no activities provided at the home. Our findings were that people were not having all of their assessed needs met.
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During our visit on 10 April 2012, we looked at four care plans. We found that they contained a range of information and assessments about people's needs and preferences. However, as we looked in more detail at individual records we saw that care plans were not all up to date and forms were not completed accurately. We saw that one person had a medical condition which meant they needed a special diet. We looked at the care plan and saw that there was no detailed information about the person's condition or how this was to be managed. At lunchtime we saw that the person was eating the same meal as everyone else. We were told by a staff member that the meal was suitable for that person but when we looked at the packaging we saw that it was not. We were told that the individual's food would be labelled with their name but staff were unable to show us any food suitable for main meals. We spoke with staff about this person's dietary needs. One staff member told us that the person could not eat two types of food and thought this was because of an unrelated medical condition the person had. Another staff member did not know anything but said they did not prepare food. We watched as tea was prepared for this person and saw that again, not all the food provided was suitable for their special diet. We raised this with staff who rectified the mistake. We looked at food records and saw that the person ate the same food as other people living in the home. During the inspection, we also found that there was written evidence in daily notes of incidences of assaults by people on each other. We found that there had been a lack of adequate assessments and care planning to reduce the level of risks relating to further assaults and altercations between the people living at the service. We spoke with staff and looked at other records but found that the assaults were not being reported to the required agencies, such as Hampshire County Council safeguarding team or the Care Quality Commission. There was no clear information on how staff were to deal with these incidences and no further consideration had been made to how this number of incidences could be reduced, for example moving one person to a different room. We also saw that a person had threatened to harm themselves, which was recorded in daily notes but there was no follow up to manage the risk that this could happen or to support the person. During our visit of 23 April 2012 we looked at care plans again, with regard to how people's needs were being met. The care plan for a different person (than we looked at before) was not up to date with aspects of health care support needed in respect of the level of insulin required. The dose had been changed and this showed in the monthly review but was different again from the medication administration record. We asked to see the medication administration record for the previous month but it could not be found. The manager could not find any written evidence regarding when the dose had been changed and therefore could not demonstrate which written document was correct. Staff were able to tell us how much insulin was administered but were not able to evidence that this was the correct amount. For the same person the level of foot care needed was not clear. The care plan stated that the person needed staff to organise this whereas the review said the resident would inform staff when they needed foot care. The review also stated that the chiropodist visited regularly yet there was only written evidence of one visit on 14 March
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2012 in the previous ten months, which was when the record started. It was therefore unclear if this person's foot care needs were being met. Another person's care plan stated that they needed to have the pressure areas on their skin checked when they had a bath. However, the person generally refused a bath and the records did not show how the skin would be checked when a bath was refused and did not detail whether the skin had been checked. We spoke with a staff member who confirmed the person often refused a bath. They also said that as the person moved around they would not develop sore patches. Therefore it was not possible to ascertain how the staff were assured that this person skin was still intact. We were told that this person chose to lie in bed and refused to eat a normal diet and ate mostly sandwiches and cakes. When we visit this person in their room they were in bed still in their night wear and had only eaten a few mouthfuls of their sandwich. We also noted that to enter their room you had to walk through another person's room. We were told that they shared the toilet facilities in the first room. Staff told us that neither person minded. However, this clearly impacted on people's privacy. There were nutritional assessments in place as well as weight charts. There were discrepancies in the recording between the two documents and within the two initial assessments and subsequent re-assessments. The first 'initial assessment' was completed in October 2011 and did not record the person's weight. They were not assessed as having any nutritional needs. The second 'initial assessment' form, dated 4 January 2012 also showed conflicting information. The person's actual weight was recorded as 60kg but a section of the form was completed to indicate that the person weighed 'less than 45kg'. The weight chart showed the person weighed 40kg on the 2 January 2012 and on 7 January 2012. On the nutritional reassessment dated 4 February 2012 the person was assessed as weighing 'less than 45 kg' but the actual weight was recorded at 48kg on the bottom of the form. On the weight chart, the person weighed 46kg on the 5 February. Therefore, it was not possible to ascertain whether the person was losing or gaining weight and how much at risk they were. One person used a wheel chair to move around. We observed that in some areas of the home the corridors were narrow and that they would need assistance to get through these areas. There were no specific facilities or moving and handling aids for people needing assistance with mobility. Staff told us that the person in the wheelchair was able to stand for short periods and to transfer to the toilet. There was a lift to the first floor, the room for one person who used a frame for walking was on the first floor. However, there was also a small ramp for them to go up and down as the there was two levels to the first floor, floor. It was not clear if these limitations had been considered when these people had come to live at the home. During the time we were at the home, people were sitting in the lounge where the television was on, staying in their bedrooms or walking around the home. There was no indication that any other activities were provided. One person told us that he had to go to bed at 9pm. However, we observed that people requested to go to bed at early times. For some people this was around 8pm. The lack of activity was also of further concern as some people had demonstrated aggressive behaviour and there was nothing to occupy them. We observed the lunch being served and eaten on 23 April 2012. There was limited
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interaction between people and staff, only taking place when people were helped to and from the table or when served food. We therefore found no evidence that outcomes for people living in the home had improved since our last inspection. Our judgement People living at the home were not protected against the risk of receiving inappropriate or unsafe care. People's needs were not being met as a result and their safety and welfare was not being promoted. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Outcome 07: Safeguarding people who use services from abuse

What the outcome says

This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

What we found
Our judgement The provider is non-compliant with Outcome 07: Safeguarding people who use services from abuse. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We did not talk with people about safeguarding procedures but looked at their written records. Other evidence During the previous inspection at Webber House on 1 December 2011 concerns were identified with this standard and a compliance action was set. We received a report from the registered provider on 3 February 2012 which stated that both the Hampshire County Council Adult Services Safeguarding policy and procedures and an in-house policy were available and easily accessible to all staff. A declaration was made in the report that staff had read the policy and signed to say they understood. The report also stated that this would be revisited in individual supervision sessions. During the inspection of 10 April 2012, we found that there was evidence of high incidences of physical or verbal assaults by residents on each other. Daily records for one person showed that between 9 and 14 January there was one incident; between 22 January and 1 February, two incidents; 15 February and 6 March, seven incidents. We also saw in daily records that a person had threatened to harm themselves. We looked at records and spoke with staff to see whether these had been reported to the local authority safeguard or to the Care Quality Commission. None of the incidents had been reported which meant people continued to be at risk.
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Therefore, there was no evidence of any improvement in this outcome for people living at the home. Our judgement People had not been protected against abuse within the home. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Outcome 08: Cleanliness and infection control

What the outcome says

Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance.

What we found
Our judgement The provider is non-compliant with Outcome 08: Cleanliness and infection control. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We did not talk with people about infection control. Other evidence During the visit on 23rd April 2012 we walked around the home and looked at communal areas, bathrooms, toilets and some of the bedrooms. The kitchen floor showed a build up of dirt in the corners. The cutlery tray in the kitchen drawer contained visible debris and dust. The dishcloth used for washing the dishes was stored damp in a plastic tub on the draining board. We saw that staff washed and dried disposable plastic cups and were told that this was usual practice. In the downstairs bathroom we saw that the frame around the toilet was rusty in some areas and stained brown in some areas. These stains appeared to be dried faeces. The seal around the bath was mouldy and stained in places. The bath hoist had signs of rust. The stair carpet had visible debris in the corners. The fire extinguisher on the first floor landing had a layer of dust on it. We saw black coloured mould behind the mixer taps in the upstairs bathroom and the seal around this bath was no longer patent and showed signs of mould in some areas. We saw that the upstairs bathroom had a perching stool stored in the bath tub that had black mould on all four rubber casters. There were faeces smeared on the raised toilet seat and a roll of toilet paper smeared with faeces. The bath hoist was rusty in some areas.
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Disposable gloves and aprons were stored in the utility room and were not available in peoples' bedrooms or bathrooms, which is where they would be needed. We were told by the manager that staff who were supporting a person with personal care would be expected to clean their bedroom and bathroom. We asked to see cleaning records and were told that Webber House does not keep cleaning records or rotas for either general cleaning or cleaning of equipment. We asked to see infection control audits and were told by the manager that Webber house does not audit infection control. The manager was unable to provide us with an infection control policy or procedure for Webber House. Our judgement People were not protected from the risk of infection because appropriate guidance had not been followed and the home was not clean. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Outcome 09: Management of medicines

What the outcome says

This is what people who use services should expect. People who use services: * Will have their medicines at the times they need them, and in a safe way. * Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf.

What we found
Our judgement The provider is non-compliant with Outcome 09: Management of medicines. We have judged that this has a minor impact on people who use the service.

Our findings What people who use the service experienced and told us We did not talk with people about medication administration procedures but did look at their records in this respect. Other evidence During the inspection of 1 December 2011 we found the provider was not compliant with this outcome. Records were not maintained accurately for medication administration, insulin was not stored appropriately and there were no care plans in place regarding medication given, 'as required'. When we visited on 3 April 2012, we found improvements in the way medication was handled. The insulin was stored securely and no-one was prescribed any medication, 'as required'. The Medication Administration Record for one person had not been completed to show how many tablets had been carried over from the previous month. Their record showed they had a box of 28 Mirtazepine tablets and had been offered 15. There should have been 13 left but there were actually 19 left in the box. This meant that either tablets had been signed for and not given or other tablets had been unaccounted for. Another person's record did show the number which had been carried forward but showed that 14 of the 22 Furosemide tablets had been signed for but there were nine tablets left. This was one more than there should have been which meant either a tablet
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had been signed for and not given or the carried forward number was incorrect. During our visit on the 23 April 2012 we found that a medication that was prescribed to be given only once a week on the Wednesday, was signed as having been given on the Monday. On checking, this was a recording error and the medication had not been administered. One member of staff told us that while they had completed training in administering medication this had been compete at during employment with another provider. They also confirmed that while they administered the insulin injections they had not received any specific training to undertake this task. We were told that there was a system in place for returning unused medication that included the completion of a returned sheet. We were also told that the number of tablets was checked when medication was received by the home. We saw that this was recorded on the MAR charts. We spoke with staff about how they took medication to people. Staff told us that in the morning breakfast was taken to people first and then medication is dispensed and administered one person at a time. Staff also confirmed that medication was taken to people individually at other times of the day. This was confirmed when we observed the lunch time medication being administered. Our judgement People were probably given their medication appropriately but records did not always show this. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard.

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Outcome 13: Staffing

What the outcome says

This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

What we found
Our judgement The provider is non-compliant with Outcome 13: Staffing. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We did not talk with people specifically about this outcome. Other evidence Our last inspection report from the visit in December 2011 noted that copies of the rosters were not available in the home. During our visit on 3 April 2012, we asked to see the staff roster for the current week. This was not found until much later in the day. We also asked for copies of the previous rosters but were told they were not in the home as they were taken out of the home to calculate wages. We asked the provider for these rosters when they arrived in the home early evening but were told they were not there. We asked the provider to explain the staffing levels to us. They told us that in terms of shift patterns and cover there were to be two members of staff covering between 8am and 10pm, one person awake and one person asleep between 10pm and 8am. During the visit on 23 April 2012 we reviewed the off duty roster for three weeks starting 9 April 2012 which showed that there were nine members of staff. This compliment included one person on maternity leave and one person on sick leave. We were also told that one person was a bank person who therefore worked as and when required. In total the home had six active and available members of staff to provide the 24 hour cover, over a seven day week. The provider told us that the staff on duty were required to undertake care, cleaning and cooking requirements within the home.
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The rosters showed that some staff were regularly working between 50 and 60 hours a week, sometimes without a reasonable amount of time in between shifts. The roster showed the manager was often one of the two staff on duty during the day. It was therefore unclear how the two roles of providing care to the residents and overall management responsibilities as the registered provider and the running of the home were being fully delivered. During our second visit, the staff member who was due to start work in the afternoon was not able to come to work. We asked how this absence was to be covered and the provider told us they would stay until 10pm herself. The second member of staff was rostered to work until 8pm. This would have meant there was only one member of staff for two hours. They told us that they were working until 10pm. We also saw that on the day of our visit a staff member had worked 4pm to 10pm the previous day, followed by a sleeping duty and then worked 8am to 8pm. In total, this meant the person's working commitment was 28 hours. One person had been assessed as requiring one to one support. Their care plan stated that, 'additional (extra) night staff' were to monitor the person's whereabouts every half an hour at night'. However, it was not evident in the home or on the rota that this one to one support for their care needs was being provided when it was needed. Concerns were also identified with the cleanliness of the premises. The care staff were responsible for the cleaning. It was also found that no activities were provided for people and they were often left on their own in the lounge watching the television, in their rooms or walking around the home. There was therefore no capacity in terms of staffing levels within the home, to cover any additional sickness, study leave or annual leave. Our judgement There were not enough staff to meet people's needs. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Outcome 14: Supporting staff

What the outcome says

This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by competent staff.

What we found
Our judgement The provider is non-compliant with Outcome 14: Supporting staff. We have judged that this has a moderate impact on people who use the service.

Our findings What people who use the service experienced and told us We did not speak with people about staff training. Other evidence When we visited on 23 April we asked the person in charge what training had taken place and how they identified what staff training needs were. They thought there was a training matrix but they were unable to locate it at the time. Neither were they able to locate training records for individual staff. We were told that some training had taken place the previous week and that more was planned. Training information for some staff was provided after the inspection. For one member for staff it indicated that they had completed all their mandatory training in October 2009, October 2010 and September 2011. The dates for 2012 were entered across the sheet for the month of February 2012 but we were advised that only some training had taken place and the rest was planned. For a second staff member, training was recorded as having been completed in October 2010 and September 2011. There were no specific dates. For this person the training for 2012 was recorded as being due in April and May. For one new member of staff, the information recorded was about what needed to happen not what had taken place. For another new member of staff, the information had been taken form the certificates they had provided relating to training they had received from a previous employer. There was no clearly identified training matrix and it was not clear how the staff training needs were assessed. We were told that training in dementia awareness and challenging behaviour, moving and handling of loads and safeguarding had been completed. In order to gain a
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certificate for the dementia awareness training staff were required to complete a work book. Further training was said to have been arranged for food hygiene, fire safety and infection prevention and control. We asked if staff supervision sessions were happening. We were told that these had started in January 2012 and were shown these records. The provider's policy was for these to take place every two months but there were no other records of supervision sessions since January. When we asked to see the staff appraisal records we were told that not many of the staff had worked there long enough to have had an annual appraisal. One member of staff told us that they had a chat with the manager but nothing had been recorded. Our judgement People could not be assured that they were safe and their health and welfare needs were being met by competent staff. This was because staff supervision and appraisals were not consistently taking place. While some staff training had taken place it was not possible to establish how their training needs were identified. The provider was not meeting this standard. We judged that this had a moderate impact on people using the service and action was needed for this essential standard.

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Outcome 16: Assessing and monitoring the quality of service provision

What the outcome says

This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

What we found
Our judgement The provider is non-compliant with Outcome 16: Assessing and monitoring the quality of service provision. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We did not speak with people about this outcome but did ask to be shown the results of a survey. Other evidence We were initially told that a satisfaction survey was performed twice a year and that surveys were sent to GPs; families; hair dresser; chiropodist; community nurses and anyone who had contact with the home and the residents. This confirmed the information provided by Marie McCann following the inspection on 1 December 2011. However, when we asked to see the outcome of the surveys and associated documentation, they were not produced. Later when we asked again, the registered provider told us there were no results, as no surveys had been conducted since 2008. We were not presented with any evidence that showed there was quality monitoring of the service. We found non compliance in seven other outcomes which had not been identified by the provider. It was therefore unclear how the provider would be able to protect people, who may be at risk, against the risks of inappropriate or unsafe care and treatment, as there was no effective system operating to regularly assess and monitor the quality of the services provided. Our judgement
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The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Outcome 21: Records

What the outcome says

This is what people who use services should expect. People who use services can be confident that: * Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential. * Other records required to be kept to protect their safety and well being are maintained and held securely where required.

What we found
Our judgement The provider is non-compliant with Outcome 21: Records. We have judged that this has a major impact on people who use the service.

Our findings What people who use the service experienced and told us We did not speak with people about this outcome. Other evidence During both our visits we looked at a range of records kept in the home and found them to be inconsistent and inaccurate. When we looked at care plans we found several areas of concern. For one person we found that their Waterlow risk assessment was completed and reviewed monthly. However, there were two in place for this resident and they were running concurrently. One showed one figure and the other showed another figure yet they were both measuring the same health needs. The figure showed on each remained the same at each review. The form with the lower score was the one used to inform the monthly review of the care plan. Inaccurate records could lead to inconsistent care based on out of date health risks. We found that one care plan was not up to date with aspects of care support needed, for example, the level of medication required by a resident who was insulin dependent. The dose had been changed and this showed in the monthly review but was different again from the medication administration record. We asked to see the medication administration record for the previous month but it could not be found. The manager could not find any written evidence regarding when the dose had been changed and
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therefore could not demonstrate which written document was correct. Another example was the level of foot care needed. The care plan stated that the resident needed staff to organise this whereas the review said the resident would inform staff when they needed foot care. The review also stated that the chiropodist visited regularly yet there was only written evidence of one visit 14 March 2012 in the previous ten months, which was when the record started. One file showed that a health care appointment letter had been sent to the home. The person was unable to attend that appointment and the manager explained why. However, there was no record made of the events. For one frail person the care plan stated that they needed to have the pressure areas on their skin checked when they had a bath. However, the person generally refused a bath and the records did not show how the skin would be checked when a bath was refused and did not detail whether the skin had been checked. The care plan stated that a pressure mattress and cushion was to be ordered. In fact, the person already had this equipment and it was in use so the care plan did not detail any specific arrangements with regard to this. This meant that the care plan was not up to date and could lead to an inconsistency of care. There were nutritional assessments in place as well as weight charts. For one person we found discrepancies in the recording between the two documents and within the two initial assessments and subsequent re-assessments. The first 'initial assessment' was completed in October 2011 and did not record the person's weight. They were not assessed as having any nutritional needs. The second 'initial assessment' form, dated 4 January 2012 also showed conflicting information. The person's actual weight was recorded as 60kg but a section of the form was completed to indicate that the person weighed 'less than 45kg'. The weight chart showed the person weighed 40kg on the 2 January 2012 and on 7 January 2012. On the nutritional reassessment dated 4 February 2012 the person was assessed as weighing 'less than 45 kg' but the actual weight was recorded at 48kg on the bottom of the form. On the weight chart, the person weighed 46kg on the 5 February. Therefore, it was not possible to ascertain whether the person was losing or gaining weight and how much at risk they were. We told by one social worker that they had been advised of an incident in the last two weeks where their client's behaviour had involved calls being made to other professionals including themselves. We were told by staff that the GP and been concerned that the person may have had a urinary tract infection, (UTI) and that a sample was requested. We were unable to find any reference to this event in the person's records or if the UTI issue had been dealt with or followed up During both our visits, we asked to see accident books but they were not completed correctly. We were given two books but some pages were blank, others had been completed to fill in the gaps which meant they were not in date order. The books were also both in use for the same time frame so that where a record had been made of an accident or incident, it was difficult to find it again. We also saw that some pages had not been completed incorrectly from the front to the back which meant the back of the page was blank and the details appeared in the wrong place. This means that records of accidents were not accurate and the books could not be relied upon for audit purposes.
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On 23 April 2012 we asked how the quality of the service was monitored by management and for the provider to provide documentation to evidence this. We were told by the registered provider, that a survey was performed twice a year and was sent to GPs; families; the hairdresser; chiropodist; community nurses and basically 'anyone' who had contact with the home. We asked to see the outcome of the surveys and associated documentation but these were not provided. Later, we asked again and the registered provider told us there were no results, as no surveys had been conducted since 2008. No evidence was provided that there was a management system for the monitoring of the service being provided. We requested evidence of staff appraisal. No information was available. Again this raised the issue of the provider not having proper information in relation to management of the regulated activity. Overall, we found that records were not completed in a way which ensured people's needs were met. Our judgement People were not protected from the risks of unsafe or inappropriate care and treatment. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

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Action we have asked the provider to take

Compliance actions
The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance.

Regulated activity
Accommodation for persons who require nursing or personal care

Regulation
Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome
Outcome 09: Management of medicines

How the regulation is not being met: People were probably given their medication appropriately but records did not always show this. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Accommodation for persons who require nursing or personal care Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 14: Supporting staff

How the regulation is not being met: People could not be assured that they were safe and their health and welfare needs were being met by competent staff. This was because staff supervision and appraisals were not consistently taking place. While some staff training had taken place it was not possible to establish how their training needs were identified. The provider was not meeting this standard. We judged that this had a moderate impact on people using the service and action was needed for this essential standard.

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The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider's report should be sent to us within 14 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete.

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Enforcement action we have taken

The table below shows enforcement action we have taken because the service provider is not meeting the essential standards of quality and safety shown below. Where the action is a Warning Notice, a timescale for compliance will also be shown.

Enforcement action taken

Warning notice This action has been taken in relation to: Regulated activity Accommodati on for persons who require nursing or personal care Regulation or section of the Act Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: People living at the home were not protected against the risk of receiving inappropriate or unsafe care. People's needs were not being met as a result and their safety and welfare was not being promoted. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome Outcome 04: Care and welfare of people who use services Registered manager: To be met by: 23 May 2012

Enforcement action taken

Warning notice This action has been taken in relation to: Regulated activity Regulation or section of the Act Outcome
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Accommodati on for persons who require nursing or personal care

Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: People had not been protected against abuse within the home. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

Outcome 07: Safeguarding people who use services from abuse Registered manager: To be met by: 23 May 2012

Enforcement action taken

Warning notice This action has been taken in relation to: Regulated activity Accommodati on for persons who require nursing or personal care Regulation or section of the Act Regulation 12 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: Outcome Outcome 08: Cleanliness and infection control Registered manager: To be met by:

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People were not protected from the risk of infection because appropriate guidance had not been followed and the home was not clean. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

23 May 2012

Enforcement action taken

Warning notice This action has been taken in relation to: Regulated activity Accommodati on for persons who require nursing or personal care Regulation or section of the Act Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: There were not enough staff to meet people's needs. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome Outcome 13: Staffing

Registered manager:

To be met by: 23 May 2012

Enforcement action taken

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Warning notice This action has been taken in relation to: Regulated activity Accommodati on for persons who require nursing or personal care Regulation or section of the Act Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete. Outcome Outcome 16: Assessing and monitoring the quality of service provision Registered manager: To be met by: 23 May 2012

Enforcement action taken

Warning notice This action has been taken in relation to: Regulated activity Accommodati on for persons who require nursing or personal care Regulation or section of the Act Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 How the regulation or section is not being met: Outcome Outcome 21: Records

Registered manager:

To be met by:

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People were not protected from the risks of unsafe or inappropriate care and treatment. The provider was not meeting this standard. We judged that this had a major impact on people using the service. Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

23 May 2012

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What is a review of compliance?

By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people.

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Information for the reader

Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public 03000 616161 / www.cqc.org.uk Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

Care Quality Commission

Website Telephone Email address Postal address www.cqc.org.uk 03000 616161 enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA

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