Archived: The Gateway

We inspected The Gateway on 21, 28 October, 5 November and these were unannounced inspections which meant that the staff and provider did not know that we would be visiting. During this period a number of concerns were raised by the local commissioners following their visits and on 23 November 2015 the registered manager provided additional information to support an assertion that they had not been notifying us of incidents. On 8 December 2015 we were notified that the home had gone into administration so we completed an additional visit on the 11 December 2015 to check if this change was having any detrimental effects.

The Gateway is a newly built care home, which has health and spa facilties on the ground floor. There are four separate floors, which can accommodate upto 40 people and can provide nursing and residential care. They provide respite services for children with long-term physical health conditions; adults with complex physical health conditions; people with spinal injuries and people with acquired brain injuries and neurological conditions.

The home has a registered manager and they have been in post since April 2015. 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.

On the 8 December 2015 the local media reported that Kiero Limited had gone into administration and we were contacted by the local authority and registered manager who also informed us of this development. The registered provider asserted they had informed us on 4 December 2015 however we found that the only contact with CQC was when the clinical services director rang to discuss an on-going registration application. On the 9 December 2015 the administrator formally notified us that they were now overseeing the operation of the home but prior to this the registered provider had not informed us of the difficulties they were experiencing or that the home was going into administration.

We gave feedback on 5 November 2015 highlighting that we had not received statutory notifications about events that had occurred from March to November 2015. The registered manager stated that they had sent us notifications and on 23 November 2015 provided us with nine copies of notifications, which they told us had been sent but were not on our system. These dated back to February 2015 and were on our system. However they did not send us any in relations to the events and incidents that we found had occurred post March 2015. Also the registered manager has not notified us of the six safeguarding alerts that were raised in December 2015 and a staffing shortage that occurred on 10 December 2015.

We found that the registered provider at registration stated they would not provide a service to children under the age of 16 years old, however, post registration they had altered the service and commenced providing services to all ages of children. In February 2015 Ofsted informed us this was being provided and our registration team visited to home with the Ofsted inspector to confirm that this was not impacting on the service or that the home now needed a dual registration. Also at some point this year the registered provider commenced accepting people who were detained under the Mental Health Act 1983 (amended 2007) and on section 17 leave to the home. We had not received updated statement of purposes at the time when these changes occurred.

The registered provider suggested it was an error within CQC systems that we had not received them but this is not the case. We have received notifications about Deprivation of Liberty Safeguard (DoLS) authorisations and amended statement of purposes in August, September and October 2015, which related to the removal of diagnosis and screening procedures from the registration and about registration applications. But we have not received any of the other required notifications.

When our inspection commenced in November 2015 the registered provider informed us they were reviewing the service to determine if they could provide services to allievate winter pressures for local NHS Trusts and also to operate a learning disability service. The home is not registered to provide services for people with a learning disability and we had not been requested to add this to their service user bands.

We found that none of the staff were registered mental health nurses and none of the staff had received indepth training for working with people who have mental health and neurological conditions; yet the registered provider advertised as a specialist service working with people who had these conditions and needs.

During the inspection the number of people who used the service varied, as they operated respite care, transitional services and rehabilitation services. On the 11 December 2015 there were 18 adults using the service and one child who was on overnight respite. All of the people had very complex needs and most people required two to one support for all of their care needs.

We found that two nurses and, ten care staff for two units and one paediatric nurse with one child care assistant for another unit were on duty during the day. Overnight there were two nurses with five care staff over two units and one paediatric nurse with two child care assistants for another unit.

From these numbers three support workers were needed per day and two support workers needed at night to provide one-to-one care to people.In addition other staff were needed for seven people who required one-to-one support per week.

This meant that for 15 adults with very complex needs there were two nurses and seven care staff available during the day which at times was reduced further when the six people received their one-to-one support at varying times across the week. Two nurses and three staff were available during the night.

The registered provider and registered manager told us that there were enough staff on duty to meet people’s needs. Some of the people we spoke with told us that they had to wait long periods of time to get assistance. Also some of the staff described how they had to prioristise their work to ensure people with more pressing needs could get ready and leave others in bed until late in the morning. We also saw that one of the nurses took several hours to give 10 people their medicines as they were repeatedly needed to see the doctor or other visiting professionals. They did ask for assistance but this was not forthcoming and meeting minutes showed the nurses had asked for an additional nurse to be employed during the day.

We saw on the rota that each day different numbers of staff were on duty and on some days the people who received one-to-one support had an allocated staff member highlighted on the rota but but not on other days. We could find no reason for these differences. We did see people being provided one-to-one support.

We found that since the provider went into administration some staff had tendered their resignation and in the last few months there had been a high turnover of staff, which we found from a review of staffing information the registered manager was covering.

The registered provider also employed physio therapists, occupational therapists, an activity coordinator and ancillary staff such as cooks and domestic staff who were on duty throughout the week. The registered manager, an assistant manager and clinical lead worked weekdays. We tended to find that staff on each unit managed the service with little direct involvement of the registered manager.

Albeit the provider had systems for monitoring and assessing the service we found that these had not assisted the registered manager to identify gaps in the care practice or make improvements. In June 2015 the registered manager had asked for changes to procedures and documents but the registered providers governance systems was so cumbersome that these had the main changes had not been made at the time of the inspection.

Alongside this, the audits failed to identify when care records were not accurately reflecting people’s needs; that Deprivation of Liberty Safeguard (DoLS) authorisations had expired and that the care records were not always accurately completed.

We found that risk assessments for people with physical health conditions were very detailed. But because staff had not received training around how to work with people whose behaviours may be challenge these issues were not clearly addressed in the care records.

We found that staff had not always followed the registered provider’s guidance so for instance had not weighed people more frequently if they were losing weight or made referrals to dieticians. This we found from discussions with visiting professionals had been an ongoing issue and despite it being raised with the registered manager had persisted.

When designing the building insufficient space had been provided for medication and the small rooms were prone to becoming too hot and there was no sinks in them for staff to wash the medicine pots. The registered provider asserted that the staff could wash the pots in each person's sink but this is not a satisfactory means for cleaning these items. Although staff recorded the treatment room temperatures we found no evidence to show action had been taken to either temporarily reduce the temperature or to make a permanent change to the temperature in these rooms to ensure it was at correct levels. Also no action was taken to provide sinks and staff were washing and drying medicine pots in the communal areas.

We found that the registered manager’s system for monitoring the operation of the service needed to be improved as they were not effective.

We saw there were systems and processes in place to protect people from the risk of harm. However we found staff were not clear that when incidents such as lack of staff or misplaced essential nutritional supplement items affected people’s care this needed to be raised as a safeguarding alert.

People’s needs were assessed and for the children and people with complex physical health care conditions their care was delivered in line with their individual care needs. The staff working with these people, particularly in the children’s service were very skilled and competent. But because the registered provider failed to employ mental health nurses or equip the staff with the skills needed to work with people with acquired brain injuries; neurological conditions and mental health needs staff were not sufficiently skilled or confident when working with these people. The registered manager had asked the registered provider to obtain this training but the registered provider had not ensured training was delivered to staff.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for but at times people were not adequately supported to manage their nutritional needs. Also the registered manager needed to ensure staff were told where nutritional supplements were stored if this changed or the staff were new to ensure people were able to deliver care and support with nutrition.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. People we spoke with told us that they knew how to complain and but did feel that their concerns were not taken on board. Staff told us they raised concerns with the registered manager but it did take time for matters to be resolved.

People were supported to maintain good health and had access to healthcare professionals and services. Both a GP and consultant visited the home on a weekly basis.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as those related to clinical issues like delivering care for people who had tracheostomy.

People told us that they made their own choices and decisions. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity.

We saw that people were engaged in a wide range of meaningful occupation and this was tailored to meet each person’s preferences. People accessed the spa facilities and if funded could routinely see the physiotherapists. The registered manager did enable those people who were not funded but would benefit from physiotherapy to gain access to these services. Also people regularly went out to events or into town.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

We found the provider was breaching five of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care, safeguarding people from improper treatment and abuse, staffing, governance and duty of candour. We also highlighted that the registered provider needed to ensure statement of purpose were submitted in line with the requirements of The Care Quality Commission Registration Regulations 2009 when the design of the service changed. Plus statutory notifications needed to be submitted in line with The Care Quality Commission (Registration) regulations 2009.

In considering the enforcement action that would be taken consideration has been given to the fact that the home is in administration and therefore the provider no longer operates the service. Also the actions that the administrator has taken to date to ensure the service is improved and that it operates in a safe manner.