Archived: Bellevue Healthcare Limited

At the last comprehensive inspection completed on 21 March, 5 and 18 April 2016 we judged the home to be rated as inadequate and found multiple breaches of our regulations. The service had been placed into serious concerns protocol with the local authority in March 2016 and at the time of this inspection that remained the case. The service was entered into this protocol because of an increased number of safeguarding alerts made by external health professionals. The professionals involved in the serious concerns protocol had significant concerns about the registered provider’s ability to provide safe care and support to people. An embargo was put in place which meant that nobody new could move into the service.

We carried out a further inspection on 12 May 2016 because of growing concerns about people’s safety. We found that although the risks had not increased they still remained around ensuring people received safe care and treatment. People were not placed at any greater risks from staff failing to administer medication in line with their prescriptions and were receiving adequate food and fluid. However, when people lost weight, we found staff were still failing to ensure referrals to dieticians were consistently made.

This latest inspection was completed because concerns were still being identified and we wanted to make sure people were safe living at the service. We also wanted to make sure the registered provider was taking action to address the concerns which we had identified during the last two inspections completed in April 2016 and May 2016.

Bellevue Healthcare Limited is registered to provide care and support to 102 people. At the time of our inspection there were 52 people using the service and 97 staff employed. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

Bellevue Healthcare Limited was registered with the Commission in 2001. A registered manager was in place until 2014 when the registered manager retired. There had been three managers since then however none applied to become registered manager. A new manager is now in post and they have started the process to become registered manager. 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.

Not having a registered manager is a breach of the registered provider’s conditions of registration. Following the inspection completed in April 2016 we issued a fixed penalty notice for this matter and the registered provider paid the £4000 fine in order to deal with this breach.

We also made the registered provider aware that they were failing to notify us of incidents and deaths, which is a breach of the Care Quality Commission (Registration) regulations 2009. We are currently dealing with this matter outside of the inspection process.

On 5 September 2016 we identified that four people were grossly underweight and all had Body Mass Indicators (BMI) of below 18. This shows that people are at risk of being malnourished and developing a compromised immune function; respiratory disease; digestive diseases; cancer and osteoporosis. One person had a BMI of 12, which placed them at very high risk of developing life threatening health conditions. Despite referring people to dieticians in July 2016 the staff had not recognised that people continued to lose weight and that their BMI were extremely low so had not got back in touch with the dieticians.

Where safeguarding alerts established that malnutrition or dehydration had occurred, there was no evidence to show that the service had taken action to reduce the risk of the incidents re-occurring. Also when people’s nutritional supplements had not been received in a timely fashion the staff had not contacted the GP or dietician to request they were delivered. This had led to people not receiving the required supplements for over a month. In the interim these people continued to lose weight.

Food and fluid balance charts had not always been completed. Records showed that people consumed less fluid than were specified in their care plans. There was no evidence to suggest that people were offered snacks outside of meal times or that people at increased risk of malnutrition were offered nutritional supplements.

We found that staff were not identifying the development of pressure ulcers clearly. This meant care plans had not been produced to detail how these were being treated or the action they needed to take if the pressure ulcer changed or became infected. Staff had not been accurately identifying and recording when people had pressure ulcers. Referrals had not been carried out in a timely manner.

Following our visit on the 5 September 2016 we wrote to the registered provider to make them aware of our serious concerns about people’s welfare and asked them to take immediate action to ensure people’s health was not compromised.

On 16 September we visited to check that the action the registered provider had said would be taken had occurred. We found that they had compiled a list of people’s current weight and people who had wounds. They had contacted GPs and dieticians for all people who were found to have compromised weights and with wounds. Also they had ensured the cook was aware of people who were losing weight or had a low weight so the cook could provide these people fortified food. Additional supplies of fortified foods were provided throughout the day and the registered provider checked that people were eating. Although improved the records still did not fully evidence the actions staff were taking when providing care and treatment for people.

We also found that one of the registered provider’s directors, who is a retired GP and without a license to practice had been completing and signing ‘Do not attempt cardio-pulmonary resuscitation (DNACPR), as senior consultant. This is a breach of the Medical Act 1983. We found that some people’s DNACPR certificate stated ‘general frailty’ rather than a specific clinical condition, which does not following General Medical Council (GMC) code of practice.

We judged this to be a major risk and in line with our enforcement policy are taking action to deal with this issue, which we will report on once completed.

The registered provider visited the service each day and we observed them carrying out checks of the service, however they had not recorded any of their visits as part of quality assurance processes. This meant we could not see what checks were being carried out.

The service had started to introduce a small number of audits. However there were gaps within these. Where actions for improvement had been identified, no action plan had been produced and there was no evidence of any action taken following the audit.

The service had started to make safeguarding alerts, however these were limited to incidents between people using the service. Safeguarding alerts for people at risk of malnutrition, dehydration and pressure sores had not been made. However, safeguarding alerts regarding these incidents had been made by visiting health and social care professionals. Since 27 July 2016 a total of five safeguarding alerts had been up-held for abuse including ones for neglect because malnourishment and dehydration had occurred.

We found that risk assessments were not always in place for people who needed them. These included people at risk of falls, and those using calls bells and lap belts. Some risk assessments were not person-centred and did not always contain accurate information.

Core care plans had been introduced at the service. This meant people had care plans in place even when no care needs had been identified. We found care plans were generic rather than person-centred and did not accurately reflect people’s actual care needs and the risks in place.

There were gaps in recruitment records which meant that it was unclear about how the registered provider decided applicants were suitable to be employed. A recruitment exercise was taking place during our inspection. Two candidates were offered positions as carer on the day and were asked to start one week later. We were concerned about this because we could not been sure if two checked references and a Disclosure and Barring Services check for each person could be obtained within this time frame.

Care records contained conflicting information about people’s capacity. In some care records, there was evidence to suggest people had capacity and similarly did not have capacity. Where people lacked capacity there was no evidence of any ‘best interest’ decisions making.

Care plans had not been signed by the people they related to. This meant we did not know if people had been involved in their care plans or if they had agreed to them. Care plans were also required to be signed by people who lacked capacity. There was no evidence in the care records where people lacked capacity to show whether their relative had Lasting Power of Attorney for care and welfare, yet they were being asked to agree to and sign to care plans.

We found that restrictive practices in place without evidence of best interest decision making. For example, we found some people were in bed with minimal clothes on, such as an incontinence pad and protective pants . In one care plan this was recorded as the person’s choice but when we visited this person we found they could not communicate.

The service had started to make im

At the last comprehensive inspection completed on 21 March, 5 and 18 April 2016 we judged the home to be rated as inadequate and found multiple breaches of our regulations. The service had been placed into serious concerns protocol with the local authority since March 2016. The professionals involved in the serious concerns protocol had significant concerns about the registered provider’s ability to provide safe care and support to people. An embargo was put in place which meant that nobody new could move into the service.

Not having a registered manager is a breach of the registered provider’s conditions of registration. Following the inspection completed in April 2016 we issued a fixed penalty notice for this matter and the registered provider paid the £4000 fine in order to deal with this breach.

We carried out a further inspection on 12 May 2016 because of growing concerns about people’s safety. We found that although the risks had not increased they still remained around ensuring people received safe care and treatment. People were not placed at any greater risks from staff failing to administer medication in line with their prescriptions and were receiving adequate food and fluid. However, when people lost weight, we found staff were still failing to ensure referrals to dieticians were consistently made.

We completed a further inspection on 5 and 15 September 2016 because concerns were still being identified and we wanted to make sure people were safe living at the service. We also wanted to make sure the registered provider was taking action to address the concerns which we had identified during the last two inspections completed in April 2016 and May 2016.

We identified that four people were grossly underweight and all had Body Mass Indicators (BMI) of below 18. This shows that people are at risk of being malnourished and developing a compromised immune function; respiratory disease; digestive diseases; cancer and osteoporosis. One person had a BMI of 12, which placed them at very high risk of developing life threatening health conditions. Despite referring people to dieticians in July 2016 the staff had not recognised that people continued to lose weight and that their BMI were extremely low so had not got back in touch with the dieticians.

Following our visit on the 5 September 2016 we wrote to the registered provider to make them aware of our serious concerns about people’s welfare and asked them to take immediate action to ensure people’s health was not compromised. On 15 September we visited to check that the action the registered provider had said would be taken had occurred. We found that they had compiled a list of people’s current weight and people who had wounds. They had contacted GPs and dieticians for all people who were found to have compromised weights and with wounds.

However we also found that one of the registered provider’s directors, who is a retired GP and without a license to practice had been completing and signing ‘Do not attempt cardio-pulmonary resuscitation (DNACPR), as senior consultant. This is a breach of the Medical Act 1983. We found that some people’s DNACPR certificate stated ‘general frailty’ rather than a specific clinical condition, which does not comply with the General Medical Council (GMC) code of practice. We issued a Notice of Decision under our urgent powers requiring that the provider review the fitness of this director and investigate the completion of the DNACPRs and the role of the clinical lead. Subsequently the director stepped down from the company.

Bellevue Healthcare Limited is registered to provide care and support to 102 people. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

A registered manager came into place in November 2016. 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 commenced this inspection as the local authority reported they were observing significant improvements in the operation of the home.

In October 2016 we did initially find evidence that action had been taken to refer people health professionals for nutrition, dehydration and pressures sores however care plans had not been developed/updated. When we visited in November 2016 to continue to review the delivery of care we found that minimal improvements noted in October 2016 had not been sustained. The registered provider continued to fail on multiple levels to ensure people were receiving safe and effective care and treatment. We found steps had not been taken to ensure service users received adequate fluids, were not unintentionally losing weight, identified wounds were managed appropriately and that service users received safe care and treatment.

We found that one person had lost 3kg in weight between 3 October 2016 and 9 November 2016. Their nutrition care records stated that any loss of 3kg should be reported and action taken. We noted that the care staff had raised this with the nurse on duty. However, the nurse failed to act and this had not been picked up via the registered provider’s systems for overseeing the performance of the home or within their recently introduced weight monitoring tool.

We saw that since the introduction of a weight monitoring tool in October 2016 staff had not recalculated the service user’s BMI despite weight change. Also staff on the residential unit had not recorded the service users’ height on this tool so it was unclear how staff had worked out the individuals BMI in the first instance. For instance one person’s weight from October 2016 had fluctuated between 50. 3 kg and 53.4kg but their BMI had always been recorded at 18.1. This person was at risk of malnutrition with a BMI of 18 and the variation of weight could have increased that risk. We found that no checks had been made to ensure staff accurately completed the tool. Thus, the senior staff were unaware of the issue.

We saw on the nursing unit the staff had recorded service users’ height but found this recording could not be relied upon. In one person’s file the dietician had recorded their height as 1.62m but staff at Bellevue Healthcare had recorded their height at 1.58m. This discrepancy had led to the true BMI being masked and could lead to staff to failing to identify if someone’s weight dropped into ranges which were indicators of risk and malnutrition.

One person's who receives food and fluid via Percutaneous endoscopic gastrostomy (PEG) records had not been updated following a dietician letter dated 16 September 2016 which stated they must receive 700mls of fluids each day in addition to food and flushes. We discussed this with the nurse who told us they were unaware of the change to the regime. The nurse informed us that the person required 500mls of fluid per day. However, inspectors noted that they had not even been receiving the 500ml of fluids per day. We reported this matter to the local safeguarding team.

We also found that one person continued to refused food and fluid. Within their care records we found contradictory information about their capacity to make these decisions. In one care plan it was recorded that the person lacked capacity to make decisions. However, in their capacity care-plan it indicated they had full capacity and every evaluation of this care plan stated that the person had full capacity to make all decisions. This was despite noting in the actions section of the plan that a Deprivation of Liberty Safeguards (DoLS) authorisation had been sought; an assessment was needed to determine if they had the capacity to decide to refuse food and fluid and a multidisciplinary team meeting needed to be held with the GP to determine if best interest decision was needed to address their refusal of food and fluid. We found the nurse evaluating the capacity care plan had failed to understand the requirements of the Mental Capacity Act 2005 and the registered provider’s oversight of this had failed to identify this gap.

We also saw that one person had been assessed in 2014 as requiring a soft diet and thickened fluid because they had an impaired gag reflex and was therefore at high risk of choking. In August 2016 the Speech and Language Therapist (SALT) team had noted that the person continued to have episodes of choking and chest infections but still refused to follow their advice so took a normal diet. The SALT team referenced that in 2014 a capacity assessment had been completed. The capacity assessment completed at that time showed that the individual was aware that eating a normal diet could be fatal either because of choking or aspirational pneumonia.

Due to the continued high level risk being posed by the refusal to eat a soft diet and take thickened fluids in August 2016 the SALT team recommended the staff revisit the person’s capacity to make this decision. However, no one from the service had completed a capacity assessment and either ensured a best interest decision was made around making sure they followed the SALT team recommendation or signed a consent form stating they accepted the risk that this decision could be fatal. The registered provider’s oversight of this had failed to identify this gap.

We found that there was no evidence of alternatives offered when people had not eaten meals. Coffee was recorded as one person’s evening meal. There were gaps in food and fluid balance records. Baseline fluid l

Bellevue Healthcare Limited is registered to provide care and support to 102 people. At the time of our inspection there were 76 people using the service and 96 staff employed. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

Bellevue Healthcare Limited had been registered with the commission since 2001. A registered manager was in place until 2014 when the registered manager retired. There had been three managers since then however none applied to become registered manager. At the time of inspection, one of the registered providers told us they were in the process of applying to become a registered manager. 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.

The service was placed into the serious concerns protocol with the local authority in March 2016. This is way of providing support to a service where there are concerns. The service was placed into this protocol because of an increased number of safeguarding alerts made by health professionals external to the service. The professionals involved in the serious concerns protocol had significant concerns about the registered provider’s ability to provide safe care and support to people. An embargo was put in place which meant that admissions into the service were stopped.

The registered providers had not always notified CQC about events which had taken place at the service. This included when DOLs applications had been granted, when the nominated individual and registered manager left their posts and when a person had died. CQC will take action to address these outside of this inspection process.

When a person died, we could not be sure if appropriate action had been taken by the service. We will look at this outside of this inspection process.

Staff did not always know the people they were providing care and support to. Some staff lacked confidence in caring for people with specific needs because they had not received the training and support to do so.

Privacy and dignity was not always maintained. We observed personal care taking place as bedroom doors were not always closed when this was carried out. People’s care records were not stored securely. Incontinence pads were displayed in communal bathrooms, in the corridors on trolleys or left on people’s bedroom floors.

People were regularly left in bed throughout the day. Staff told us this was because of people’s health needs or because it was safer for people. The two registered providers told us that there was no reason why people should be in bed throughout the day unless it was their choice to do so.

Evidence of consent was not available in all of the care records which we looked at. At the start of our inspection not everyone who needed Deprivation of Liberties Safeguards had them in place. Staff displayed very limited knowledge and understanding about the Mental Capacity Act. Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) were not accessible at the start of our inspection.

Care plans were not person-centred and lacked the detail needed to provide care and support to people according to their wishes, needs and preferences. Care plans were not always reviewed within the timescales set by the registered provider and lacked detail. People had the same care plans in place regardless of whether they were needed. Some people did not have the care plans in place which were specific to their individual needs.

Risk assessments contained limited information and did not always match care plans. They were not regularly reviewed. Some people did not have the risk assessments in place which they needed.

We could not be sure if appropriate action had been taken when a person experienced a fall because no additional checks had been carried out to check the person. A safeguarding alert had not been made in light of this.

When people moved into the service we could see that there were gaps in their initial assessment records. The service had not taken action to request this information from the people involved.

We could see people were involved with health professionals however regular health checks were not up to date. There were gaps in the records about visits from health professional and their recommendations.

There was no evidence of people’s involvement in their care records. There was no evidence of people’s wishes, likes and dislikes. The registered providers confirmed staff wrote peoples care plans without involving them.

Training for end of life care was not up to date. Records relating to people’s wishes relating to the end of their lives were not up to date.

Risk assessments and food and fluid balance records were in place but were not fully completed. Some people were not supported to eat when choosing to stay in their own rooms.

Medicines were not managed safely. Some prescribed topical cream prescription labels were not legible and nutritional supplements did not contain people’s names.

Infection prevention and control procedures were not always followed. Some areas of the building required cleaning and some items of bathroom furniture were in need of repair or replacement. People’s toiletries were found mixed together in communal bathrooms.

Safeguarding alerts had not been made by the service. Staff training in safeguarding was not up to date. Staff displayed very limited knowledge and understanding of what could constitute a safeguarding alert and the procedure which they needed to follow.

Staff told us they had been a significant lack of leadership at the service; however all spoke positively about the two registered providers who were now providing day to day management.

There was a lack of clinical leadership in place to make sure staff were carrying out the duties expected of them. No one was accountable for the service in the absence of the registered providers.

The vision and values for the service were not being followed by the staff in place at the service. Staff told us they had struggled with the number of different managers which had been in place and the number of changes which had been made.

A survey had been carried out in 2015 however no action plan was in place. The two registered providers told us they had responded to key points identified in the survey however there were no records to support this.

There were no quality assurance processes in place. This meant the registered provider had not identified the concerns found during inspection.

The service had taken on a ‘Step down bed’ contract with a local hospital which had been busier than expected. We found that there was a lack of communication between the registered provider and the local hospital. Information needed about people placed at the service under this contract was not always sought. The service failed to make any safeguarding alerts against the local hospital when they needed to.

Staff did not carry out the duties expected of them. There was no-one in place to support staff to ensure that these duties were carried out. When staff raised potential safeguarding alerts with senior staff they had failed to take action. They had not raised a safeguarding alert or had not shared this information with the two directors.

The CQC had not been notified of any potential safeguarding alerts because the service had failed to make them to the local authority or CQC.

Staff told us there had been a lack of communication at the service because there had been no consistent manager for some time. Some staff told us they had discussed their concerns with the registered provider however felt that they had not been listened to or their concerns had not been resolved.

There were not enough staff in place to provide care and support to people. There were limited systems in place to cover sickness and annual leave.

Supervision, appraisal and training were not up to date. Staff participated in an induction programme and records were in place to support this.

There were systems in place to recruit people which included a disclosure and barring services check and two checked references however nursing PINS were not checked.

Disciplinary procedures were in place however formal records were not. During our inspection staff were taken into the disciplinary process.

Certificates relating to the health and safety of the building were up to date. Maintenance checks were carried out however they were not always at the frequency expected by the registered provider.

Each person had their own room and we could see that these rooms contained people’s personal possessions. People had the choice of spending time in their rooms, in communal lounges and in the garden.

A small number of complaints had been made over the last year. We could see that appropriate action had been taken and records were in place to support this.

We found ten breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to person-centred care, consent, care and welfare, safeguarding, quality assurance and staffing. In light of the serious concerns identifie

Bellevue Healthcare Limited is registered to provide care and support to 102 people. Three of the units at the service were being used. These were the Amara Unit which provided care and support to people living with a dementia, a unit for older people who required predominantly residential care but some people needed nursing care and a third unit for young adults living with a physical disability. The unit for older people requiring nursing care was closed. At the time of the inspection 36 people used the service.

A new manager came into post in September 2016 and became the registered manager in November 2016. 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.

The last comprehensive inspection of the service was completed on 21 March, 5 and 18 April 2016. We found multiple breaches of our regulations and judged the home to be rated as inadequate. The service has also been under a serious concerns protocol with the local authority since March 2016.

In June 2016 we issued a fixed penalty notice because no registered manager had been in place for over a year. The registered provider paid the £4000 fine in order to deal with this breach.

We have carried out a further four inspections of the service with these taking place in May 2016, September 2016, October and November 2016 and in December 2016. These have occurred either because of growing concerns about people’s safety or because other visiting professionals were finding improvements. Consistently we have found that the action the registered provider has taken to address the breaches of regulation had not been effective. At times we have found the level of risk posed to people who used the service had increased. At other times we have found some improvement but this was not sustained.

We have repeatedly found that when people received food and fluid via Percutaneous endoscopic gastrostomy (PEG) this was not managed in line with their prescriptions. A PEG is a means of feeding when oral intake is not adequate, for example, because difficulty when swallowing. Also we found there was conflicting information in the care records about the volume of the additional fluids the individuals’ required. Records of PEG balloon checks showed these were not reviewed as required. Although we asked the registered provider and registered manager to take action on follow up inspections we have found the same problems continued to occur.

At the first inspection 21 March, 5 and 18 April 2016 we identified that when people were underweight staff were not contacting GPs and dieticians about this matter. In September 2016 we found people were grossly underweight and at risk of being malnourished and developing a compromised immune function; respiratory disease; digestive diseases; cancer and osteoporosis. We found following our raising of this issue at the first inspection staff were referring people to dieticians but had not re-referred individuals when they continued to lose weight and their BMI were extremely low. Staff had not weighed people on a regular basis. At the November and December 2016 inspections we found staff continued to inconsistently monitor people’s weight and were not demonstrating that they took action when individuals were not eating and drinking sufficient.

From the first inspection in 21 March, 5 and 18 April to last inspection in December 2016 we routinely found that wound care has not been effective; the requirements of the Mental Capacity Act 2005 have been inadequately followed and this compromised people’s safety; medication practices remained unsafe; care records were inaccurate and staff failed to demonstrably take action when people have not been eating or drinking. The governance arrangements have not been effective or supported staff to resolve any of these problems.

We asked the registered provider and registered manager on two occasions to investigate the discrepancies around the insulin administration.

We have reported a number of concerns to the local safeguarding team around poor management of PEG regimes; medication practices; people’s compromised nutritional status; and wound care.

Following our visit on the 5 September 2016 we required the registered provider to take immediate action to ensure people’s health and safety was not compromised.

In November 2016 we issued an urgent NOD for the registered provider to review the fitness of one of the directors. This was because we found that they were inappropriately completing and signing, as senior consultant, ‘Do not attempt cardio-pulmonary resuscitation’ (DNACPR) papers. This required the registered provider to investigate why one of the Directors was signing these papers and to review the role of the clinical lead. Subsequently the Director stepped down from the company.

In November 2016 we also issued an urgent Notice of Decision, which imposed several conditions on the registered provider’s registration. These required that no one was admitted to the home without first discussing this with us at the Commission, that action be taken to manage risks identified for two people around their hydration and compromised gag reflex and that staff completed capacity assessments for these two people. The conditions also required that the registered provider assessed the competency of all the staff deployed at the home and where necessary took action to ensure staff performed to an acceptable standard.

At this inspection we again found that where people refused to drink sufficient fluids staff did not demonstrably take action to contact GPs and other healthcare professionals to help reduce the potential conditions associated with dehydration. The registered manager told us when staff had contacted the GP about people not taking sufficient fluids for three days they had been shouted at and told not to call the surgery. No records were available to show when this occurred or that the GP had behaved in this manner. No baseline thresholds were recorded on care plans so we could not determine how staff would know when the GP needed to be contacted.

Staff continued to fail to understand how to apply the requirements of the Mental Capacity Act 2005 (MCA) and allowed people who lacked capacity to make high risk decisions. An example of this was that staff allowed people to eat normal food when the Speech and Language team had advised against this because they were at significant risk of choking.

We found that although action had been taken to improve the way PEG feed regimes were managed. Prescription details were still being inconsistently recorded in the care record and the administration record sheet. There were no measures in place to monitor the administration of PEG feeds and so staff could not readily demonstrate feeds had been given. The records of the volume of fluid to be given each day were confusing.

We found that it was unclear how wounds were being treated, why dressings were changed less frequently than required for instance the daily records for one person stated they needed dressings changed every three to four days but the dressings had not been changed for seven days.

Again we found that actions identified in audits and incident reviews were not completed. For instance care plan audits identified that the records were inaccurate and needed updating but staff had not completed this work. Records continued to show that people were mobile and used commodes when they were not or loved ones were still alive although they had died some time ago.

We found that staff had been reviewing care records and risk assessments to ensure they were more person-centred and accurately reflected people’s needs. However, as both the registered provider and registered manager acknowledged this work was not complete.

We found that a new system for medication administration had been introduced, which was computerised. It alerted the registered manager and pharmacists to the need for new stock and when deviation from prescribing guidelines occurred. We established that stock balances were correct. However, we found improvements were needed to the way topical creams and ‘as required’ medication was managed.

We reviewed the training records for all nurses and care staff and found that no area of training was up to date for all staff. This meant that we could not be sure if staff were competent to provide care and support to people. Also we noted that not all of the staff completing PEG feeds had received training to complete this activity.

Staff could not find people’s records for food and fluid from the previous week and we were informed that they had been archived. We looked through the most recently archived material and found the information was not there and the records we saw were not in date order. We pointed out at the last inspection this was problematic as staff could not be assured that they had a good oversight of changes in people’s needs; the material was used to compile accurate care plan evaluations; or that action had been taken when needed.

There were sufficient staff on duty to meet the needs of people who used the service. We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

The service had a clear process for handling complaints.

We found the registered provider was continuing to breach the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified during the inspection on 21 March, 5 and 18 April 2016.

Bellevue Healthcare Limited is registered to provide care and support to 102 people. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

A new manager came into post in September 2016 and became the registered manager in November 2016. 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.

At the last comprehensive inspections completed on 21 March, 5 and 18 April 2016 we judged the home to be rated as inadequate and found multiple breaches of our regulations. The service has also been under a serious concerns protocol with the local authority since March 2016.

In April 2016 we noted that no registered manager had been in place since November 2014. Not having a registered manager is a breach of the registered provider’s conditions of registration. In June 2016 we issued a fixed penalty notice for this matter and the registered provider paid the £4000 fine in order to deal with this breach.

We carried out a further inspection on 12 May 2016 because of growing concerns about people’s safety. We found that although the level of risk had not increased concerns remained around ensuring people received safe care and treatment. People’s level of risk from staff failing to administer medication in line with their prescriptions remained unchanged. When people lost weight, we found staff were still failing to ensure referrals to dieticians were consistently made.

Due to concerns still being identified we completed an inspection on 5 and 16 September 2016. We also wanted to make sure the registered provider was taking action to address the concerns which we had identified during the last two inspections completed in April 2016 and May 2016.

We identified that four people were grossly underweight and all had Body Mass Indicators (BMI) of below 18. This showed that people were at risk of being malnourished and developing a compromised immune function; respiratory disease; digestive diseases; cancer and osteoporosis. One person had a BMI of 12, which placed them at very high risk of developing life threatening health conditions. Despite staff referring people to dieticians in July 2016 they had referred individuals when they continued to lose weight and their BMI were extremely low.

Following our visit on the 5 September 2016 we wrote to the registered provider to make them aware of our serious concerns about people’s welfare and asked them to take immediate action to ensure people’s health was not compromised. On 16 September we visited to check that the action the registered provider had said would be taken had occurred. We found that they had compiled a list of people’s current weight and people who had wounds. They had contacted GPs and dieticians for all people who were found to have compromised weights and those with wounds.

We also found that one of the registered provider’s directors, who is a retired GP and without a license to practice had been completing and signing ‘Do not attempt cardio-pulmonary resuscitation’ (DNACPR), as senior consultant. This is a breach of the Medical Act 1983. We issued a Notice of Decision under our urgent powers requiring that the provider review the fitness of this director and investigate the completion of the DNACPRs and the role of the clinical lead. Subsequently the director stepped down from the company.

On 13 October and 11 November 2016 we completed a further inspection because the local authority reported they were observing significant improvements in the operation of the home.

We did initially find evidence that action had been taken to refer people to health professionals for nutrition, dehydration and pressures sores although care plans had not been developed/updated. However, in November 2016 we found that these minimal improvements had not been sustained. The registered provider continued to fail to ensure people were receiving safe and effective care and treatment on multiple levels. We found steps had not been taken to ensure service users received adequate fluids, were not unintentionally losing weight, identified wounds were managed appropriately and that service users received safe care and treatment.

We found at the inspection in November 2016 that one person who received food and fluid via Percutaneous endoscopic gastrostomy (PEG) had not had their records relating to this updated. A PEG is an endoscopic medical procedure in which a tube (PEG tube) is passed into a person’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate, for example, because of dysphagia or sedation.

We issued a Notice of Decision under our urgent powers requiring that no one was admitted to the home without first discussing this with us. Action was also taken to manage risks for two people, complete capacity assessments for these two people and assess the competency of the staff deployed at the home.

At this inspection we found that the person’s care plan had been reviewed and updated but this did not reflect the times specified in the dietician’s letter.

Another person’s PEG regime information did not match that set out by the dietician and there was conflicting information in the care records about the volume of the additional fluids.

For two people their PEG regimes were not always recorded as given. Also one person needed their PEG balloon to be checked each Sunday but the records showed this was not occurring as required.

We asked the registered provider and registered manager to take action to ensure people’s PEG regimes were followed and reported these matters to the local safeguarding team.

We found that a new system for medication administration had been introduced, which was computerised. It alerted the registered manager and pharmacists to stock need and deviation from prescribing guidelines. However, it only became operational on 3 December 2016 so reports and alerts had yet to be produced. The new system had led, potentially short-term, to an increase in the time taken to administer medicines. We established that stock balances were correct.

We found that one person’s insulin medication was not administered in line with the prescription.

We asked the registered provider and registered manager to investigate the discrepancies around the insulin administration and reported this matter to the local safeguarding team. The registered manager contacted the pharmacist to ask them to check the electronic administration sheet to see that the right amount of medication had been given. They also liaised with the person’s diabetic nurse to ensure they were administering medication correctly and obtain written evidence of the latest prescription and instructions around when to administer the insulin.

We also found on 19 December 2016 the nurse recorded that they had given a morning insulin dose of 10 units when the person’s blood glucose level was 5.9. When we questioned this the nurse crossed out the entry of 10 units and wrote six saying it was a mistake.

Again we found that actions identified in audits and incident reviews were not completed such as one person pulled a metal curtain pole down on themselves in November 2016. The incident form records to prevent further injury the poles were to be removed and replaced with light weight ones. The action was to be completed by 27 November 2016. However, we saw that one pole remained in situ and the other window had no curtains or pole in place.

We found that the senior managers were introducing new systems for overseeing the home such as provider audits but these, and the other systems were not picking up the issues we found. Actions from care plan audits completed in October 2016 were still not completed.

We could see that staff had been participating in training, however not all staff were up to date with their mandatory training. We reviewed the training records for all nurses and care staff and found that no area of training was up to date for all staff. This meant that we could not be sure if staff were competent to provide care and support to people. We obtained feedback from the people involved in completing competency checks on the staff. This showed that although staff had received up to date training they were not putting this training into practice.

Staff still did not ensure they gave sufficient fluids or demonstrably took action when people had reduced fluid intake or passed more fluids than they consumed. They still took no action when people refused to have their weight taken or lost significant weight. The registered manager told us when staff had contacted the GP about people not taking sufficient fluids for three days they had been shouted at and told not to call them. No records were available to show when this occurred or what GP had behaved in this manner.

We found multiple inaccuracies in eight sets of care records we reviewed. Again care plans were contradictory. Although improvements had been made to the MCA information for the two people mentioned in the Notice of Decision this had not been extended to others. Records for three people indicated they all had memory impairment and were forgetful but their care records stated they had capacity to make decisions. No information was provided to detail how they had reached this conclusion.

The manager of the young adults unit had identified two people at risk of malnutrition and trialled smo

At the last inspection completed in April 2016 we judged the home to be rated as inadequate and found multiple breaches. More concerns had been raised over the intervening weeks so we visited to ensure people were not at an increased risk of harm.

Bellevue Healthcare Limited is registered to provide care and support to 102 people. At the time of our inspection there were 60 people using the service and 91 staff employed. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

Following the last inspection we had identified that the registered provider was failing to notify us about occasions when people who used the service had sustained serious injuries or died. We informed the registered provider this was a breach of the Care Quality Commission (Registration) regulations 2009. Subsequently they started to send in notifications and we identified occasions when people had died unexpectedly or been injured. We were concerned that the information indicated that the home may have neglected people’s care and treatment needs and that the registered provider failed to understand the requirements of the regulations.

We found that the risks around ensuring people received safe care and treatment had not increased. People were not placed at any greater risks from staff failing to administer medication in line with their prescriptions. People were receiving adequate food and fluid. When people lost weight, we found staff were still failing to ensure referrals to dieticians were consistently made.

Bed rails were checked on a regular basis. However, there was no guidance available for this which meant we could not be sure what checks were being carried out.

At the last inspection we raised that people’s dignity was compromised because staff undertook personal care with their bedroom door open. Staff also did not consider people’s dignity when they sleeping and the custom and practice was to leave their doors open irrespective of whether they were in a compromising position or not fully dressed. We found the registered provider interpreted this feedback as the need to close all of the bedrooms doors and disregard people’s choices or needs.

The registered provider had completed falls risk assessments but had not used this information to inform the action they should take. Thus, no falls monitoring systems such as pressure pads and motion alarms had been put in place for people who might be unsafe attempting to walk about in their room. We found they failed to understand how these risks could be reduced.

We found that the registered provider had started to collate all of the information about injuries people had sustained but was yet to complete an analysis of this information.

Bellevue Healthcare Limited had been registered with the commission since 2001. A registered manager was in place until 2014 when the registered manager retired. There had been three managers since then however none applied to become registered manager. At the time of inspection, one of the registered providers told us they were in the process of applying to become a registered manager. 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.

Not having a registered manager is a breach of the provider’s registration conditions and we are dealing this matter with outside of the inspection process.

We found the provider was breaching eleven of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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.

One person told us, 'This is the best place I've ever been to.' Another person said, 'the staff are gorgeous they are the best ever.'

We saw that staff interacted and communicated well with people. The staff were attentive and demonstrated a good knowledge and understanding of the needs of people. We saw that the atmosphere in the home was friendly and relaxed.

We saw that people had their needs assessed and that care plans were in place and we saw that there were effective processes in place to ensure safe sharing of information with other providers.

We found that medicines were administered safely.

We saw that care and support was provided by suitably qualified, skilled and experienced staff.

We found that systems were in place to regularly monitor the quality of service.

People told us; 'It is ideal', 'The staff are a fantastic bunch and always so friendly', and 'I find everything is spot on and have no complaints whatsoever'.

The relatives told us that they were confident that the manager would make sure the service met people's needs. Some relatives had raised concerns about a staff member's attitude with us, the manager and the local authority. We found that the concerns had been fully investigated and resolved to the satisfaction of all involved. Relatives told us; 'When issues arise these are quickly sorted out'.

From our observations and discussions with people we found that care staff worked in ways that supported people to lead fulfilling lives and respected people's decisions.