Glanmor is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide personal care and accommodation for up to seven people with mental health and associated health needs. At this inspection six people were being supported by this service. This inspection took place on 8 and 9 October and was unannounced.
A registered manager was in post at the time of this inspection. The registered manager was on a period of absence from the service and was not available during our inspection. 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. Our inspection was supported by the director of the service and a deputy manager.
The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is part of an ongoing Local Authority safeguarding investigation and may in the future be considered by CQC under our specific incident process. The information shared with CQC about the incident indicated potential concerns about the management of risk of incident within the service. This inspection examined those risks.
At the last comprehensive inspection in June 2016, the service was rated Good overall and Requires Improvement in the 'Safe' domain. We undertook a focused inspection in May 2017 to check that they had followed their plan and to confirm that they now met the legal requirements. Following this focused inspection, the service was rated Good overall and in the ‘Safe domain’.
At this inspection we found concerns across all the five domains and the ‘Safe’ and Well-led domains are now rated as Inadequate. We identified four breaches of the Regulations, Regulation 10 Dignity and respect, Regulation 12 Safe care and treatment, Regulation 17 Good governance and Regulation 18 Staffing.
The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. 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.
The recording of incidents and accidents, subsequent investigations, actions taken and measures to minimise risks had not been safely managed. Staff confided there were times when it had been hard to reach the registered manager and they felt isolated in dealing with situations without appropriate guidance being given.
There were people who at times expressed their frustrations and anxiety using behaviours which staff found difficult to manage. Approaches from staff were not always consistent and documentation in place lacked guidance and mitigation of the risks.
Risks in the home had not always been safely managed or action taken to prevent harm in a timely manner. We found serious fire safety concerns at Glanmor that potentially risked the safe evacuation of people and unsuitable measures in place to manage a fire. Following our inspection, we made an immediate referral to the Fire safety team who have since been out and inspected this service.
Medicine systems did not protect people from potential harm. There were inconsistencies between the records of medicines returned for disposal and records of medicines administered.
Measures to prevent and reduce the risk of infection control had not always been taken. Parts of the home were not clean and in need of maintenance and repair.
Staffing levels in the home were not reflective of the level of needs people had. Staff consistently raised their concerns about staffing levels and we saw during our inspection one staff was left to manage for several hours.
We observed the training matrix and saw there were gaps across training subjects that staff had not completed or refreshed their training. The registered manager of the service had also not refreshed their own practice within the designated timeframes. Staff had not received regular supervisions.
We found that there were inequalities in the way people were treated around the issue of smoking within the service. This had impacted negatively on some people who were being discriminated against.
Each person had a care plan in place, however we saw that these were not always person centred and were focused from the staff’s perception. There was often a lack of guidance on how staff were to support people.
We have concerns about the provider and management team at this service to meet the requirements of the regulations placing people at risk of receiving inappropriate and unsafe care
Prior to this inspection the provider failed to notify us of two serious injury incidents to a person in the service. At this inspection we found a further incident of physical abuse had not been made to The Care Quality Commission. This had not been picked up through the provider’s quality monitoring of the service.
Quality monitoring at the service was not robust. Effective monitoring or regular quality checks had not been completed by the management team in order to identify shortfalls and take timely action to protect people from receiving unsafe care.
You can see what action we told the provider to take at the back of the full version of the report. We are taking further action in relation to this provider and 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.