Archived: Stadium Court Care Home

Updated 22 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We undertook an unannounced inspection of Stadium Court on 19, 20 and 21 September 2017. Our inspection team consisted of five inspectors, a medicines inspector and two experts by experience. An expert by experience is a person who has personal experience of using, or caring for someone who uses this type of service.

We checked the information we held about the service and provider. This included the notifications that the provider had sent to us about incidents at the service and information we had received from the public. At the time of our inspection, the service was under a large scale safeguarding enquiry (LSE) led by the local authority. This was due to a number of on-going safety concerns. We used feedback from LSE meetings, the public and the notifications we had received from the provider to formulate our inspection plan.

We spoke with 23 people who used the service, 12 people who visited relatives at the service and two visiting health care professionals. We did this to gain people’s views about the care and to check that standards of care were being met. We also spoke with staff who worked at the service to gain their feedback about the care and to check they knew how to keep people safe and meet people’s needs. We spoke with 19 members of care staff, seven nurses, three unit managers, the home manager and members of the provider’s service recovery team.

We spent time observing how people received care and support in communal areas and we looked at the care records of 28 people to check they were accurate and up to date. We also looked at records relating to the management of the service. These included staff files, rotas and quality assurance records.

During our inspection, we shared our concerns about safety at this service with the local authority and local Clinical Commissioning Group. We also made a number of safeguarding referrals to the local safeguarding team and shared our fire safety concerns with the fire service.

Updated 22 November 2017

We carried out an unannounced inspection of this service on 19, 20 and 21 September 2017. At our previous inspection in December 2016 we identified a number of Regulatory breaches and we told the provider that immediate improvements were needed to ensure people consistently received care that was safe, effective, caring, responsive and well-led. The service was rated as ‘inadequate’ and was placed into ‘special measures’. We also placed a condition onto the provider’s registration that prevented them from admitting new people to the service. We then re-inspected the service in April 2017. At that inspection, we identified that some improvements had been made. However, we also identified two continued Regulatory breaches. We warned the provider that they needed to become compliant with these regulations by 31 July 2017 and the condition preventing new admissions to the service remained in place. The service remained inadequate in the Well-led domain; therefore the service remained under special measures. You can read the reports from our previous inspections, by selecting the 'all reports' link for Stadium Court Care Home on our website at www.cqc.org.uk.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service is registered to provide accommodation and personal care for up to 168 people. At the time of this inspection, care was delivered to people across four separate units. These units were named; Spode, Stafford, Wade and Wedgwood. Spode, Stafford and Wade units provided long term care to people and Wedgwood unit provided short term care and rehabilitation. People who used the service may have a physical disability and/or mental health needs, such as dementia. At the time of our inspection 116 people were using the service.

At this inspection, we found that the required improvements had not been made and we identified new and continued Regulatory breaches. The service has been rated as ‘inadequate’ overall and will remain in special measures.

The home did not have a registered manager. However, the newly appointed home manager had applied to be registered with us and their application was being assessed at the time of 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 and associated Regulations about how the service is run.

At this inspection, we found that the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not always being identified and addressed by the manager or provider.

Risks to people’s health, safety and wellbeing were not consistently identified and managed and people did not always receive their care in accordance with their care plans. Medicines were not managed safely.

Staff were not always effectively deployed to consistently meet people’s needs in a safe and timely manner. Staff, in particular agency staff did not always know people’s individual needs and care preferences in order to provide safe and responsive care and support.

Incidents of potential abuse and neglect were not always recorded and reported in line with local and national guidance. This meant people were not always protected from the risk of abuse and neglect.

Staff received some training to help them support people. However, there were significant training gaps that left people at risk of receiving poor, unsafe care.

People were supported to access health and social care professionals in response to changes in their health and wellbeing needs. However, advice from professionals was not always followed in a timely manner to promote people’s health, safety and wellbeing.

People’s capacity to consent to their care was not always assessed and we could not always see that the requirements of the Mental Capacity Act 2005 were followed when people were unable to consent to their care. Some people had restrictions placed upon them that had not been assessed and planned for to ensure their rights were protected. We saw that restrictions placed on people were not always requested through the Deprivation of Liberty Safeguards (DoLS) when people could not consent to their care.

People were not always involved in the assessment and planning of their care. This meant people sometimes received care that did not meet their care preferences.

Staff did not always provide care and support in a manner that promoted people’s dignity. People were not always supported to make choices about their care.

Social and leisure based activities were promoted. However, some people felt these did not always meet their individual needs.

Written complaints were managed in accordance with the provider’s policy. However, effective systems were not in place to ensure verbal complaints were consistently recorded and acted upon to improve people’s care experiences.

Safe recruitments systems were in place. However, improvements were needed to ensure the provider could assure people that agency staff were suitable to work at the service.

People were provided with food and drink. However, staff did not always support people to make informed meal choices.

People’s right to privacy was promoted.