This inspection took place on 26 and 28 September, 2 and 11 October 2017. The visit on the 26 September was unannounced. This meant that the provider and staff did not know we would be visiting. Subsequent visits were announced. Blackwell Vale Care Home is a 51-bed home providing residential, nursing and dementia care. There were 49 people living at the home at the time of the inspection.
A registered manager was in post and our records showed she had been registered with the Care Quality Commission [CQC] since 2010. A registered manager is a person who has registered with CQC 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.
We found concerns with the safety and security of the premises. We accessed the top floor of the building via an open fire door early in the morning. We also found a number of hazardous items and equipment that were accessible to people throughout the home, including those living with dementia.
Infection control was poor and we found dirty bedding and equipment which was so heavily contaminated it had to be cleaned or discarded during our inspection. Bathrooms and toilets were not fit for purpose. A number were used as storage, or were damaged and unable to be used. Toilets were positioned on raised plinths which were damaged, unsightly and were not impermeable to urine meaning they could not be effectively cleaned. Some posed a risk to people due to sharp edges.
Personal Emergency Evacuation Plans (PEEPS) were in place for people who had died, and a number were missing for people that had moved into the home. These were updated during our inspection. Individual risks to people were assessed, but care plans developed to mitigate risks were not always followed; in relation to choking for example.
We found medicines were not safely managed. Records were not accurately maintained and we found a medicine error following a review of stock levels. Guidance was not fully in place to describe how medicines given as and when required should be administered. Prescribed medicines were not always made available to people in a timely manner. The registered manager carried out a full audit of all medicines following the concerns we raised and found some further discrepancies which they put plans in place to correct.
Records did not support that staff had received the training they required to carry out their role safely. Nursing competency and clinical training records were not up to date and could not evidence that nursing skills were being maintained and monitored. It was difficult to ascertain from training records, the percentages of staff that had received up to date training. Staff told us they received regular supervision and that they felt well supported.
Sufficient numbers of suitably qualified staff were not always deployed effectively in the home. The provider was having difficulty in covering shifts due to staff absence at short notice particularly at the weekends.
CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes.
People were not always supported to have choice and control of their lives. Records did not demonstrate that staff supported them in the least restrictive way possible and contained conflicting information. The policies and systems in the service did not always support this practice.
There were complaints about the quality and variety of food provided and meetings were taking place to address this at the time of the inspection. We found kitchen staff had not been trained in the preparation of special meals including pureed diets, and meals were provided which contained lumps and posed a choking risk to people. Training was provided soon after we raised this concern.
We observed care that was kind and considerate and most people and relatives we spoke with told us they were happy with the care provided. We were told, and observed documentation that demonstrated, there had been a prolonged period of staff unrest on the upstairs Nightingale and Chadwick dementia care units. This had resulted in staff refusing to work with others and even sickness and stress. We were advised that this did not impact upon people who used the service but we judged that although this behaviour was caused by a small number of staff, the impact was widespread and affected the smooth operation of the service.
A complaints procedure was in place and we found a number of complaints had been made including relating to the manner and attitude of staff. These had not all been thoroughly investigated and we referred some of these complaints to the local authority safeguarding adults team. Following our inspection the senior management team reviewed all complaints and in some cases took action to look into individual concerns in more detail.
Care plans were in place for each person but the information in plans varied in quality and detail. Some care plans were detailed and person centred, others contained inaccurate information and did not reflect care as it was being delivered at the time of the inspection. Others contained contradictory information so it was difficult to ascertain which was the correct version.
A range of activities were available and we observed group and individual activities. There were mixed views about the range available to ensure people had opportunities to engage in meaningful activities of their choice and to go outside. We were told by some people however, that activities had improved of late. Staff had worked hard to create areas of interest in the home such as a garden room. A sensory room was also available.
An effective system was not in place to monitor the quality and safety of the service and records for not all up to date and accurately maintained. The registered manager and provider had not picked up all of the concerns we identified during this inspection.
Following the inspection, we wrote to the provider to request a detailed improvement plan which stated what action they had taken or planned to take to address the concerns and shortfalls identified during the inspection.
We referred all of our concerns about the service to Cumbria County Council and following our inspection, the local authority had placed the home into 'organisational safeguarding'. This meant that the local authority was monitoring the home closely.
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 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.
We found six breaches of the Health and Social Care Act 2008. These related to safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, receiving and acting on complaints, good governance and staffing.
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.