Archived: Harry Sotnick House

Updated 4 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 had made the improvements required following our inspection in September 2016 and 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.

Two inspectors, a pharmacist specialist and an expert by experience completed this unannounced responsive comprehensive inspection on 3, 4 and 5 October 2017. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before our inspection we reviewed the information we held about the home and information of concern we had received from health and social care professionals and the local authority. We looked at previous inspection reports, various action plans and service improvement plans the registered provider had sent to us since the last inspection. We also reviewed notifications of incidents. A notification is information about important events which the service is required to send us by law.

We spoke with four people and seven relatives to gain their views of the home. Some people who lived at the home were not able to talk with us about the care they received, so we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to understand the experience of people who could not talk with us. We observed care and support being delivered by staff and their interactions with people in communal areas of the home.

We spoke with the registered manager, the regional director and regional manager for the registered provider. We spoke with the deputy manager, a regional clinical lead and clinical lead as well as three registered nurses, a team leader, four members of care staff, a member of catering staff and an activities coordinator.

We looked at the care plans and associated records for 14 people and the medicine administration records for 19 people. We looked at a range of records relating to the management of the service including records of; accidents and incidents, quality assurance documents, five staff recruitment files and policies and procedures.

We received feedback from four health and social care professionals who supported some of the people who lived at the home.

Updated 4 November 2017

We carried out this unannounced urgent inspection of the home on 3, 4 and 5 October 2017. The inspection was prompted in part by notification of two incidents which had occurred in the home. Following the first of these incidents a person who lived at the home died. This incident is subject to further investigation and as such this inspection did not examine the circumstances of this event.

However, the information shared with CQC about the incident indicated potential concerns about the management of risks associated with; a failure to follow professional guidance adequately, the safe monitoring of people’s hydration and nutrition needs, the administration of medicines and the changing needs of people as they move towards end of life care. A second incident reported to CQC did not involve a person who lived at the home; however this raised serious concerns about the risks associated with the management of medicines in the home. All of these identified risks have been examined in this inspection.

The registered provider has an extensive history of non-compliance with the required regulations in this home. You can see the reports which have been published about our inspection program at this home on www.cqc.org.uk .

In December 2016 the home was rated as Inadequate and placed into special measures by the Commission. Two separate conditions were imposed on the registered provider’s registration for this home which required the registered provider to provide information to the commission on a fortnightly basis showing the actions they were taking to comply with all the required Regulations and provide information on the number of agency staff working in the home.

This home was last inspected in May 2017 where we found the home to be compliant with all the Regulations and was fulfilling the requirements of these conditions. However, further work was required to embed good practices in the home. The home was moved out of special measures although the two conditions imposed on the registered provider’s registration of this home remained in place. The registered provider applied to have these conditions removed from their registration on 14 July 2017; however they remained in place at the time of this inspection.

At this inspection we have identified four breaches of the Health and Social Act 2008 (regulated Activities) Regulations 2014.

The overall rating for this provider 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.

¿ Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

The home provides accommodation, nursing and personal care for up to 92 older people, most of whom live with dementia. Accommodation is arranged over two floors with stair and lift access to all areas. A third floor provides staff facilities. At the time of our inspection 70 people lived at the home.

A registered manager was in post. 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.

Medicines were not always managed in a safe and effective manner to ensure the safety and welfare of people. Medicines errors had not always been identified or investigated and learned from.

We identified a number of incidents in the home during our inspection relating to the poor clinical knowledge and understanding of registered nurses.

There was a lack of good clinical leadership in the home. Nursing staff did not always demonstrate a good understanding of their roles and responsibilities. Where clinical errors had been made learning from these was not always recognised and shared in the service.

Whilst there were safe recruitment practices in the home, there were not always sufficient staff with suitable skills, knowledge and experience deployed to meet the needs of people. There was a high dependency on the use of agency registered nurses in the home.

The risks associate with people’s changing clinical needs were not always assessed and actions taken to mitigate these in a timely way.

We saw there was confusion and misunderstanding about what constituted end of life care in the home; care plans in place and actions taken by staff were not always consistent and appropriate to ensure people received care which was in line with their needs and preferences at the end of their life.

People were cared for in a kind and compassionate way. Their plans of care were mostly person centred.

People were encouraged to interact with each other and participate in a wide variety of stimulating activities and events.

There was a system in place to allow people to express any concerns or complaints they may have, and people had the opportunity to express their views on the quality and effectiveness of the service provided at the home.

Where people could not consent to their care, staff sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

People received nutritious food in line with their needs and preferences. Food and fluid records were well maintained and people enjoyed the food they received.