Archived: Sister Dora Nursing Home

Updated 17 February 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.

The inspection took place on 25 November 2016 and was unannounced.

The inspection team consisted of two inspectors.

We looked at the notifications that we had received from the provider about events that had happened at the service. A notification is information about important events which the provider is required to send us by law. We reviewed the information we received from other agencies that had an interest in the service, such as the local authority and commissioners.

We spoke with eight people who used the service; they were able to tell us their experiences with the service. We spoke with all other people who used the service, however due to their communication needs they were unable to provide us with detailed information about their care. We observed people’s care in the communal areas and visited people who were in their bedrooms at intervals during the day.

We spoke with four relatives of people who used the service to gain feedback about the quality of care. We spoke with the registered manager, the regional director, the nurse on duty, one senior care staff, four care staff, the activities coordinator and members of the ancillary team. We looked at eight people’s care records, staff rosters, two staff recruitment files and the quality monitoring audits. We did this to gain people’s views about the care and to check that standards of care were being met.

After the inspection we shared safety concerns with the local authority because we had significant concerns about people's health, safety and wellbeing.

Updated 17 February 2017

This inspection took place on 25 November 2016 and was unannounced. We found that people were not provided with safe care and treatment they were not supported to consent to their care, treatment and support, there were insufficient staff to keep people safe and the service was not well led. We identified numerous Regulatory breaches.

The overall rating for this service is Inadequate and we are now considering the appropriate regulatory response to the problems we found. 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.

Sister Dora Nursing Home provides support and care for up to 47 people, some of whom may be living with dementia. At the time of this inspection 33 people used the service.

The service had 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.

Risks to people's health, safety and wellbeing were not consistently identified, managed and reviewed and people did not receive their planned care. Staff did not follow people's management plans or instructions from health care professionals to ensure people's risks were reduced. This had a major impact on people's well being and they were at high risk of receiving inappropriate care that did not meet their needs and reflect their preferences.

Medicines were not managed safely. People did not receive their medications as prescribed, at the time they were due or in a safe way. As a consequence people were at a high risk of receiving inappropriate care and treatment which would significantly reduce their quality of life.

People were not always protected from the risk of abuse. People sustained injuries, some unexplained and some caused by staff working practices, which had not been analysed effectively, which meant the risk of further incidents was not reduced. Incidents of suspected abuse were not reported or investigated. People were at high risk of harm because no action was taken to mitigate the identified risks.

There were not enough suitably skilled staff available to keep people safe and meet people's individual care needs. There was a lack of leadership, the nurses and senior staff were not in sufficient numbers to supervise, monitor and guide staff to ensure good care and support was provided. Staff did not always have the knowledge and skills required to meet people's individual care needs and keep people safe. As a consequence people were at a high risk of unsafe and inappropriate care because there were not sufficient suitable skilled and competent staff available. This had a major impact on ensuring people were safe and their health and well being was assured.

People's health and nutritional needs were not consistently monitored and managed effectively to promote their health, safety and wellbeing. People were at high risk of deteriorating ill health, malnutrition and dehydration because their care and support needs were not well managed or monitored.

The requirements of the Mental Capacity Act 2005 were not always followed to ensure decisions were made in people's best interests when they were unable to do this for themselves. People were being unlawfully restrained and restricted, care and treatment was provided against their will. Staff did not always show they respected and understood people's rights to make choices about their care.

Complaints were not acted upon to reduce the risk of the complaint arising again. The provider did not have effective systems in place to assess, monitor and improve the quality of care. People who used the service were placed at extreme risk of harm and actual harm because the service was not safe, effective or responsive to their individual care and support needs and not well led.

We found numerous breaches of the Regulations of The Health and Social Care Act 2008 (Regulated Activities) 2014 and issued an urgent notice of decision to suspend all new admissions into the service until we had the assurance that people who used the service were safe and the risks to peoples' health and well being was reduced.