This inspection took place on 17 October 2016 and was unannounced. A second day of inspection took place on 18 October 2016 and was announced. Donwell House provides care for up to 63 people some of whom have nursing needs and/or may be living with dementia. There are two wings at Donwell House; one wing is made up of two residential care units. The other wing has two nursing units.
At the time of the inspection there were 53 people using the service, many of whom were living with a dementia. 29 people had been assessed as needing nursing care.
We last inspected Donwell House on the 9, 10 and 14 March 2016 and found the provider had breached a number of regulations we inspected against. Specifically the provider had breached Regulations 7, 9, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered manager had failed to demonstrate the necessary competence, skills and experience to manage the carrying on of a regulated activity. The provider did not do everything that was reasonably practicable to make sure people using the service received personalised care and treatment that was appropriate, met their needs and reflected their preferences. Care and treatment was not provided in a safe way. Assessment planning and delivery of care was not based on appropriate risk assessment. Not everything was done to reasonably and practicably mitigate risks. Medicines were not managed in a proper and safe way. Policies and procedures were not followed appropriately. People were not being protected from neglect and improper treatment. Systems and processes were not established and operated effectively to prevent abuse, neglect and improper treatment of people. The nutrition and hydration needs of service users was not being met. A variety of nutritious, appetising food was not available to meet people’s needs. Up to date assessments for nutrition and hydration needs were not being followed. Systems and processes were not established and operated effectively to ensure compliance. Systems did not assess, monitor and improve the quality and safety of the service. They did not assess, monitor and mitigate risks. Accurate, complete and contemporaneous records of care and treatment were not maintained. Feedback was sought but not acted upon to improve quality. The provider did not ensure audit and governance systems were effective. Staff did not have appropriate training to enable them to carry out the duties they were employed to perform. Staff had not received regular appraisals of their performance.
During this inspection we found evidence of continued breaches of regulation. Specifically regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found the provider to be in breach of regulation 10. 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.
A registered manager was not registered with the Care Quality Commission at the time of the inspection. A manager was in post but they had only started the role on 3 October 2016.
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.
Premises safety was a concern. There were duplicate fire zones and room numbers within the building. The actions identified from a fire risk assessment completed in April 2016 had not been rectified, this included action in relation to an inadequate fire detection system and inadequate training for the evacuation of people. A service user evacuation register was out of date and the fire log book contained 29 personal emergency evacuation plans (PEEPs) when there were 53 people resident in the building.
Routine checks on fire and premises safety had not been completed in a regular and timely manner. At the time of the inspection there was no evidence of an in-date gas safety certificate or in date certificates of lifting operations and lifting equipment regulations (LOLER).
Risks had not always been identified and mitigated against. For example for people who had swallowing difficulties there had been no assessments completed in relation to the risk of choking. Where people could display behaviour that challenged others there was no assessment of risk.
Care records contained conflicting information, there were no specific and detailed strategies for staff to follow in relation to how to support people or how people wanted to be supported and care records had not been updated to reflect changes in people’s needs.
Decision specific mental capacity assessment and best interest decisions had not been completed for the use of potentially restrictive care practices such as bed rails and wheelchair lap belts. Where mental capacity assessments had been completed they were not decision specific, did not relate to restrictive practice and had been completed by either one nurse or one senior care staff member. The mental capacity act (2005) code of practice was not being followed.
Medicines were not managed in a safe way. There was conflicting information in care records about the form of people’s medicines, for example crushed medicines and liquid medicines. There was no evidence of mental capacity assessments, best interest decisions or specific care plans in relation to people whose GP had stated they could have medicines administered covertly. Protocols for the administration of ‘as and when required’ medicines were often not in place, and where they were in place they lacked specific detail to guide staff on when to administer the medicine.
A box of homely medicines were available in the treatment room, however the deputy manager told us they were not used.
The temperature of the treatment room often exceeded recommended guidelines which meant the effectiveness of some medicines may have been compromised.
Staffing levels were being maintained by the use of agency nurses and care staff. Staff had not received relevant training, supervision or appraisals to ensure they had the necessary skills and competence. There was no systematic approach to determining the number of staff and the range of skills staff needed to meet people’s needs and keep them safe.
There was limited engagement and interaction from some staff during mealtimes. We observed one person was supported by three different staff during one meal, another staff member was observed to be touching a person’s mouth with a spoonful of food prompting them to open their mouth whilst they were still eating.
Records in relation to the management of regulated activity, such as safeguarding’s, accidents, incidents and complaints were not available pre August 2016.
There was a continued failure to ensure an effective quality assurance and governance procedure was in place to monitor, assess and drive improvement in the quality of the service provided. An improvement plan completed by the provider had not identified the concerns noted throughout this inspection, even though it stated that some areas requiring improvement had been completed.
Some staff had warm and caring relationships with people and treated people in a kind, caring and sensitive way.
Staff were recruited appropriately and necessary background checks completed.
Some improvements had been made to nutrition and hydration; however food and fluid charts were not detailed and did not record the amount of food or fluid people needed to aim for each day. Nor did they detail the specific dietary needs of each person.
We saw people were supported to access health care professionals however there was not always evidence that information had been followed up on. For example, a GP who had been contacted about a person’s medicine management.
Activities coordinators were in post and there were various activities available for people.
Staff had confidence in the new manager to drive improvement. Staff felt listened to and supported and thought improvements were being made.
The overall rating for this service is ‘Inadequate’ and the service remains 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.