Background to this inspection
Updated
4 October 2023
Why we inspected
This was a targeted inspection to follow up on concerns received regarding unsafe staffing levels and the management of the home.
Inspection team
This inspection was completed by 2 inspectors.
Service and service type
Keegan’s Court Residential Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Keegan’s Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection and had contact with the local authority. Local authorities together with other agencies may have responsibility for funding people who used the service and monitoring its quality.
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.
During the inspection
We spoke with 2 people about the support they received. Additionally, we spoke with 2 staff members including a carer and a cook. Following the inspection site visit we spoke on the phone with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We looked at documents relating to fire safety including the providers evacuation strategy.
Updated
4 October 2023
About the service
Keegan’s Court Residential Care Home is a care home providing support with personal care to 3 people at the time of this inspection. The home can accommodate a maximum of 19 older people. Accommodation is provided in an adapted building providing 15 beds in the main building and two bungalows, each providing 2 beds.
People’s experience of using this service and what we found
People were not safe from avoidable harm. Despite being aware of the lack of heating fuel, the provider had failed to purchase supplies resulting in the heating failing. This resulted in the physical temperature of the home reducing to an uncomfortable level increasing the risk of harm to people.
People were not protected from the risk of abuse or ill-treatment. The provider failed to act when concerns regarding staff members conduct were identified and passed to them. This put people at the risk of receiving inappropriate or potentially abusive behaviour.
People were not treated with dignity or respect. Confidential information was not secured and was accessible to those without authority. This information contained sensitive financial information and information regarding people’s health and welfare. People’s privacy could not be assured as communal toilet doors did not close or could not be locked.
The provider failed to ensure an effective fire management plan was in place, known, and followed by staff supporting people. This put people at the risk of harm in the event of an emergency. The provider failed to assess potential risks to people putting them at the risk of harm. The provider failed to ensure there were enough suitably qualified staff available to support people at all times.
People did not always receive their medicines safely or as prescribed. The provider failed to safely store medicines and failed to ensure medicines were administered in line with the guidance provided. The provider did not effectively analyse significant incidents to learn from them and to make changes to improve people’s safety. People were not effectively protected from the risk of infection as the provider did not have adequate infection prevention and control measures in place. There was visible dirt in areas of the home and on fixtures. The provider had failed to update or implement the latest infection prevention and control guidance. The provider failed to complete checks on visitors to ensure they did not pose a risk to people.
The provider did not have effective quality monitoring procedures in place to drive improvements in the care they provided. The management team did not have clearly defined roles and responsibilities. The provider failed to have effective contingency plans in place regarding the restructuring of their business.
The provider followed safe recruitment practices.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 19 August 2022).
At that inspection there were breaches of regulation regarding safe care and treatment, safeguarding people from abuse, dignity and how the location was managed.
Why we inspected
The inspection was prompted by concerns about the management of the location and to follow up on breaches identified at the last inspection. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence the provider needs to make improvements. Please see the safe, caring and well-led sections of this report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Keegan’s Court Residential Care Home on our website at www.cqc.org.uk
We have identified breaches in relation to keeping people safe, safeguarding people from abuse, staffing and overall governance.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’.
The provider has not made enough improvement and there is still a rating of inadequate for key questions safe and well led. We have commenced action in line with our enforcement procedures. This will mean we will continue with the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.