Background to this inspection
Updated
7 March 2018
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 met 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 under the Care Act 2014.
This inspection took place on 26 October and 01 November 2017 and was unannounced. The inspection was carried out by one inspector.
Prior to the inspection we reviewed information we held about the service including statutory notifications that had been submitted. Statutory notifications include information about important events which the provider is required to send us. Prior to the inspection we also reviewed information received from the local authorities commissioning and safeguarding teams.
During the inspection we observed how staff offered support to people who used the service. We spoke with three people and one person’s relative, and four staff members. We also spoke with the registered manager and the provider.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed care records relating to four people who used the service and other documents central to people’s health and well-being. These included staff training records, medication records and quality audits.
Updated
7 March 2018
Elizabeth House is a purpose built care home and is registered to provide accommodation and personal care for up 60 older people some of whom live with dementia. At the time of our inspection 57 people were living at the home.
The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.
The inspection took place on 26 October and 01 November 2017. This inspection was in response to concerns we received from the local authority regarding unsafe care practises and a lack of managerial oversight in the home. This inspection focused on the Alexandra Unit which provides care to people living with dementia, as feedback suggested this was the area of the home where the concerns were identified by the local authority..
The inspector arrived on the morning of 26 October 2017 to inspect the service unannounced. On 01 November 2017 we met with the provider to seek assurances due to the nature of the concerns identified at this inspection. We have also referred our findings to the local authority commissioning and safeguarding team.
At our previous inspection on 09 February 2016 we found that people's medicines were not always managed safely, however, we rated the service overall good and asked the provider to make improvements in this area. At this inspection we found that improvements had been made in relation to management of medicines, however we found that the service was not meeting the standards in relation to providing safe care and effective management and governance.
People told us they felt safe, however we found that people who required positioning to maintain their skin integrity did not receive this as required. Risks to people’s safety and welfare were not consistently identified and responded to. Where people were at risk of harm, or had experienced harm these incidents were not consistently reported to local safeguarding authorities or investigated by management. People’s medicines were managed well and they received their medicines as the prescriber intended.
People did not consistently receive care that was well led and robustly monitored. People’s personal care records were not regularly reviewed, completed or updated when required. Audits of people’s care records were not effectively reviewed to ensure actions were completed, and notifiable incidents were not consistently reported to CQC when required. Staff felt that the manager was not visible around the home and we found that leadership in the home was not sufficiently proactive to keep people safe. Notification that were required to be submitted to CQC regarding significant events had not been made.