Archived: Lane End House

Updated 18 September 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is 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.

This inspection took place on 22 June 2015 and was unannounced.

The inspection team was made up of one inspector and a specialist advisor who had specialist knowledge in the care of frail older people, especially people living with dementia and those with end of life care needs.

Before the inspection, we examined previous inspection reports, action plans the provider had sent us, safeguarding meeting minutes, and other information we had received, along with notifications. A notification is information about important events which the provider is required to tell us about by law.

During the inspection we spent time talking to eight people, one health professional visiting the home, two members of staff, and the registered manager. We observed interactions between people and staff. Some people were not able to share their experiences of life at the home with us verbally so 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 looked at the staffing records of one new member of staff and records of service quality audits, including minutes of staff and resident meetings. We looked at the care records of seven people.

Following the inspection we requested information from health and social care professionals and GP’s who visit the home.

Updated 18 September 2015

This inspection was unannounced and took place on the 22 June 2015. Lane End House can accommodate up to 22 older people with a variety of long term conditions, including those living with dementia and physical disabilities. On the day of our inspection 13 people were living at the home.

The home has 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. In this home the registered manager is also the nominated individual of the registered provider.

There has been a history of non-compliance with the requirements of the law at this service since February 2014. At this time we issued three warning notices relating to care and welfare, infection control and quality assurance. In May and June 2014 inspections found non compliance remained with care and welfare. In November 2014 we inspected the service again and found non compliance was continuing, because we found risk assessments were not in place to prevent and protect people from injury, pain and harm. Care plans were not detailed enough to guide staff on how to meet individual needs. Medicine practices were not safe. The principles of the Mental Capacity Act 2005 (MCA) to ensure any decisions were made in the person’s best interests had not been applied. People’s independence had not always been promoted and people had not been involved in decisions regarding their care. Effective systems were not in place to ensure the quality of the service provided was good and incidents were learnt from. Staffing levels were not always planned to ensure they were adequate to meet the needs of people. As a result we issued the provider with a formal notice which prevented them from being able to admit any new person to the home. The provider sent us regular action plans detailing what action they were/had taken to reach compliance. The last action plan was received on 10 April 2015.

At this inspection 13 people were being accommodated. We found staffing levels had not been arranged to ensure the needs of people could be met at all times. We found not all areas of the home were clean. Staff were not competent regarding medicines administration practices. Appropriate checks had been carried out on staff before they worked in the home. Safeguarding policies and procedures were available and staff understood these.

We found staff had received training but the provider was not reviewing the training to ensure staff were putting their learning into effect. Staff did not demonstrate a basic understanding of the Mental Capacity Act. However, the provider had reviewed care plans and ensured the principles of the Act had been applied to people’s records.

We found staff were not always caring or respectful when supporting people. Where people needed support with their meals this was not always offered in a respectful and dignified manner. People’s privacy and dignity was not always promoted.

Care plans were person centred and had been developed with people and their relatives. Activities were offered but these tended to be larger group activities.

Quality assurance procedures in the home were not effective. It was not possible to establish an open culture existed within the home. The provider had failed to clearly display their previous rating given from the most recent inspection.

The overall rating for this provider is ‘Inadequate’. This means that the service is therefore in special measures. The service 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.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.