Archived: Royal Bay Residential Home

Updated 2 May 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) 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 Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on the 12 March 2019.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question of Safe and Well-led to at least good. The provider told us they would implement robust systems to safely monitor and respond to the risk of falls for people. At this inspection this had not happened. The provider also informed us they intended to ensure that medication errors did not occur. At this inspection this had not been addressed safely for people.

This focused inspection was prompted by information of concern regarding incidents of serious harm to people that had been raised to us by social services and health professionals. At least three of these incidents are subject to an investigation by CQC and as a result this inspection did not examine the specific circumstances of these incidents. The information shared with CQC about the incidents indicated potential concerns about the management of risk in relation to falls. This inspection examined those risks.

The information shared with CQC about incidents showed potential serious concerns about the management of risk of falls, scalding, hydration, unsafe moving and handling techniques. Concern was expressed about delays in reporting and seeking medical assistance for serious injuries to healthcare professionals. We looked at these concerns in detail during the inspection.

Inspection team:

The inspection was carried out by three Inspectors, and an Expert by Experience [ExE]. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The ExE had expertise in supporting older people living with dementia who used regulated services.

Service and service type:

Royal Bay Residential Home is a care home. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home had appointed a new manager since our last inspection. They started their role as manager in July 2018. They were not registered with the Care Quality Commission. This means that the provider remained legally responsible for how the service is run and for the quality and safety of the care provided. The home has without a registered manager since December 2017.

Notice of inspection:

The inspection was unannounced.

What we did:

The provider had not been asked for a Provider Information Return [PIR] because we had undertaken the inspection at short notice due to concerns for people’s safety.

During the inspection process we spoke with 11 people, three people’s representatives and reviewed:

• Statutory Notifications we received from the provider

• Ten people's care records and wound records for all that had been documented. We reviewed a total of 31 injuries and incidents for people between 24 October 2018 and 9 March 2019

• Six people’s medicines records

• Three staff members’ recruitment records

• Staff training plan for all staff

• Records of accidents, incidents, complaints and compliments

• Audits and quality assurance reports

• We observed activities and the lunch time meal experience for people

• Observed the care of people using the service and spoke with one person’s visiting relative

• We spoke with two members of care staff, two senior carers, the manager, the deputy manager, the administrator, the clinical director, the communications director

• We spoke with West Sussex County Council's [WSCC] social services social worker

Updated 2 May 2019

About the service:

Royal Bay residential home is a care home registered to provide residential care for up to 42 people. There were 33 people living at the service at the time of the inspection. People who lived at the home included people who lived with complex needs including disabilities and long-term conditions such as dementia, sensory loss, Parkinson’s disease, diabetes and Chronic Obstructive Pulmonary Disease [COPD]. COPD is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, and non-reversible asthma. We were told that two people were receiving end of life care.

People’s experience of using this service:

Some people did not always receive safe care or treatment at the home. People were at continued risk of serious harm and injuries.

Some people did not always receive access to healthcare services in a timely way which meant they were left with significant injuries, pain and serious deteriorating health conditions with avoidable delays to receiving appropriate intervention and treatment. Staff were not suitably skilled or knowledgeable and did not recognise serious deterioration in people's health. This placed people at significant risk of harm, injury and deterioration in their health conditions without timely urgent care or treatment from appropriate professionals. Serious incidents and concerns were not always recognised, investigated or reported under safeguarding guidelines by the management or the provider, so the relevant agencies were not aware and could not take action.

Lessons were not learnt from serious incidents and practices were not changed to mitigate risks of further harm to people. Following the last inspection, the provider sent us an action plan to tell us how they would ensure people were safeguarded from the risk of falls. At this inspection people continued not to be safeguarded from the risks of falls and serious injury. Staff did not follow moving and handling best practice techniques which placed people at risk of harm.

Medicines were not always managed safely which placed people at risk of harm. Staff were not always skilled or suitably trained to understand the effects of the medicines given to people. Staff did not use systems to help them identify when people may be in pain if they could not tell staff this, as some people were living with dementia.' We could not be assured that there were sufficient numbers of suitably skilled staff to give people their medicines when they needed it and when it was prescribed.

The risk posed by some people’s medical conditions were not always managed effectively, such a diabetes. Some people were at significant risk of dehydration. One person was admitted to hospital due to signs of being unwell and on admittance was diagnosed as being severely dehydrated.

Where some people had been assessed as significantly underweight this was not managed safely to reduce further unexplained weight loss.

There was not always sufficient competent staff with the right skills and knowledge to support peoples complex needs safely and with dignity and respect.

Call bell records showed and people told us that not all calls for assistance had been responded to by staff. The manager confirmed that the some calls for a person had been ‘reset’ without staff attending to them at the time, this had left a person feeling ‘frightened’.

There was a negative culture which meant that staff were afraid to challenge practices and a lack of managerial and provider oversight where opportunities to identify themes from incidents were missed to help prevent possible further injury.

Candour was not culturally evident throughout the staffing, management and provider levels. The manager told us, “I'm not going to lie and cover up anymore.”

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the home did not support this practice.

There were systemic failings across the home that meant people did not always receive safe care or treatment. As a result, we asked the provider to take urgent action to make people safe. We made urgent safeguarding referrals to the local authority and to the police regarding the serious concerns we had about people’s immediate safety.

Rating at last inspection:

At our last inspection on 27 February 2018 [Published 29 June 2018] we rated the service as ‘Requires improvement.’ At this focused inspection the service was rated as ‘Inadequate.’

Why we inspected:

This focused inspection was undertaken due to information of risk and concern about serious injury and recurrent reports of people falling at the home that had not been reported to us. We had identified and been told by health and social care professionals of concerns about the management and leadership of the home.

Enforcement:

We have taken urgent action to safeguard people from the risk of harm. 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:

For more details, please see the full report which is on the CQC website at www.cqc.org.uk