Archived: Kilmory

Updated 31 March 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 was planned to check 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.

The inspection took place on 17 November 2014 and was unannounced. This meant the staff and provider did not know we would be visiting. This inspection was in response to concerns about the service that had been brought to our attention. These concerns related to medicines and staffing. The inspection team consisted of two inspectors and a pharmacist.

Prior to the visit we spoke with commissioners who commissioned services for two people and two people’s social workers. We examined previous inspection reports and notifications we had received. A notification is information about important events which the provider is required to tell us about by law.

During the visit we reviewed records which included support guidelines for each person living at Kilmory, three staff recruitment records, staff supervision records and records relating to the management of the service. Following the inspection we asked the provider to send us further evidence of the recruitment checks that had taken place in relation to permanent and agency staff and audits of the service. The provider was not able to provide all of the information we requested because it was not available.

People were not able to verbally share with us their experiences of life at the service. This was because of their complex needs. We therefore spent time observing care staff interactions with people and care provided. 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.

During the inspection we spoke with one person’s relative, one support worker, the interim manager, the operations manager and the operations director. Following the inspection we spoke with another person’s relative, another commissioner of the service and a person’s Independent Mental Capacity Advocate (IMCA). The role of the IMCA is to help particularly vulnerable people who lack the capacity to make important decisions about serious medical treatment and changes of accommodation, and who have no family or friends that it would be appropriate to consult about those decisions. We also spoke with three support workers and the new interim manager who took over the service two days after our inspection.

Updated 31 March 2015

This inspection took place on 17 November 2014 and was unannounced. The inspection took place in response to concerns that had been brought to our attention in relation to medicines and staffing.

Kilmory provides residential care for up to six people who have a severe learning disability and who may also experience a physical disability. People who live at Kilmory may present with behaviours that challenge staff. There were four people living at the service when we inspected. The service has locked external doors and people are not free to leave on their own. People have their own bedrooms and access to shared communal facilities.

At our previous inspection on 03 June 2014 the provider was not meeting the requirements of the law in relation to care and welfare, safeguarding people from abuse, supporting workers or assessing and monitoring the quality of service provision. Following the inspection the provider sent us an action plan to tell us they would make improvements by 15 August 2014. During this inspection we looked to see if improvements had been made to meet the relevant requirements and found not all of the required improvements had been made.

The service has not had a registered manager since 7 June 2014. 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 and associated Regulations about how the service is run.

The service was not safe as permanent staff had left since our previous inspection and the service had six staff vacancies. There were insufficient numbers of staff who were sufficiently experienced in working with people living at Kilmory to provide people’s care safely, resulting in the high use of agency and bank staff. There were insufficient numbers of senior support workers. Staff were working excessive hours to provide people’s care. Not all staff were familiar with how people usually appeared and staff had failed to notice the signs that a person had experienced an injury.

The required staff pre-employment checks had not been fully completed for all staff. This placed people at risk of receiving care from staff who had not undergone relevant checks on their suitability to work with vulnerable people. Staffing of the service had impacted negatively on people’s experience of the care provided to them.

People had detailed support plans in place that provided staff with guidance about how to meet people’s needs and manage risks to them but not all staff had read them. People’s care was not always provided by staff who were familiar with how to manage potential risks to them.

Medicines had not always been requested, obtained or stored safely. Controlled medicines had not been stored correctly. People had clear guidelines in relation to their medicines administration but staff had not always read them which placed people at risk of harm.

Staff had not received the training they needed in order to enable them to support people effectively. There were insufficient staff who had been medicine administration trained and who were competent to meet people’s needs safely. Staff had not received supervision recently or had an appraisal of their work. People were not supported by staff who were adequately trained or supervised.

The bathrooms did not meet all people’s needs who had a physical disability. Action had not been taken in relation to the broken lift. People with a disability may not have been able to access the upstairs bathrooms in an emergency.

Staff were not consistently responsive to people’s communications. Insufficient numbers of suitably qualified, skilled and experienced staff and a reliance on staff new to their roles had resulted in inconsistent care and support for people. Not all staff had worked with people at Kilmory long enough to understand their triggers for behaviours that may challenge staff. Some staff were anxious about working with people.

Staff did not always identify signs of people’s distress or react promptly. Staff had clear guidelines to enable them to interact with people but did not always follow them. People did not always receive the care they needed as described in their guidelines.

Some actions from the previous inspection had been completed but there continued to be a lack of evidence to demonstrate how people’s social care needs were met.

People did not always receive the care needed in relation to personal hygiene, as people did not like receiving care from unfamiliar staff. People’s care was not always focused on them as individuals. They were not always able to spend their time as they wished due to staff shortages.

People’s representatives did not feel confident that complaints were listened to adequately or resolved to their satisfaction.

People’s care was negatively impacted upon by the lack of consistent management of the service. The provider had not ensured continuity for people, by keeping the interim manager in post, until a new permanent manager was appointed. They had notified us in June 2014 they planned to do so.

There had been a consistent failure to ensure people’s social care needs were met. Although this issue had been identified internally in January 2014 and in our June 2014 inspection. Audits had been completed but the outcomes did not reflect the quality of care we found at this inspection.

People had been placed at risk as the provider had failed to act upon a report they had received on the safety of the lift in October 2013. A person experienced an accident using the lift.

The provider had taken action to assess whether people were being deprived of their liberty. Relevant applications had been submitted and were being processed. Where people lacked the capacity to make decisions best interest decisions had been made.

People had received adequate support to ensure their nutritional needs were met. People had been supported to attend hospital appointments and had seen a variety of health professionals.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.