14 June 2018
During a routine inspection
Capesthorne House is an eight bedded 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is set back off a road in the centre of the local community within proximity to local shops and primary school.
The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.
The provider applied to the Commission to deregister the home in view of the risks we identified during this inspection. At this inspection we found an extreme level of risk impacting on the people living at the home with a likelihood of the risks continuing at that level due to the provider not mitigating risks effectively enough during this inspection. This meant there was a serious level of risk to a person’s life, health or well-being. The Commission are considering undertaking a criminal investigation into the serious incidents which had occurred. You can see what action we told the provider to take at the back of the full version of the report.
This location requires a registered manager to be in post. A registered manager was in post at the time of our inspection. 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.
On this inspection we found there were safeguarding procedures in place but they had not always been followed appropriately. Safeguarding concerns had not been reported to the appropriate authorities.
We found risks to people and others had not been managed effectively. There was an override button above five doors which were in reach of people. This meant that people with a deprivation of liberty safeguard authorisation in place to keep them safe from leaving the premises were put at risk of accessing the community unsupervised, when it was unsafe for them to do so. The provider had known about this but had not acted quickly to mitigate the risk. After we raised our concerns with the provider, they acted by installing a new more secure key system.
Staff told us about the different types of abuse and they understood how to report a safeguarding concern. However, not all safeguarding concerns which had occurred since the last inspection had been reported to the relevant safeguarding authority.
There was a system in place of recording incidents and accidents however, we found multiple incident forms which had not been analysed. We undertook a random check and found not all incidents had been recorded onto the provider’s electronic system. This meant not all incidents were being reported appropriately or analysed for trends or themes. The provider was not aware of all serious incidents which had occurred in the home.
People who were living at Capesthorne House had a support plan and risk assessment screen in place. We found they were either not detailed enough or had not been reviewed every time an incident had occurred. For example, a detailed specific risk assessment had not been devised for one person who self-harmed.
The design of the home and the environment were not suitable for people with highly complex behaviours which were challenging. The garden fence was adjacent to a busy road and residential housing. People’s privacy and dignity was not being upheld as onlookers were able to observe people in distress.
The system in place of ensuring all building maintenance repairs were undertaken was not robust enough. There were several repairs which had not being completed in a timely manner. This meant the environment was unkempt and did not uphold people’s dignity.
We checked the electronic systems of administering and storing prescribed medications at the location. We found some anomalies where the stock control numbers of prescribed medicines did not correspond with the number of prescribed medicines recorded as administered. This was due to errors where staff had not signed for a prescribed medicine when it was administered.
The staffing levels were not always meeting the needs of the people at the home. This was due to the number of serious incidents which staff were required to respond to. The provider had not ensured everyone living at the home had their one to one or two to one support at all times in accordance with their care plan.
We have made a recommendation about staff recruitment. The provider's recruitment systems included a disclosure barring service check. The risk assessment for a previous conviction was not robust.
Staff we spoke with told us about people’s care needs. They understood people’s individual behaviours but reported they did not always feel safe when dealing with people’s behaviours. We found entries in the records of staff being injured during an incident where a person living at the home went into crisis.
People who lived at Capesthorne House had a deprivation of liberty safeguard authorisation in place for care and treatment. We had concerns people’s choices were not always being adhered to.
Staff did not always provide people with person centred care. They were aware of people’s likes and dislikes. People were supported to go out into their community.
Whilst we observed staff during the inspection treating people with respect and dignity we found examples whereby this was not always consistent.
The governance arrangements of the home were not robust enough. The senior managers had not ensured there was enough oversight of the home to check on the quality and safety of the service. The registered manager was suspended from duties during our inspection pending an investigation.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.
Services in special measures 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. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.