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Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Manton Heights Care Centre

Woodlands, off Manton Lane, Bedford, MK41 7LW

Tel: 01234267556

Date of Inspections: 01 October 201224 September 201223 September 201217 September 2012

Date of Publication: December 2012

We inspected the following standards in response to concerns that standards weren'tbeing met. This is what we found:

Care and welfare of people who use services Enforcement action taken

Meeting nutritional needs Enforcement action taken

Cooperating with other providers Action needed

Safeguarding people who use services from abuse

Enforcement action taken

Management of medicines Enforcement action taken

Safety, availability and suitability of equipment Action needed

Staffing Enforcement action taken

Records Enforcement action taken


Details about this location

Registered Provider Ranc Care Homes Limited

Overview of the service

Manton Heights Care Centre is a purpose built care home with accommodation on two floors. The home provides residential and nursing care for 79 older people. In addition there is a separate 12 bedded unit to accommodate adults with acquired brain injury. It is registered with the Care Quality Commission as a Care Home with Nursing.

Type of service Care home service with nursing

Regulated activities Accommodation for persons who require nursing or personalcare

Treatment of disease, disorder or injury


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 4

More information about the provider 5

Our judgements for each standard inspected:

Care and welfare of people who use services 6

Meeting nutritional needs 9

Cooperating with other providers 11

Safeguarding people who use services from abuse 13

Management of medicines 15

Safety, availability and suitability of equipment 17

Staffing 18

Records 20

Information primarily for the provider:

Action we have told the provider to take 22

Enforcement action we have taken 23

About CQC Inspections 26

How we define our judgements 27

Glossary of terms we use in this report 29

Contact us 31


Summary of this inspection

Why we carried out this inspection

We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, reviewed information sent to us by other organisations, carried out a visit on 17 September2012, 23 September 2012, 24 September 2012 and 1 October 2012 and observed how people were being cared for. We talked with people who represent the interests of people who use services, talked with people who use the service, talked with carers and / or family members and talked with staff. We talked with stakeholders.

What people told us and what we found

We visited Manton Heights over four days (17, 23 and 24 September, and also 1 October 2012) following serious concerns being received about the care provided to people and peoples' needs not being met. During our visits, a maximum of 28 people were living in thehome.

We identified serious concerns related to poor staffing levels, poor record keeping, chaotic mealtimes with people missing meals, long delays in call bells being answered, and long delays in the administration of medicines.

On 23 September, we spoke with many of the residents and their family members, all who said they were unhappy with the level of care they were receiving, due to the lack of staff on duty. People also told us they were concerned about the lack of knowledge staff had about their needs. Residents and relatives told us the staff were "kind and caring", but "there was not enough of them". People said that because many staff were agency staff and therefore not familiar with the home and residents, they did not have confidence in thestaffs' knowledge about peoples' care needs being understood and met.

Relatives told us they felt it necessary to visit regularly throughout the day to ensure their family member was appropriately washed, dressed and received meals, by providing most care themselves: we observed this during our visits.

You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 06 November 2012, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.


We have taken enforcement action against Manton Heights Care Centre to protect the health, safety and welfare of people using this service.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Care and welfare of people who use services Enforcement action taken

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement

The provider was not meeting this standard.

Due to the lack of care planning and access to care records, people did not experience care, treatment and support that met their needs and protected their rights.

We have judged that this has a major impact on people who use the service and have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.

Reasons for our judgement

During our visits to Manton Heights, we identified major concerns about the way in which care was being provided and managed and the impact that this was having for the people living in the home. We saw that people did not have accurate, accessible care plans for staff to provide appropriate planned care. Staff on duty said they did not know the person or know anything about their history or needs, and had no records to refer to or other staff to take direction from; they said they were doing their best in the circumstances but felt that people were left at risk and were vulnerable because of this practice.

We found that the staff on duty, including the regional and other senior managers and nurses in charge of the home, were not aware of peoples' individual needs and had failed to take information gathered prior to admission into account when planning and delivering care.

We spoke with a number of relatives who told us they had provided pre-admission information to the home, but this had not been responded to, retained, or communicated across the staff team. They also told us they had to continually repeat information to staff, which had caused them considerable anxiety.

A relative talked to us about their family member who was a known risk in relation to falls; this had been communicated to the home prior to admission and it was agreed that they would have a sensor mat in their bedroom from the point of admission. However this was not put in place for almost a week after admission and during this time they had at least three unobserved falls.

Individual care plans were not available for staff to use; we were told that these could be located on the electronic system. However staff, including the regional manager, were unable to access these. This meant that staff had no idea of individual routines, support


needs or specific care requirements; we considered this placed people at risk of receiving inappropriate or unsafe care.

We spoke with over 20 relatives during our inspection and most of them told us they did not have any confidence in their relative receiving the appropriate level of care required to meet their needs, and many of them were coming into the home to directly care for their relative themselves.

We spoke with staff, including the regional and senior managers covering the home, aboutwhich people had nursing needs, if people had wounds or dressing requirements, if peoplehad allergies or medical conditions, but no-one could provide this information. A number ofrelatives told us their family member had developed a wound or sore skin since their admission, which staff had been unaware of. We were told that people had not had dressings changed as required, with some people waiting over five days instead of every other day as per their preadmission notes. We were told by relatives and nursing staff that at times the dressing required to dress a wound was not available so an alternative was used or the wound was left unattended. The available records were unable to evidence how wound healing was being tracked and monitored. Care practices left people at increased risk of developing pressure sores; for example we observed people being left sitting in wheelchairs or in the same position in bed for long periods of time.

Despite assurance given by the provider to address these matters, during our inspection on 1 October 2012 and from feedback from commissioners on the 2 and 3 October 2012, itwas evident that staff were still unable to identify who had wounds or when these required a change of dressing. A tissue viability nurse had visited the home on 26 September 2012;they had assessed people with wound care needs, had identified the appropriate care regime and documented this in peoples' records, yet despite this, peoples' dressings had not been changed as prescribed.

We noted there had been a number of people who had suffered falls within the home, with 17 unobserved falls happening since the beginning of September 2012. We found that riskassessments for people at risk of falls were not in place and where this risk had been identified there was little evidence of action taken to manage this and reduce risk factors. We found that where a risk of falls had been identified, that staff failed to take appropriate action to manage this risk.

People told us that on admission their relatives had some mobility and needed support to maintain this. However they were continually placed into wheelchairs and not given the time to walk with staffs support. These matters were raised with the provider and despite assurances given, we found during our visit on 1 October 2012 that practice in this area remained unchanged; people continued to spend long periods of time in wheelchairs and without support to mobilise. Relatives and care staff continued to report that people spent long periods of time in bed, without help to change position or to attend to continence needs as there were insufficient staff to support them. This is unacceptable and has placed people at risk of deterioration.

Records and handover information highlighted that a person had suffered a seizure on 30 September 2012; however care staff on duty on the 1 October 2012 were unaware that this had happened. We reviewed this person's care records and there was no evidence of the person's condition being assessed or monitored prior to or following the seizure. There were no current seizure monitoring records in place, no assessment documentation on file,and no care or management plan for staff to follow to maintain this person's safety in the event of a seizure. It was a further concern when we noted that this individual was


prescribed antiepileptic medication to be given covertly, yet staff could not confirm the medication was correctly taken by the person.


Meeting nutritional needs Enforcement action taken

Food and drink should meet people's individual dietary needs

Our judgement


Due to inadequate staff, poor access to care plans, and poor monitoring processes in place at mealtimes, people were not protected from the risks of inadequate nutrition and dehydration.



We visited Manton Heights over four days (17, 23 and 24 September, and also 1 October 2012) following serious concerns being received about the care provided to people and peoples' needs not being met.

During our visits, we observed several mealtimes throughout the day. We saw people were often served food already plated without being offered a choice. We saw mealtimes were chaotic with staff not knowing who had received food or not. People were left in their rooms or seen wandering around, and on several occasions we saw people had not received their meal: staff had failed to be aware of this or monitor who had received food.On the 1 October 2012 staff assisted a person to prepare for a planned hospital appointment. They were dressed and made ready for the journey but no breakfast or drink was offered despite the fact that the hospital was some 40 miles away and the person would not be able to obtain a meal until much later in the day. We had to intervene and insist that the person received food and drink before the journey. Care staff were dismissive of the person's needs and failed to recognise that this action could be abusive through omissions in care.

We spoke with a number of residents and relatives who told us they were aware of occasions when people had missed meals without staff knowing and said they had "been forgotten". They said this had brought this to the attention of managers and staff, but were told this was not possible. However, one person told us they later observed a resident being given food after they had raised this.

People also told us that staff had said they were too busy to get people a drink of water when requested and during our visits we observed people asking for drinks and having to wait long periods of time before this was attended to; on some occasions we had to be prompt staff to attend to this aspect of peoples care.

We looked at the daily records for 14 out of 26 people and found some people had food and fluid monitoring charts. However, these were incomplete, not always dated, and staff


told us they did not know who required nutritional intake monitoring. We observed staff completing food and fluid charts retrospectively from memory and not able to accurately recall what food or fluids people had consumed; staff were unaware of the nutritional needs identified for people they were completing charts on, or the impact insufficient nutrition may have on people. Despite this issue being raised with the provider, we saw no improvement in practice. People therefore remained at risk of dehydration and malnutritiondue to inadequate processes in place, or being followed, for staff to monitor nutritional requirements.

We saw from the daily staff handover sheet that people with specific dietary needs were recorded; examples included diabetic and coeliac requirements. However, staff on duty were not aware of this information or peoples' individual dietary needs; care plans were notaccessible to provide this information.

Staff were unaware of peoples' likes or dislikes, or peoples' medical conditions which couldbe affected from foods they ate; examples included people with diabetes or allergies. We saw relatives had put prompts up in individual rooms to alert care staff to a known food allergy. However, this information had not been referred to or acted on, resulting in someone receiving food they were allergic to on more than one occasion.

Kitchen staff told us peoples' dietary needs were not always communicated with them in order for food to be appropriately prepared. We were told of people with diabetic needs and people requiring a soft diet which the kitchen staff had not been aware of. A relative told us that someone had been served crispy, chunky food which they were unable to eat due to needing a soft diet.

During our visits, we observed people who were not able to eat independently, being served food or drinks which were left in front of them without support being given. Relatives told us that food was often put in front of people who required assistance, but help was not provided. One person said a meal had been placed in front of their relative who was not able to feed themselves, but no help or support had been given: the relative said they later found the spilt soup down the side of the chair. Staff had failed to notice or attend to this, resulting in the persons missing their meal, but also being left in an uncomfortable position with wet, soiled clothing for a period of time.

We observed one person being assisted at breakfast time, and support being given to people at lunchtime. However, we observed a number of relatives visiting throughout the day and providing support to family members themselves; they told us they were not confident that their relative would receive sufficient food or drinks if they did not assist them directly. People also said it was unusual to see staff help people at mealtimes as there was usually not enough staff to do so.


Cooperating with other providers Action needed

People should get safe and coordinated care when they move between different services

Our judgement


Peoples' health, safety and welfare was not always protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider did not work consistently in co-operation with others.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.


During our visit on 23 September 2012, we spoke with the community nurse whose team provided nursing support and treatment for one person living in the home. We were told they experienced confusion between care staff within the home over the nursing roles and responsibilities for people, and poor communication regarding the needs of people.

We were told that access to information was often difficult, and the community nurses had recently found care staff had not followed the advice recorded in the person's care records about contacting the community nurses if any clinical issues arose. As such, we were told the person had been prescribed antibiotics by the doctor following an inaccurate, inappropriate diagnostic test being carried out by staff within the home.

We looked at the daily care records for 14 out of the 26 people living at the home and found one person had been transferred to hospital following a fall. However, we did not see evidence of detailed information related to this transfer and staff were not able to access any information given to the ambulance staff, if any, about the required information for transfer.

We spoke with a number of relatives during our visit who said they had provided key information to the home and staff about the needs of their family member, but had found these had not been taken into account or responded to. One example included a letter provided from a person's doctor which stated their wound dressing needed to be changed every two days. We were told by staff this letter could not be located and the relatives confirmed the dressing had not been changed for five days.

During our visit on 1 October 2012, we spoke with the relative of someone attending a planned hospital appointment that morning. We were told they had given the information tothe care staff previously but this had been lost, so staff had promised to contact the hospital to obtain the necessary information: however, we were told no attempt had been made by the staff to do this resulting in the person's relative arranging this.


We found that the provider did not have suitable arrangements in place to protect the welfare and safety of people when care was shared or transferred between services and other professionals.


Safeguarding people who use services from abuse Enforcement action taken

People should be protected from abuse and staff should respect their human rights

Our judgement


People who use the service were not protected from the risk of abuse because staff lackedknowledge about identifying the possibility of abuse and steps to prevent abuse from happening.



During our visit on 23 September 2012, we spoke with staff on duty about safeguarding vulnerable people. Staff did not have a good understanding or awareness of what constituted abuse or safeguarding concerns, and could not tell us how they would report such concerns.

We looked at the available daily care records for people living in the home and found a number of people had been 'found on the floor' following unobserved falls, some of whom had sustained injuries. We discussed this with staff on duty who were unaware of the number of falls, and did not consider this to be a cause for concern or a risk of abuse through neglect or omissions in care. We were shown a number of completed accident forms relating to falls, but through discussions with the regional and senior managers in charge of the home at that time, identified that no review of these records had been made; the regional manager was also unaware of the number of falls noted, and no processes were in place to address the identified issues.

We had received information just prior to our visit from the local authority about the number of medication errors which they had identified during their visit to the home on 20 September 2012; these had not been appropriately reported to the local authority under the safeguarding vulnerable adults' procedure (SOVA). Nursing staff, including the regionalmanager in charge of the home at the time, were unaware of these errors through a lack ofmonitoring processes in place, and when we spoke with them, they did not know these constituted a safeguarding concern which should have been reported. The local authority made the safeguarding alerts themselves.

On the 23 September 2012 we received information from peoples' relatives about concerns of poor care, basic hygiene needs not being carried out, and meals being missed, putting people at risk of neglect. We were told these had been raised with staff and the manager, but no actions had been taken to address these. During our visits, we did not see evidence of any concerns raised by people being recorded or how these would


be managed.

On the 23 September 2012 we found evidence of missed doses of medication and also doses being administered closely together, potentially putting people at risk of overdosing. We had also received information from the local authority about medication errors which they had been required to report under the SOVA procedures as the provider had failed to identify these and recognise the impact on peoples' safety. Following this inspection we were given assurances by the registered provider that prompt action would be taken to address these failings. On 1 October 2012 we found that medication errors continued and several people had not received vital medications including warfarin.

Despite actions taken by the provider to address safeguarding concerns with medication errors and non-compliance, these had been ineffective and people continued to be put at risk through omissions in care.


Management of medicines Enforcement action taken

People should be given the medicines they need when they need them, and in a safe way

Our judgement


People were not protected against the risks associated with medicines because the provider did not have appropriate processes in place to manage and administer medicines safely.



Just prior to our visit on 23 September 2012, we were alerted to concerns which had been raised anonymously, and also through information provided by the local authority, about poor management of medicines and risks to peoples' safety.

During our visits we observed long delays in people receiving their medicines due to the time taken to complete the medication rounds. We saw that the morning medication round was taking a long time to be completed and in some instances it took over four hours to complete. As a result, some peoples' medication doses were either missed or administered very close together, not in line with prescribing regimes and thereby putting people at risk.

We were told by several peoples' relatives that during their pre-admission assessment, people had been assessed as able to self-administer their medications. However, we weretold that on admission to the home, this practice had not been put in place and people were told they had to have their medicines administered by a member of staff, therefore reducing their independence.

During our visits, we identified serious concerns with the management of medicines and processes in place. We found the medication system chaotic and medicines were left in anunlocked, unattended storeroom potentially accessible to anyone entering.

We identified gaps in peoples' medication administration records (MAR charts) which nursing staff told us was often due to medications not being available. We discussed our concerns with the commissioners of this service and found that the home had not been ordering medicines for people correctly, resulting in medications not being available. Staff we spoke with, including the regional and senior managers, did not know whose responsibility it was for ordering medicines, and no processes were in place to monitor thisand ensure orders were correctly placed.


We were told by the regional manager and the provider that the supplier for the home had recently been changed due to medicines not being available. However, we saw that no arrangements had been made to manage the change over period, and the provider had failed to recognise that medicines' not being available was a result of the home not placingorders correctly.

We observed the medicines trolleys were locked when not in use and kept in a cupboard. However, the cupboard where some medications were being held was not locked and we found many packets of medicines lying around accessible to anyone entering the room.

We observed the medicines administration to be delayed and disorganised, often falling to the responsibility of the bank or agency nurse on duty who was unfamiliar with people living in the home. The medication records did not routinely contain a photograph of each person to assist in staff identifying people they were giving medicines to. Nursing staff on duty continually told us how vulnerable they felt working in such conditions. We brought this to the attention of the regional and other senior managers but practice remained unchanged and no assistance was provided to the nurses involved.

We spoke with an agency nurse on duty for her second shift, who raised concerns with us about the administration of warfarin within the home; this requires close monitoring of the dose to be given. The nurse told us that they had spent an hour the previous week on theirfirst shift, trying to sort out the warfarin records with the regional manager in an attempt to ensure peoples' warfarin records were accessible and correct for nurses to follow. The nurse was very concerned to find that despite all of her efforts, none of the paperwork had been retained for her to refer to on her next shift or for other nurses to also refer to. No protocols were present in the home for staff to follow regarding warfarin administration. The absence of guidance for staff in this situation meant that people were placed at risk of unsafe administration or a lack of administration depending on the knowledge of individual nurses. Despite reassurances from the registered provider, we found that on the 1 October2012 a person had not received warfarin for 3 days as the nurses on shift were not aware of the dosage to give and did not have a protocol to follow for this eventuality. We also received information from the commissioners of the service who confirmed that on 3 October 2012, four people had still not had their warfarin medications, putting people at serious clinical risk.We found omissions in medication records where people had not received doses as prescribed and also found the time between doses was at times very short, again putting people at risk. We were told that some people had missed their medications as the drugs had not been available. Some relatives told us they had been asked to bring additional medicines in from home for these to be administered to people.

We had addressed our findings and concerns with the registered provider following our visit on 23 September 2012. The provider assured us that prompt improvements would be made. Despite assurances made by the provider, we visited the home again on 1 October and found no improvements in the medicines management processes. Due to the seriousness of the concerns, the lead pharmacist for the NHS complex care team was alsoreviewing practices in the home during this visit; they raised their concerns with us for the safety and wellbeing of people who had not received their medications correctly, putting them at serious clinical risk. We saw that some peoples' medications were due to run out the following day which staff had not identified, and without the intervention of the pharmacist this would not have been ordered that day. Furthermore on the 3 October 2012the council confirmed that they had identified that day that the failure to administer medications as prescribed was ongoing.


Safety, availability and suitability of equipment Action needed

People should be safe from harm from unsafe or unsuitable equipment

Our judgement


Due to a lack of equipment available to promote the independence and comfort of people living at Manton Heights, people were not always protected from the use of unsuitable equipment.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.


On our first visit to Manton Heights on 17 September 2012, staff told us there was a lack ofequipment to assist people or promote peoples' independence. For example, we were told there were two mobile commodes for 29 people. Staff also informed us that there was onlyone bed pan and two urine bottles available.

We were shown the moving and handling equipment and were told there was one hoist, and five slings, all of which were a size medium. However, some people living in the home required a large sling but these were not available.

During our other visits on 23 and 24 September and 1 October 2012, we observed staff being unable to locate peoples' walking aides, and were told by one person's relative that a newly purchased wheelchair brought in with them was missing: staff confirmed this couldnot be found.

Some peoples' relatives told us they had asked the manager about available toilet seat raisers due to the height of their loved one. They said they were told these were not available and were not required within the home due to each room having en suite facilities. As such, one relative told us their husband had struggled to reach the toilet comfortably or safely due to the lack of this equipment.

Staff spoke to us about the lack of clinical waste bins in peoples' rooms, which we observed during our visits. One member of staff raised concerns about safely transferring clinical waste from a person's bedroom to the bathrooms, where the clinical waste bins were situated.

During our visits, we saw insufficient quantities of equipment available to meet peoples' needs safely.


Staffing Enforcement action taken

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement


People were put at risk due to low staffing numbers, and insufficient qualified, skilled and experienced staff to meet peoples' needs.



On 14 September 2012 the Care Quality Commission (CQC) was contacted by a whistle blower who raised serious concerns about the staffing arrangements in place at Manton Heights and about the impact this was having on the quality of care for people living at the home. In response to this, we conducted an urgent inspection on 17 September 2012. We were subsequently told by the local authority that they had visited the home after us and had also identified major concerns in the staffing levels, with high use of agency staff unfamiliar with the home or the needs of people living there.

On 21 September 2012, the local authority had informed the regional manager in charge ofthe home that additional staff were urgently required to provide the appropriate level of care for the number of people living in the home. In the absence of actions by the regional manager to obtain additional staff, the local authority had intervened to facilitate further agency staff to cover shifts at the service over the weekend.

When we arrived on 23 September 2012, we found three members of staff on duty to care for 28 people with a variety of physical and psychological needs. We found the staff to be extremely pressured, but trying to do their best for people. At the time, we observed peoples' needs were not being met; examples included people not receiving assistance at mealtimes, or being helped with personal hygiene needs. One relative complained to us that her husband was dressed but on closer inspection he had no underwear and no sockson. Other relatives told us that at times they had visited and their relative had been left unattended in bed for long periods of time and at times their continence needs had not been managed.

The staff we spoke with told us they were very short staffed and had to rely on agency or bank staff to cover shifts. We observed that staff were not available to answer call bells and these were ringing continuously for many minutes. One member of staff was trying to serve breakfast as people arrived in the dining room and also trying to get all of the peopleup who required only one member of care staff to assist them. People needing more that one member of care staff to assist with their needs had to wait until late morning before


they could be helped to get up. We saw some people were still in bed by late morning. People living at Manton Heights were observed to be sitting in wheelchairs in the dining room and some of them remained there over the course of the morning and over lunch. They were not offered the opportunityto go to the toilet and were left sitting in the dinning room with nothing to occupy their time except the television being put on in the distance. We did not see any meaningful activitiesbeing offered to people at this service on any of our visits.

We looked at the staff rotas and found no correlation to the staff on duty. Staff, including nurses in charge of shifts, were not able to tell us how many staff there should have been on duty. We were unable to locate a rota of any kind for the weekend of the 15 and 16 September 2012 and rotas that were found on the 1 October 2012 were duplicates with conflicting information recorded.

We spoke with the regional and other senior managers who were unable to clarify who was employed by the home and who was available to work. The regional manager told us of staff suspensions which had recently taken place, including the home manager and a registered nurse, although we were unable to see evidence to support the rationale for thisor any plans to manage the impact of this on care provision. We were also informed that the deputy manager had resigned and the regional manger had accepted this resignation with immediate effect. These decisions had significantly destabilised the home.

We found there was no clinical or managerial leadership in place for staff, resulting in staff performing tasks as they arose. We saw that the number of registered nurses was limited and nurses were working under extreme pressure. The nurses we spoke with during our visits on 23 and 24 September 2012 told us they felt clinically compromised and wished to leave, but felt their duty was to "do the best they could".

We raised our concerns with the registered provider on 23 September 2012 and again on 24 September 2012, who gave assurances that staffing would be addressed immediately and that a team of managers would start to arrive at the home from the following day. We were informed that changes would be made and care staff numbers increased to reduce the risks.

We returned to the home on 1 October 2012 to reassess the staffing concerns identified: whilst we found the number of care staff had increased to six, all staff on duty were from an agency and were unfamiliar with the home or people living there. Senior interim managers present in the home told us that the regional manager was no longer at the home and much of the information on staffing and staff recruitment was not available for them to refer to. As a consequence they were still unable to establish the exact informationon the staff employed by the company to work at the home, and were reliant on agency staff covering shifts. Senior registered nurses and managers told us during this visit that they felt clinically compromised by the way in which care was being provided and managed in the home and that they felt risk factors for people living in the home were unacceptable.

Despite action taken by the provider they had failed to stabilise the staffing team and to implement systems and processes to ensure the safe delivery of care. Registered nurses and managers moved in to the home to assist with the situation were working under extreme pressure; their actions lacked coordinationation and this had created increased confusion about leadership and clinical direction.


Records Enforcement action taken

People's personal records, including medical records, should be accurate and kept safe and confidential

Our judgement


People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not accessible or maintained.



During our visits, we asked the staff on duty and also the regional and other senior managers about the number of people living in the home at that time, and the level of needthey had; this information could not be clarified by anyone and there were no records available which detailed this information.

No staff member was able to tell us who had a wound or required dressings, or who had medical conditions including diabetes or epilepsy, and records were unable to clarify this detail.

We looked at the daily records for 14 out of 26 people and found these had not been consistently completed: we saw significant gaps in the daily records without obvious reasons. We also saw daily records had been completed retrospectively without this being recorded as such.

We identified a high number of people 'found on the floor' having fallen. However, records regarding this information were limited and there was no documented evidence of people having been assessed, or any treatment or support required after their fall. Staff we spoke with were unaware of who had fallen or any injuries sustained. The regional and other senior managers told us a central record for the home to record, report and monitor falls did not exist.

We looked at the nutritional monitoring forms which were in place for some people and found these were incomplete or not dated. We saw staff completing these from memory at the end of a shift: we asked staff about this and were told this was how the forms were "usually done as there was never any time to do it during the day".

We also looked at medicines processes and found unexplained omissions in peoples medicine administration records (MAR) and poor medicines records management.


Peoples' relatives told us that they had provided key information to care staff and the manager about the needs of their family member; examples included likes and dislikes andspecific medical conditions or allergies. We did not see evidence of this information being recorded in peoples' care records for staff to follow when planning and delivering care to people. Relatives told us that information they had given had not been acted on in relation to peoples' care needs.

During our visits, we found care plans with peoples' needs and assessments were not accessible, and staff we spoke with confirmed this. We were told there was an electronic system for records which staff on duty, both nursing and care staff, could not access. We were also told the regional and other senior nurses covering the home could not access the computer records. We incidentally found some hard copies for peoples' care records on 24 September 2012 but staff said they had not known about them and had not referred to them. We looked at a small number of these and found them to be out of date and inaccurate regarding the information contained within them.

We looked at staff records and found these to be poorly maintained. Due to the serious concerns with staffing levels, we looked at the staff rotas and found these did not correlate to staff we saw on duty. We also looked at the fire records and found the staff signing in and out sheet did not match the staff rotas for who was meant to be on duty.

We were told about recent staff suspensions and discussed this with the regional manager. There was no evidence we found to support the rationale for the decisions madeand were told by the regional manager there was not a written process we could look at to support the actions taken over the suspensions.

We raised our concerns with the provider at the time who told us this would be rectified quickly. We returned to the home on 1 October to reassess our previous findings and identified serious concerns remained regarding the management of records and lack of information available. We saw peoples' records were now available but the contents were disorganised and information missing: we also found that records we had reviewed on 23 and 24 September were not within peoples' files and staff could not locate these anywhere.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activities Regulation

Accommodation for persons who require nursing or personal care


Regulation 24 HSCA 2008 (Regulated Activities) Regulations2010

Cooperating with other providers

How the regulation was not being met:

Suitable arrangements were not in place when working in cooperation with others to ensure that appropriate care planning for people takes place. Regulation 24 (1(a)).

Regulated activities Regulation




Safety, availability and suitability of equipment


Equipment was not available in sufficient quantities to ensure thesafety of people, and meet their individual assessed needs. Regulation 16 (2).

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.



Enforcement action we have taken to protect the health, safety and welfare of people using this service

Enforcement actions we have taken

The table below shows enforcement action we have taken because the provider was not meeting the essential standards of quality and safety (or parts of the standards) as shown below.

Urgent procedure to vary a condition of registration

This action has been taken in relation to:

Regulated activities Regulation or section of the Act



Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010

Care and welfare of people who use services


People were not protected against the risks of receiving care or treatment that was inappropriate or unsafe because people had not received assessments of their needs (Regulation 9 (1(a)).

Care was not planned or records accessible to meet peoples' needs or ensure their welfare and safety. Regulation 9 (1(b)(i,ii)).





Meeting nutritional needs


People were not protected from the risk of inadequate nutrition and hydration through a lack of choice, and some people had missed meals. Regulation 14 (1(a)).

People did not receive the required level of support; food and



fluid charts were incomplete and written retrospectively. Regulation 14 (1(c)).





Safeguarding people who use services from abuse


People were not safeguarded against the risk of abuse through failure of staff to be aware of peoples' needs; this resulted in a large number of people falling within the home on a regular basis. People were also put at risk through incorrect medication administration, and also through omissions in basic care and hygiene needs. Regulation 11 (3(d)).





Management of medicines


People were not protected against the risks associated with unsafe use and management of medicines. This resulted from a lack of processes in place for obtaining, recording and handling stock, poor storage systems, poor record keeping and poor administration practices. Regulation 13.



Treatment of disease, disorder or


Staffing


People were put at risk due to low staffing numbers, and



injury insufficient qualified, skilled and experienced staff to meet peoples' needs. Regulation 22.





Records


People were at risk of unsafe or inappropriate care or treatment through inaccurate and inaccessible care records. Regulation 20 (1(a)).

Records could not be located promptly to allow staff to provide the required care for peoples' needs. Regulation 20 (2(a)).

For more information about the enforcement action we can take, please see our Enforcement policy on our website.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact.

Minor impact – people who use the service experienced poor care that had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact – people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact – people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.

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