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Review ofcompliance

Ms Marie McCann

Webber House

Region: South East

Location address:3 Station Road

Park Gate

Southampton

Hampshire

SO31 7GJ

Type of service: Care home service without nursing

Date of Publication: June 2012

Overview of the service: The service is registered by Ms MarieMcCann to provide the regulated activityaccommodation for persons who requirenursing or personal care. The home canaccommodate up to thirteen residentswho are generally older and may havedementia.

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Our current overall judgement

Webber House was not meeting one or more essential standards.We have taken enforcement action against the provider to protectthe safety and welfare of people who use services.

The summary below describes why we carried out this review, what we found and anyaction required.

Why we carried out this review

We carried out this review to check whether Webber House had taken action in relation to:

Outcome 04 - Care and welfare of people who use servicesOutcome 07 - Safeguarding people who use services from abuseOutcome 08 - Cleanliness and infection controlOutcome 09 - Management of medicinesOutcome 13 - StaffingOutcome 14 - Supporting staffOutcome 16 - Assessing and monitoring the quality of service provisionOutcome 21 - Records

How we carried out this review

We reviewed all the information we hold about this provider, carried out a visit on 10 April2012, carried out a visit on 23 April 2012, looked at records of people who use services,talked to staff, reviewed information from stakeholders and talked to people who useservices.

What people told us

We spoke with the majority of people during our two visits as we conducted our inspectionand moved around the home.

We spoke with a person living in the home who said they were well looked after. We spokewith three people who informed us that there was, 'nothing to do' at the home.

One said they would have liked to have watched another program but it was too mucheffort to get to their room. We later discovered that the television in their room did not workthough they did have a radio. They also said they liked to read the newspaper but theyonly had one in the home which they shared. We spoke with a person who had specificdietary needs, to clarify what diet they needed and what food they ate at mealtimes.

We also spoke with a visitor who said their relative was very happy and well looked after.

for the essential standards of quality and safetySummary of our findings

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They liked the home because it was small and homely.

What we found about the standards we reviewed and how well WebberHouse was meeting them

Outcome 04: People should get safe and appropriate care that meets their needsand supports their rights

People living at the home were not protected against the risk of receiving inappropriate orunsafe care. People's needs were not being met as a result and their safety and welfarewas not being promoted.

The provider was not meeting this standard. We judged that this had a major impact onpeople using the service. Where areas of non-compliance have been identified duringinspection they are being followed up and we will report on any action when it is complete.

Outcome 07: People should be protected from abuse and staff should respect theirhuman rights

People had not been protected against abuse within the home.


Outcome 08: People should be cared for in a clean environment and protected fromthe risk of infection

People were not protected from the risk of infection because appropriate guidance had notbeen followed and the home was not clean.


Outcome 09: People should be given the medicines they need when they need them,and in a safe way

People were probably given their medication appropriately but records did not alwaysshow this.

The provider was not meeting this standard. We judged that this had a minor impact onpeople using the service and action was needed for this essential standard.

Outcome 13: There should be enough members of staff to keep people safe andmeet their health and welfare needs

There were not enough staff to meet people's needs.

The provider was not meeting this standard. We judged that this had a major impact on

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people using the service. Where areas of non-compliance have been identified duringinspection they are being followed up and we will report on any action when it is complete.

Outcome 14: Staff should be properly trained and supervised, and have the chanceto develop and improve their skills

People could not be assured that they were safe and their health and welfare needs werebeing met by competent staff. This was because staff supervision and appraisals were notconsistently taking place. While some staff training had taken place it was not possible toestablish how their training needs were identified.

The provider was not meeting this standard. We judged that this had a moderate impacton people using the service and action was needed for this essential standard.

Outcome 16: The service should have quality checking systems to manage risksand assure the health, welfare and safety of people who receive care

The provider did not have an effective system to regularly assess and monitor the qualityof service that people receive.


Outcome 21: People's personal records, including medical records, should beaccurate and kept safe and confidential

People were not protected from the risks of unsafe or inappropriate care and treatment.


Actions we have asked the service to take

We have asked the provider to send us a report within 14 days of them receiving thisreport, setting out the action they will take. We will check to make sure that this action hasbeen taken.

We have taken enforcement action against Ms Marie McCann.

Where we have concerns we have a range of enforcement powers we can use to protectthe safety and welfare of people who use this service. When we propose to takeenforcement action, our decision is open to challenge by a registered person through avariety of internal and external appeal processes. We will publish a further report on anyaction we have taken.

Other information

Please see previous reports for more information about previous reviews.

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What we found

for each essential standard of qualityand safety we reviewed

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The following pages detail our findings and our regulatory judgement for each essentialstandard and outcome that we reviewed, linked to specific regulated activities whereappropriate.

We will have reached one of the following judgements for each essential standard.

Compliant means that people who use services are experiencing the outcomes relating tothe essential standard.

Where we judge that a provider is non-compliant with a standard, we make a judgementabout whether the impact on people who use the service (or others) is minor, moderate ormajor:

A minor impact means that people who use the service experienced poor care that had animpact on their health, safety or welfare or there was a risk of this happening. The impactwas not significant and the matter could be managed or resolved quickly.

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

A major impact means that people who use the service experienced poor care that had aserious current or long term impact on their health, safety and welfare, or there was a riskof this happening. The matter needs to be resolved quickly.

Where we identify compliance, no further action is taken. Where we have concerns, themost appropriate action is taken to ensure that the necessary changes are made.

More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety

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Outcome 04:Care and welfare of people who use services

What the outcome says

This is what people who use services should expect.

People who use services:* Experience effective, safe and appropriate care, treatment and support that meets theirneeds and protects their rights.

What we found

Our judgement

The provider is non-compliant with Outcome 04: Care and welfare of people who useservices. We have judged that this has a major impact on people who use the service.

Our findings

What people who use the service experienced and told usWe spoke with the majority of people during our two visits as we conducted ourinspection and moved around the home.

We spoke with a person living in the home who said they were well looked after. Wespoke with three people who informed us that there was, 'nothing to do' at the home.

One said they would have liked to have watched another program but it was too mucheffort to get to their room. We later discovered that the television in their room did notwork though they did have a radio. They also said they liked to read the newspaper butthey only had one in the home which they shared. We spoke with a person who had

specific dietary needs, to clarify what diet they needed and what food they ate atmealtimes.

We also spoke with a visitor who said their relative was very happy and well lookedafter. They liked the home because it was small and homely.

Other evidenceWhen we last inspected the home on 1 December 2011, we identified three peoplewhose care plans we wanted to look at. However, only two of them had one in place.The recording of information was not accurate or complete. There were no activitiesprovided at the home. Our findings were that people were not having all of their

assessed needs met.

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During our visit on 10 April 2012, we looked at four care plans. We found that theycontained a range of information and assessments about people's needs andpreferences. However, as we looked in more detail at individual records we saw thatcare plans were not all up to date and forms were not completed accurately.

We saw that one person had a medical condition which meant they needed a special

diet. We looked at the care plan and saw that there was no detailed information aboutthe person's condition or how this was to be managed. At lunchtime we saw that theperson was eating the same meal as everyone else. We were told by a staff memberthat the meal was suitable for that person but when we looked at the packaging we sawthat it was not. We were told that the individual's food would be labelled with their namebut staff were unable to show us any food suitable for main meals. We spoke with staffabout this person's dietary needs. One staff member told us that the person could noteat two types of food and thought this was because of an unrelated medical conditionthe person had. Another staff member did not know anything but said they did notprepare food. We watched as tea was prepared for this person and saw that again, notall the food provided was suitable for their special diet. We raised this with staff whorectified the mistake. We looked at food records and saw that the person ate the samefood as other people living in the home.

During the inspection, we also found that there was written evidence in daily notes ofincidences of assaults by people on each other. We found that there had been a lack ofadequate assessments and care planning to reduce the level of risks relating to furtherassaults and altercations between the people living at the service. We spoke with staffand looked at other records but found that the assaults were not being reported to therequired agencies, such as Hampshire County Council safeguarding team or the CareQuality Commission. There was no clear information on how staff were to deal with

these incidences and no further consideration had been made to how this number ofincidences could be reduced, for example moving one person to a different room.

We also saw that a person had threatened to harm themselves, which was recorded indaily notes but there was no follow up to manage the risk that this could happen or tosupport the person.

During our visit of 23 April 2012 we looked at care plans again, with regard to howpeople's needs were being met.

The care plan for a different person (than we looked at before) was not up to date with

aspects of health care support needed in respect of the level of insulin required. Thedose had been changed and this showed in the monthly review but was different againfrom the medication administration record. We asked to see the medicationadministration record for the previous month but it could not be found. The managercould not find any written evidence regarding when the dose had been changed andtherefore could not demonstrate which written document was correct. Staff were able totell us how much insulin was administered but were not able to evidence that this wasthe correct amount.

For the same person the level of foot care needed was not clear. The care plan statedthat the person needed staff to organise this whereas the review said the residentwould inform staff when they needed foot care. The review also stated that thechiropodist visited regularly yet there was only written evidence of one visit on 14 March

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2012 in the previous ten months, which was when the record started. It was thereforeunclear if this person's foot care needs were being met.

Another person's care plan stated that they needed to have the pressure areas on theirskin checked when they had a bath. However, the person generally refused a bath andthe records did not show how the skin would be checked when a bath was refused and

did not detail whether the skin had been checked. We spoke with a staff member whoconfirmed the person often refused a bath. They also said that as the person movedaround they would not develop sore patches. Therefore it was not possible to ascertainhow the staff were assured that this person skin was still intact. We were told that thisperson chose to lie in bed and refused to eat a normal diet and ate mostly sandwichesand cakes. When we visit this person in their room they were in bed still in their nightwear and had only eaten a few mouthfuls of their sandwich. We also noted that to entertheir room you had to walk through another person's room. We were told that theyshared the toilet facilities in the first room. Staff told us that neither person minded.However, this clearly impacted on people's privacy.

There were nutritional assessments in place as well as weight charts. There werediscrepancies in the recording between the two documents and within the two initialassessments and subsequent re-assessments. The first 'initial assessment' wascompleted in October 2011 and did not record the person's weight. They were notassessed as having any nutritional needs. The second 'initial assessment' form, dated 4January 2012 also showed conflicting information. The person's actual weight wasrecorded as 60kg but a section of the form was completed to indicate that the personweighed 'less than 45kg'. The weight chart showed the person weighed 40kg on the 2January 2012 and on 7 January 2012. On the nutritional reassessment dated 4February 2012 the person was assessed as weighing 'less than 45 kg' but the actual

weight was recorded at 48kg on the bottom of the form. On the weight chart, the personweighed 46kg on the 5 February. Therefore, it was not possible to ascertain whetherthe person was losing or gaining weight and how much at risk they were.

One person used a wheel chair to move around. We observed that in some areas of thehome the corridors were narrow and that they would need assistance to get throughthese areas. There were no specific facilities or moving and handling aids for peopleneeding assistance with mobility. Staff told us that the person in the wheelchair wasable to stand for short periods and to transfer to the toilet.

There was a lift to the first floor, the room for one person who used a frame for walking

was on the first floor. However, there was also a small ramp for them to go up anddown as the there was two levels to the first floor, floor. It was not clear if theselimitations had been considered when these people had come to live at the home.

During the time we were at the home, people were sitting in the lounge where thetelevision was on, staying in their bedrooms or walking around the home. There was noindication that any other activities were provided. One person told us that he had to goto bed at 9pm. However, we observed that people requested to go to bed at earlytimes. For some people this was around 8pm. The lack of activity was also of furtherconcern as some people had demonstrated aggressive behaviour and there wasnothing to occupy them.

We observed the lunch being served and eaten on 23 April 2012. There was limited

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interaction between people and staff, only taking place when people were helped to andfrom the table or when served food.

We therefore found no evidence that outcomes for people living in the home hadimproved since our last inspection.

Our judgementPeople living at the home were not protected against the risk of receiving inappropriateor unsafe care. People's needs were not being met as a result and their safety andwelfare was not being promoted.

The provider was not meeting this standard. We judged that this had a major impact onpeople using the service. Where areas of non-compliance have been identified duringinspection they are being followed up and we will report on any action when it iscomplete.

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Outcome 07:Safeguarding people who use services from abuse



People who use services:* Are protected from abuse, or the risk of abuse, and their human rights are respected andupheld.

What we found

Our judgement

The provider is non-compliant with Outcome 07: Safeguarding people who use servicesfrom abuse. We have judged that this has a major impact on people who use theservice.

Our findings

What people who use the service experienced and told usWe did not talk with people about safeguarding procedures but looked at their writtenrecords.

Other evidenceDuring the previous inspection at Webber House on 1 December 2011 concerns wereidentified with this standard and a compliance action was set.

We received a report from the registered provider on 3 February 2012 which stated thatboth the Hampshire County Council Adult Services Safeguarding policy and procedures

and an in-house policy were available and easily accessible to all staff. A declarationwas made in the report that staff had read the policy and signed to say theyunderstood. The report also stated that this would be revisited in individual supervisionsessions.

During the inspection of 10 April 2012, we found that there was evidence of highincidences of physical or verbal assaults by residents on each other. Daily records forone person showed that between 9 and 14 January there was one incident; between 22January and 1 February, two incidents; 15 February and 6 March, seven incidents. Wealso saw in daily records that a person had threatened to harm themselves. We lookedat records and spoke with staff to see whether these had been reported to the local

authority safeguard or to the Care Quality Commission. None of the incidents had beenreported which meant people continued to be at risk.

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Therefore, there was no evidence of any improvement in this outcome for people livingat the home.

Our judgementPeople had not been protected against abuse within the home.


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Outcome 08:Cleanliness and infection control


Providers of services comply with the requirements of regulation 12, with regard to theCode of Practice for health and adult social care on the prevention and control of infectionsand related guidance.

What we found

Our judgement

The provider is non-compliant with Outcome 08: Cleanliness and infection control. Wehave judged that this has a major impact on people who use the service.

Our findings

What people who use the service experienced and told usWe did not talk with people about infection control.

Other evidenceDuring the visit on 23rd April 2012 we walked around the home and looked atcommunal areas, bathrooms, toilets and some of the bedrooms.

The kitchen floor showed a build up of dirt in the corners. The cutlery tray in the kitchendrawer contained visible debris and dust. The dishcloth used for washing the disheswas stored damp in a plastic tub on the draining board. We saw that staff washed anddried disposable plastic cups and were told that this was usual practice.

In the downstairs bathroom we saw that the frame around the toilet was rusty in some

areas and stained brown in some areas. These stains appeared to be dried faeces. Theseal around the bath was mouldy and stained in places. The bath hoist had signs ofrust.

The stair carpet had visible debris in the corners. The fire extinguisher on the first floorlanding had a layer of dust on it.

We saw black coloured mould behind the mixer taps in the upstairs bathroom and theseal around this bath was no longer patent and showed signs of mould in some areas.We saw that the upstairs bathroom had a perching stool stored in the bath tub that hadblack mould on all four rubber casters. There were faeces smeared on the raised toilet

seat and a roll of toilet paper smeared with faeces. The bath hoist was rusty in someareas.

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Disposable gloves and aprons were stored in the utility room and were not available inpeoples' bedrooms or bathrooms, which is where they would be needed.

We were told by the manager that staff who were supporting a person with personalcare would be expected to clean their bedroom and bathroom. We asked to seecleaning records and were told that Webber House does not keep cleaning records or

rotas for either general cleaning or cleaning of equipment. We asked to see infectioncontrol audits and were told by the manager that Webber house does not audit infectioncontrol. The manager was unable to provide us with an infection control policy orprocedure for Webber House.

Our judgementPeople were not protected from the risk of infection because appropriate guidance hadnot been followed and the home was not clean.


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had been signed for and not given or the carried forward number was incorrect.

During our visit on the 23 April 2012 we found that a medication that was prescribed tobe given only once a week on the Wednesday, was signed as having been given on theMonday. On checking, this was a recording error and the medication had not beenadministered.

One member of staff told us that while they had completed training in administeringmedication this had been compete at during employment with another provider. Theyalso confirmed that while they administered the insulin injections they had not receivedany specific training to undertake this task.

We were told that there was a system in place for returning unused medication thatincluded the completion of a returned sheet. We were also told that the number oftablets was checked when medication was received by the home. We saw that this wasrecorded on the MAR charts.

We spoke with staff about how they took medication to people. Staff told us that in themorning breakfast was taken to people first and then medication is dispensed andadministered one person at a time. Staff also confirmed that medication was taken topeople individually at other times of the day. This was confirmed when we observed thelunch time medication being administered.

Our judgementPeople were probably given their medication appropriately but records did not alwaysshow this.

The provider was not meeting this standard. We judged that this had a minor impact onpeople using the service and action was needed for this essential standard.

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Outcome 13:Staffing



People who use services:* Are safe and their health and welfare needs are met by sufficient numbers of appropriatestaff.

What we found

Our judgement

The provider is non-compliant with Outcome 13: Staffing. We have judged that this hasa major impact on people who use the service.

Our findings

What people who use the service experienced and told usWe did not talk with people specifically about this outcome.

Other evidenceOur last inspection report from the visit in December 2011 noted that copies of therosters were not available in the home.

During our visit on 3 April 2012, we asked to see the staff roster for the current week.This was not found until much later in the day. We also asked for copies of the previousrosters but were told they were not in the home as they were taken out of the home tocalculate wages. We asked the provider for these rosters when they arrived in the home

early evening but were told they were not there.

We asked the provider to explain the staffing levels to us. They told us that in terms ofshift patterns and cover there were to be two members of staff covering between 8amand 10pm, one person awake and one person asleep between 10pm and 8am.

During the visit on 23 April 2012 we reviewed the off duty roster for three weeks starting9 April 2012 which showed that there were nine members of staff. This complimentincluded one person on maternity leave and one person on sick leave. We were alsotold that one person was a bank person who therefore worked as and when required.In total the home had six active and available members of staff to provide the 24 hour

cover, over a seven day week. The provider told us that the staff on duty were requiredto undertake care, cleaning and cooking requirements within the home.

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The rosters showed that some staff were regularly working between 50 and 60 hours aweek, sometimes without a reasonable amount of time in between shifts. The rostershowed the manager was often one of the two staff on duty during the day. It wastherefore unclear how the two roles of providing care to the residents and overallmanagement responsibilities as the registered provider and the running of the homewere being fully delivered.

During our second visit, the staff member who was due to start work in the afternoonwas not able to come to work. We asked how this absence was to be covered and theprovider told us they would stay until 10pm herself. The second member of staff wasrostered to work until 8pm. This would have meant there was only one member of stafffor two hours. They told us that they were working until 10pm. We also saw that on theday of our visit a staff member had worked 4pm to 10pm the previous day, followed bya sleeping duty and then worked 8am to 8pm. In total, this meant the person's workingcommitment was 28 hours.

One person had been assessed as requiring one to one support. Their care plan statedthat, 'additional (extra) night staff' were to monitor the person's whereabouts every halfan hour at night'. However, it was not evident in the home or on the rota that this one toone support for their care needs was being provided when it was needed.

Concerns were also identified with the cleanliness of the premises. The care staff wereresponsible for the cleaning.

It was also found that no activities were provided for people and they were often left ontheir own in the lounge watching the television, in their rooms or walking around thehome.

There was therefore no capacity in terms of staffing levels within the home, to cover anyadditional sickness, study leave or annual leave.

Our judgementThere were not enough staff to meet people's needs.


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Outcome 14:Supporting staff



People who use services:* Are safe and their health and welfare needs are met by competent staff.

What we found

Our judgement

The provider is non-compliant with Outcome 14: Supporting staff. We have judged thatthis has a moderate impact on people who use the service.

Our findings

What people who use the service experienced and told us

We did not speak with people about staff training.

Other evidenceWhen we visited on 23 April we asked the person in charge what training had takenplace and how they identified what staff training needs were. They thought there was atraining matrix but they were unable to locate it at the time. Neither were they able tolocate training records for individual staff.

We were told that some training had taken place the previous week and that more wasplanned. Training information for some staff was provided after the inspection. For onemember for staff it indicated that they had completed all their mandatory training in

October 2009, October 2010 and September 2011. The dates for 2012 were enteredacross the sheet for the month of February 2012 but we were advised that only sometraining had taken place and the rest was planned. For a second staff member, trainingwas recorded as having been completed in October 2010 and September 2011. Therewere no specific dates. For this person the training for 2012 was recorded as being duein April and May. For one new member of staff, the information recorded was aboutwhat needed to happen not what had taken place. For another new member of staff,the information had been taken form the certificates they had provided relating totraining they had received from a previous employer. There was no clearly identifiedtraining matrix and it was not clear how the staff training needs were assessed.

We were told that training in dementia awareness and challenging behaviour, movingand handling of loads and safeguarding had been completed. In order to gain a

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certificate for the dementia awareness training staff were required to complete a workbook. Further training was said to have been arranged for food hygiene, fire safety andinfection prevention and control.

We asked if staff supervision sessions were happening. We were told that these hadstarted in January 2012 and were shown these records. The provider's policy was for

these to take place every two months but there were no other records of supervisionsessions since January.

When we asked to see the staff appraisal records we were told that not many of thestaff had worked there long enough to have had an annual appraisal. One member ofstaff told us that they had a chat with the manager but nothing had been recorded.

Our judgementPeople could not be assured that they were safe and their health and welfare needswere being met by competent staff. This was because staff supervision and appraisalswere not consistently taking place. While some staff training had taken place it was notpossible to establish how their training needs were identified.

The provider was not meeting this standard. We judged that this had a moderate impacton people using the service and action was needed for this essential standard.

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Outcome 16:Assessing and monitoring the quality of service provision



People who use services:* Benefit from safe quality care, treatment and support, due to effective decision makingand the management of risks to their health, welfare and safety.

What we found

Our judgement

The provider is non-compliant with Outcome 16: Assessing and monitoring the qualityof service provision. We have judged that this has a major impact on people who usethe service.

Our findings

What people who use the service experienced and told usWe did not speak with people about this outcome but did ask to be shown the results ofa survey.

Other evidenceWe were initially told that a satisfaction survey was performed twice a year and thatsurveys were sent to GPs; families; hair dresser; chiropodist; community nurses andanyone who had contact with the home and the residents. This confirmed theinformation provided by Marie McCann following the inspection on 1 December 2011.However, when we asked to see the outcome of the surveys and associated

documentation, they were not produced. Later when we asked again, the registeredprovider told us there were no results, as no surveys had been conducted since 2008.

We were not presented with any evidence that showed there was quality monitoring ofthe service. We found non compliance in seven other outcomes which had not beenidentified by the provider.

It was therefore unclear how the provider would be able to protect people, who may beat risk, against the risks of inappropriate or unsafe care and treatment, as there was noeffective system operating to regularly assess and monitor the quality of the servicesprovided.

Our judgement

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The provider did not have an effective system to regularly assess and monitor thequality of service that people receive.

The provider was not meeting this standard. We judged that this had a major impact onpeople using the service. Where areas of non-compliance have been identified duringinspection they are being followed up and we will report on any action when it is

complete.

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Outcome 21:Records



People who use services can be confident that:* Their personal records including medical records are accurate, fit for purpose, heldsecurely and remain confidential.* Other records required to be kept to protect their safety and well being are maintainedand held securely where required.

What we found

Our judgement

The provider is non-compliant with Outcome 21: Records. We have judged that this hasa major impact on people who use the service.

Our findings

What people who use the service experienced and told usWe did not speak with people about this outcome.

Other evidenceDuring both our visits we looked at a range of records kept in the home and found themto be inconsistent and inaccurate.

When we looked at care plans we found several areas of concern. For one person wefound that their Waterlow risk assessment was completed and reviewed monthly.

However, there were two in place for this resident and they were running concurrently.One showed one figure and the other showed another figure yet they were bothmeasuring the same health needs. The figure showed on each remained the same ateach review. The form with the lower score was the one used to inform the monthlyreview of the care plan. Inaccurate records could lead to inconsistent care based on outof date health risks.

We found that one care plan was not up to date with aspects of care support needed,for example, the level of medication required by a resident who was insulin dependent.The dose had been changed and this showed in the monthly review but was differentagain from the medication administration record. We asked to see the medication

administration record for the previous month but it could not be found. The managercould not find any written evidence regarding when the dose had been changed and

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therefore could not demonstrate which written document was correct. Another examplewas the level of foot care needed. The care plan stated that the resident needed staff toorganise this whereas the review said the resident would inform staff when they neededfoot care. The review also stated that the chiropodist visited regularly yet there was onlywritten evidence of one visit 14 March 2012 in the previous ten months, which waswhen the record started.

One file showed that a health care appointment letter had been sent to the home. Theperson was unable to attend that appointment and the manager explained why.However, there was no record made of the events.

For one frail person the care plan stated that they needed to have the pressure areason their skin checked when they had a bath. However, the person generally refused abath and the records did not show how the skin would be checked when a bath wasrefused and did not detail whether the skin had been checked.

The care plan stated that a pressure mattress and cushion was to be ordered. In fact,the person already had this equipment and it was in use so the care plan did not detailany specific arrangements with regard to this. This meant that the care plan was not upto date and could lead to an inconsistency of care.

There were nutritional assessments in place as well as weight charts. For one personwe found discrepancies in the recording between the two documents and within the twoinitial assessments and subsequent re-assessments. The first 'initial assessment' wascompleted in October 2011 and did not record the person's weight. They were notassessed as having any nutritional needs. The second 'initial assessment' form, dated 4January 2012 also showed conflicting information. The person's actual weight was

recorded as 60kg but a section of the form was completed to indicate that the personweighed 'less than 45kg'. The weight chart showed the person weighed 40kg on the 2January 2012 and on 7 January 2012. On the nutritional reassessment dated 4February 2012 the person was assessed as weighing 'less than 45 kg' but the actualweight was recorded at 48kg on the bottom of the form. On the weight chart, the personweighed 46kg on the 5 February. Therefore, it was not possible to ascertain whetherthe person was losing or gaining weight and how much at risk they were.

We told by one social worker that they had been advised of an incident in the last twoweeks where their client's behaviour had involved calls being made to otherprofessionals including themselves. We were told by staff that the GP and been

concerned that the person may have had a urinary tract infection, (UTI) and that asample was requested. We were unable to find any reference to this event in theperson's records or if the UTI issue had been dealt with or followed up

During both our visits, we asked to see accident books but they were not completedcorrectly. We were given two books but some pages were blank, others had beencompleted to fill in the gaps which meant they were not in date order. The books werealso both in use for the same time frame so that where a record had been made of anaccident or incident, it was difficult to find it again. We also saw that some pages hadnot been completed incorrectly from the front to the back which meant the back of thepage was blank and the details appeared in the wrong place. This means that recordsof accidents were not accurate and the books could not be relied upon for auditpurposes.

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On 23 April 2012 we asked how the quality of the service was monitored bymanagement and for the provider to provide documentation to evidence this. We weretold by the registered provider, that a survey was performed twice a year and was sentto GPs; families; the hairdresser; chiropodist; community nurses and basically 'anyone'who had contact with the home. We asked to see the outcome of the surveys andassociated documentation but these were not provided. Later, we asked again and the

registered provider told us there were no results, as no surveys had been conductedsince 2008. No evidence was provided that there was a management system for themonitoring of the service being provided.

We requested evidence of staff appraisal. No information was available. Again thisraised the issue of the provider not having proper information in relation to managementof the regulated activity.

Overall, we found that records were not completed in a way which ensured people'sneeds were met.

Our judgementPeople were not protected from the risks of unsafe or inappropriate care and treatment.


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Compliance actions

The table below shows the essential standards of quality and safety that are not beingmet. Action must be taken to achieve compliance.

Regulated activity Regulation Outcome

Accommodation for persons whorequire nursing or personal care

Regulation 13HSCA 2008(Regulated

Activities)Regulations 2010

Outcome 09:Management ofmedicines

How the regulation is not being met:

People were probably given their medicationappropriately but records did not always showthis.

The provider was not meeting this standard.We judged that this had a minor impact onpeople using the service and action wasneeded for this essential standard.

Accommodation for persons whorequire nursing or personal care

Regulation 23HSCA 2008(RegulatedActivities)Regulations 2010

Outcome 14:Supporting staff

How the regulation is not being met:

People could not be assured that they were

safe and their health and welfare needs werebeing met by competent staff. This wasbecause staff supervision and appraisalswere not consistently taking place. Whilesome staff training had taken place it was notpossible to establish how their training needswere identified.

The provider was not meeting this standard.We judged that this had a moderate impacton people using the service and action was

needed for this essential standard.

Actionwe have asked the provider to take

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Enforcement action we have takenThe table below shows enforcement action we have taken because the service provider isnot meeting the essential standards of quality and safety shown below. Where the action isa Warning Notice, a timescale for compliance will also be shown.

Enforcement action taken

Warning notice

This action has been taken in relation to:

Regulatedactivity

Regulation orsection of the Act

Outcome

Accommodati

on forpersons whorequirenursing orpersonal care

Regulation 9 HSCA 2008

(Regulated Activities)Regulations 2010

Outcome 04: Care and welfare of people

who use services

How the regulation orsection is not being met:

Registeredmanager:

To be met by:

People living at the homewere not protected againstthe risk of receivinginappropriate or unsafecare. People's needs werenot being met as a result

and their safety and welfarewas not being promoted.

The provider was notmeeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have beenidentified during inspection

they are being followed upand we will report on anyaction when it is complete.

23 May 2012


Warning notice


Regulatedactivity Regulation orsection of the Act Outcome

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Accommodation forpersons whorequirenursing or

personal care

Regulation 11 HSCA 2008(Regulated Activities)Regulations 2010

Outcome 07: Safeguarding people whouse services from abuse


Registeredmanager:

To be met by:

People had not beenprotected against abusewithin the home.

The provider was notmeeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have been

identified during inspectionthey are being followed upand we will report on anyaction when it is complete.

23 May 2012


Warning notice


Regulatedactivity


Outcome

Accommodation forpersons whorequirenursing orpersonal care


Outcome 08: Cleanliness and infectioncontrol


Registeredmanager:

To be met by:

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People were not protectedfrom the risk of infectionbecause appropriateguidance had not beenfollowed and the home wasnot clean.

The provider was notmeeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have beenidentified during inspectionthey are being followed upand we will report on any

action when it is complete.

23 May 2012


Warning notice


Regulatedactivity


Outcome



Outcome 13: Staffing


Registeredmanager:

To be met by:

There were not enough staffto meet people's needs.

The provider was not

meeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have beenidentified during inspectionthey are being followed upand we will report on anyaction when it is complete.

23 May 2012


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Warning notice


Regulatedactivity


Outcome



Outcome 16: Assessing and monitoringthe quality of service provision


Registeredmanager:

To be met by:

The provider did not havean effective system toregularly assess andmonitor the quality of

service that people receive.

The provider was notmeeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have beenidentified during inspectionthey are being followed up

and we will report on anyaction when it is complete.

23 May 2012


Warning notice


Regulated

activity

Regulation or

section of the Act

Outcome



Outcome 21: Records


Registeredmanager:

To be met by:

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People were not protectedfrom the risks of unsafe orinappropriate care andtreatment.

The provider was notmeeting this standard. We judged that this had a majorimpact on people using theservice. Where areas ofnon-compliance have beenidentified during inspectionthey are being followed upand we will report on anyaction when it is complete.

23 May 2012

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What is a review of compliance?

By law, providers of certain adult social care and health 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 Care Quality Commission (CQC) has written guidance about what people who useservices should experience when providers are meeting essential standards, calledGuidance about compliance: Essential standards of quality and safety .

CQC licenses services if they meet essential standards and will constantly monitorwhether they continue to do so. We formally review services when we receive informationthat is of concern and as a result decide we need to check whether a service is still

meeting one or more of the essential standards. We also formally review them at leastevery two years to check whether a service is meeting all of the essential standards ineach of their locations. Our reviews include checking all available information andintelligence we hold about a provider. We may seek further information by contactingpeople who use services, public representative groups and organisations such as otherregulators. We may also ask for further information from the provider and carry out a visitwith direct observations of care.

Where we judge that providers are not meeting essential standards, we may setcompliance actions or take enforcement action:

Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says whatthey will do to make sure they comply. We monitor the implementation of action plans inthese reports and, if necessary, take further action to make sure that essential standardsare met.

Enforcement action: These are actions we take using the criminal and/or civil proceduresin the Health and Social Care Act 2008 and relevant regulations. These enforcementpowers are set out in the law and mean that we can take swift, targeted action whereservices are failing people.

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Information for the reader

Document purpose Review of compliance report

Author Care Quality Commission

Audience The general public

Further copies from 03000 616161 / www.cqc.org.uk

Copyright Copyright © (2010) Care Quality Commission(CQC). This publication may be reproduced inwhole or in part, free of charge, in any formator medium provided that it is not used forcommercial gain. This consent is subject tothe material being reproduced accurately andon proviso that it is not used in a derogatorymanner or misleading context. The material

should be acknowledged as CQC copyright,with the title and date of publication of thedocument specified.

Care Quality Commission

Website www.cqc.org.uk

Telephone 03000 616161

Email address [email protected]

Postal address Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

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