Archived: Angela Court

Updated 5 December 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 17 and 22 December 2014 and on 5, 11, 26 January and 1 February 2015 and was unannounced.

The inspection team included four inspectors. In preparation for the inspection, we reviewed previous inspection reports, information from the multiagency safeguarding process, and information we received directly and from notifications. A notification is information about important events which the service is required to send to the Care Quality Commission (CQC) by law. This enabled us to ensure we were addressing any potential areas of concern.

We met all of the people who lived at the service; most of them were living with dementia and were unable to communicate their experience of living at the home in detail. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We spoke with six people using the service, and eight of their relatives and friends to obtain their feedback.

We spoke with 45 staff which included managers, nursing, care and support staff and agency workers. We looked in detail at the care provided for eleven people which included reviewing their care records. We looked at seven staff records, and at a variety of quality monitoring arrangements in the home. We obtained feedback from 15 health and social care professionals, which included commissioners, GP’S, nurses, social workers and a variety of therapists.

Updated 5 December 2016

This inspection took place on 17 and 22 December 2014 and on 05, 11 and 26 January and 1 February 2015 and was unannounced. This was our fourth inspection during 2014. The inspection continued over several weeks because of the level of on-going concerns and in order to inform regulatory decisions about next steps. We brought forward the inspection because of concerns raised with us about people’s care and welfare and about staffing levels at the home. Previously, on 04 April 2014 we visited Angela Court and had no concerns. We visited again on 20 July 2014 because of concerns raised with us about staffing levels. We found a breach of regulations in staffing due to staff vacancies and high sickness absence. We issued a compliance action and the provider set out actions being taken to address our concerns. On 16 September 2014, we undertook a further inspection visit and found improvements in staffing levels had been made.

Angela Court is registered to provide accommodation for 37 older people who require nursing and personal care. Many of the people who were living at the home have advanced dementia and lack capacity, and are not able to communicate their experiences of care. Some have complex needs and require a high level of care and supervision from staff to keep them safe. A number of people display behaviours that challenge the service.

The home is required to have a registered manager as a condition of registration. Angela Court does not currently have a registered manager, the previous one last worked at the home in August 2014 and has since left and deregistered with CQC. There has been a series of interim management arrangements at the home since then. A new manager was recruited and started working at the home on 5 January 2015, and plans to register. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not protected from abuse. This was because sufficient actions were not taken to keep people safe and prevent avoidable harm. Angela Court has been the subject of a whole home multiagency safeguarding investigation since 17 November 2014, the third such investigation during 2014. Whole service investigations are held where concerns about possible institutional abuse or neglect are being investigated. These are cases where there are indications that systemic abuse or care and safety failings may have caused or are likely to cause significant harm. On the 16 January 2015, the multiagency safeguarding meeting concluded the safeguarding concerns amounted to the neglect of people living at Angela Court.

As part of that process, a multi-disciplinary safeguarding protection plan was agreed with the provider, CQC, police and health and social care professionals to protect people’s safety and well-being. This included health professionals visiting the home regularly as part of the support plan and in a protection role.

People were not protected from unsafe and unsuitable premises. In particular, we highlighted burn and scald risks related to the central heating and hot water supply at the home. Following this, the provider took immediate steps to mitigate the risks, for example, displayed warning signs and where possible, put in place measures to stop people accessing hot water supplies unsupervised. Further plumbing and maintenance work was undertaken to address these concerns.

On three days of our visit, there was a strong smell of urine in the lounge, main corridor and dining room areas of the home. This was because cleanliness and hygiene standards in communal areas of the home were not being consistently maintained and because the carpets needed replacing. On 26 January 2015 when we visited, the carpet in the lounge area had been replaced and the odour had gone.

People’s health, safety and welfare were put at risk because there were not sufficient numbers of suitably qualified, skilled and experienced staff on duty at all times.

We were so concerned about some of the findings during our inspection visits that, on 13 January 2015, we wrote to the provider. We used our urgent enforcement powers to require them to provide an action plan and assurance to us by the 15 January 2015 about how they planned to ensure people living at Angela Court were being kept safe. The provider’s response acknowledged the concerns raised and gave a commitment to addressing them. The letter confirmed urgent action had been taken to manage the premises and protect people from risks related to hot water, hot pipes and other environmental concerns. It also outlined further actions being taken to improve staffing and skill levels as well as day to day leadership and supervision of staff at the home.

The staff training arrangements did not ensure staff had the knowledge and skills they needed to support people’s care and treatment needs. Staff needed more training to manage people with behaviours that challenged the service and to understand how to meet the needs of people living with dementia. We identified other gaps in training in relation to managing people with choking risks, the Mental Capacity Act 2005 and Deprivation of Liberty safeguards and in relation to nutrition, hydration and pressure area care.

People’s care needs were not effectively communicated to staff and people did not always receive care in accordance with their individual care plans. Some people were not appropriately supported at mealtimes, which increased their risk of malnutrition and dehydration. Others were at increased risk of choking because speech and language therapist recommendations about how to support those people to eat and drink safely were not being followed.

The care provided at the home was very focused on supporting people with daily living tasks rather than in response to people’s individual needs and wishes. We saw examples of staff being caring and respectful of people. However, we also saw occasions where staff did not engage with people and did not treat them with dignity and respect.

People were at significant risk because accurate records about each person were not consistently maintained. We found gaps in people’s food and fluid charts, repositioning and personal care charts as well as in prescribed cream charts. We could not be assured from these records that people’s care needs were being met.

The quality assurance processes in the home were inadequate; some of them had lapsed and many of the concerns found were not identified by the provider’s own monitoring arrangements or had not been acted on. Many of the actions taken by the provider to protect people were in response to concerns identified by visiting professionals, and the inspection. This demonstrated the provider was reactive rather than proactive in managing risks for people. Where improvements were made, these were not being sustained and risks remained.

On 29 January 2015, the provider contacted CQC to inform us they had identified seven people who needed immediate transfer to an alternative more stable service. They confirmed they were working with the local authority and health professionals who were assisting them to facilitate those people's transfers in a safe and caring way. 

On 30 January 2015, CQC received notifications from Devon County Council and the Northern, Eastern and Western Devon Clinical Commissioning Group (CCG). These showed they had decided to give notice of the termination of the individual contracts for all people at the home for whom they had funding responsibility. This was due to the considerable concerns regarding the quality of care provided at the home and because people’s care and safety could not be guaranteed. They informed the provider of their intention to move people from Angela Court as soon as practicably possible. By 5 February 2015 the remaining people left Angela Court and currently, there is no one living at the home.

During the inspection, we identified a number of serious concerns about the care, safety and welfare of people who lived at Angela Court. We found 16 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, now replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People continued to be at risk of  harm because the provider’s actions did not sufficiently address the on-going failings. This was despite the significant amount of support provided by the multi-agency team to address those failings. There has been on-going evidence of inability of the provider to sustain full compliance since March 2011.

Notwithstanding the findings of this inspection, enforcement action was not necessary once we were satisfied that service users were no longer accommodated at this location and satisfactory action plans from the provider addressing the breaches were accepted by CQC.