Archived: Bentley Care Home

Updated 2 June 2017

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

This inspection took place on 10, 11, 13 April and 03 and 08 May 2017 and was unannounced.

This inspection was carried out by two Adult Social Care (ASC) inspectors on 10, 11, 13 April 2017. On 13 April they were also accompanied by a specialist advisor (SPA) who was specialist in the use of medicines. An ASC inspection manager and an ASC inspector attended on 03 and 08 May 2017.

We carried out this inspection because concerns were raised by stakeholders in relation to safeguarding investigations at the home.

We spoke with 11 people who used the service, and with eight visiting relatives. We also spoke with the provider, the manager, the deputy manager, the care taker, the administrator, and four care staff and two domestic staff and the cook and kitchen assistant and the activities coordinator.

We looked at six care files which included the daily records, five staff recruitment files and other records relating to staff training and supervision. We also looked at other records and documentation in the home relating to the safety of the premises.

We observed people and staff throughout the inspection and saw how people were being cared for.

Updated 2 June 2017

We carried out an unannounced inspection of Bentley Care Home on 10, 11 and 13 April, and also 03 and 08 May 2017.

Bentley Care Home is registered to provide accommodation and support for up to 58 adults who require support with their mental and physical health. At the time of the inspection 48 people were living at the home.

The building is converted from three large Victorian houses divided into two units. These are known as 'Lily' and 'Tulip'. People have their own bedroom and share bathroom and shower facilities. Each unit has sitting and dining facilities for people to share.

The home had a manager who was in the process of applying to be the registered manager. 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.

At this inspection we found serious breaches of Regulations 9, 10, 11, 12, 13, 14, 16, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were assessed by CQC as extreme, as the seriousness of the concerns placed a significant risk on the lives, health and well-being of the people living in the home.

The premises were unsafe and poorly maintained. The kitchen had been closed by the Environmental Health Department as it was unsafe and the home had a serious rodent problem that was not being managed appropriately. The food preparation areas were unsuitable and placed people at risk from food poisoning. People were found to be smoking in the building which was unsafe and against the home’s policies and no action had been taken to address this.

Medicines were not safely managed which placed people’s health at risk and staffing levels were insufficient to meet people’s needs.

The Mental Capacity Act 2005 was not adhered to in the home. Staff did not have the knowledge and skills to support people or follow legal processes to make sure decisions were in people’s best interests.

There were no systems or processes in the home to ensure that the service provided was safe, effective, caring, responsive or well led. The manager and provider were unable to demonstrate the skills, knowledge or ability to make the urgent changes that were required to make the service safe during the time period of a month in which the inspection took place.

On 09 May 2017 CQC used its urgent powers to keep people safe.

The provider has 28 days to appeal against this action to the First Tier Tribunal (Care Standards) under section 32 (1) (b) of the Health and Social Care Act 2008. Once this period has passed, the action will be reported upon.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special

measures' by CQC.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.