About the service:

Glenside Manor Healthcare consists of six adult social care services and a hospital all situated in the same complex. Pembroke Lodge is registered to provide accommodation and personal care for up to 16 people with neurological conditions, including acquired brain injury and neurological disorders. At the time of the inspection three people were living at the home.

People’s experience of using this service:

• The quality of care people received had significantly deteriorated since the last inspection.

• People had been placed at risk of avoidable harm because heating systems were not operating efficiently, the heating was supplemented by mobile heaters and there was no hot water at times.

• People’s care and treatment was being delivered by agency staff that did not know their preferences and how they liked their care delivered.

Rating at last inspection:

This service was rated inadequate published on 05 February 2019

Why we inspected:

This inspection was conducted in response to whistleblowing concerns in relation to the heating not working efficiently and at times a lack of hot water. We also received concerns about poor staffing levels.

Enforcement:

Following the focused inspection we wrote a letter of intent to the provider. We told the provider that “The Commission was considering whether to use its powers pursuant to the urgent procedure (for suspension, or imposition or variation or removal of conditions of registration) under Section 31 of the Health and Social Act 2008.” The provider responded by providing alternative accommodation to people living in Pembroke Lodge.

Follow up:

At the last inspection on 7 and 15 November 2018 the service was rated Inadequate and placed into special measures. We asked the provider to take action to make improvements. We issued warning notices on safeguarding, care and treatment and for staffing. We also imposed conditions on the service. Other enforcement actions taken in relation to Pembroke Lodge were subject to representations.

The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Glenside Manor Healthcare consists of six adult social care services and a hospital all situated on the same complex. Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

This inspection took place on 7 and 15 November 2018 and was unannounced. Pembroke Lodge is one of the six adult social care locations. Up to sixteen people can be accommodated at the home. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain.

At the time of the inspection, there were three people living at Pembroke Lodge. It is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

A registered manager was in post. 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. Staff said the unit manager “often pops in” to the home. The staff were not aware who was the registered manager. The staff on duty told us this registered manager rarely visited the home.

In December 2016 the provider told us that the service was not accommodating people and was “dormant”. The provider failed to inform the CQC that the regulated activity of accommodation for people who require nursing or personal care at Pembroke Lodge was reinstated in July 2018. Although we asked the provider to resubmit a notification to lift dormancy, we have not received this.

Following the inspection CQC formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We requested further information from the unit manager to be provided by 30 November 2018. We received some of the information requested but not all.

Quality assurance systems were not effective. Audits were not robust and did not provide an accurate assessment of the quality of care delivered. Action plans were not developed to drive improvements. The CQC was not kept informed of accidents and incidents reportable under the Care Quality Commission (Registration) Regulations 2009: Regulation 18.

People were not safe from the risk of potential harm. Risk assessments were not clear on the actions to minimise the risk. There were people who expressed their frustration and anxieties using behaviours that staff found difficult to manage. Documentation about these incidents did not show behaviour management plans were always followed. Records of incidents were not detailed and did not include the actions taken to manage difficult behaviours. Staff told us they were not confident to use MAPA holds. MAPA (Management of Actual or Potential Aggression) programme teaches management and intervention techniques to help staff manage escalating behaviour in a safe manner.

Recruitment procedures did not ensure the staff employed at the home were suitable to work with vulnerable adults. The CQC received whistleblowing concerns about staff not being able to speak basic English and that agency staff were working without appropriate checks. These agency staff were working at Pembroke Lodge to maintain staffi