Quinnell House

This service was last inspected in May 2019 and rated Good. This inspection was planned and undertaken due to the age of the rating. At this inspection, we found improvements were needed, and the rating of the service has changed to Requires Improvement. The provider was in breach of legal regulations in relation to safe care and treatment and the governance of the service.

People’s safety was not consistently considered, and risk was not managed pro-actively. There were no records of lessons learned following incidents. Care plans and risk assessments were not person centred and were missing detail about their social needs and how these were met. Fire training, evacuations and drills had not been undertaken. The emergency fire grab bag was not accessible and PEEPs for people were not all in place and accurate. This was immediately actioned to ensure people and staff were safe. The overview for peoples’ weights had shown weight loss of up to 5kgs in a month for 9 people that had not been checked or followed up with appropriate actions. For some people, their weight continued to decrease. Staff had been taking wound/skin integrity photographs which were not identifiable, labelled, measured or described accurately and had not been done in a dignified way. There was a lack of documented information regarding peoples’ wounds which meant they could not be monitored and advice sought in a timely manner. Staff had not all received the training, supervision or appraisals required to provide safe, consistent care. The governance and overview of processes had not ensured safe and consistent care. The in-house audits and governance systems were not consistently robust and had not identified all the shortfalls found and discussed during the inspection process. For example, staff were using their own mobile phones to record activities and photograph skin integrity issues. This has immediately been stopped and appropriate handsets purchased to link with the computer care plans. Deprivation of Liberty safeguards were out of date and had not been reapplied for.

There were enough staff deployed, and recruitment processes had recently been audited and improved, this had ensured the safe recruitment of staff. The home was clean and staff followed good practice guidelines in infection control procedures. Feedback relating to communication and response to concerns was mixed with some people reporting positive and timely responses from the service when issues were raised, and others telling us there was often a delay in getting answers when they raised queries. New staff received an induction and training which enabled them to manage people’s health and social care effectively. People’s privacy was respected and their independence encouraged within the limits of personal safety. People told us that staff were kind and caring. Staff treated people with kindness and compassion, and there was a friendly culture in the service.

We have asked the provider for an action plan in response to the concerns found at this assessment. CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.