30 January 2017
During a routine inspection
The overall rating for this service is 'Inadequate' and the service is in special measures. 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 provider's found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this time frame so that there is still a rating of inadequate overall, we will take action in line with our enforcement procedures 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. The 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 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 questions it will no longer be in special measures.
The registered manager was present during our inspection. 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.
During our comprehensive inspection, we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
Risk assessments were not personalised and relevant to the individual.
Information was not available for staff to know how to manage the risks and improve safety to people who swallowing or eating and drinking difficulties. Plans in place for managing risk were not detailed, informative, or specific to the individual. Therefore, staff did not have adequate information to guide them when a person’s risk of choking had increased.
Staff did not have training in the wider risks relating to Dementia, including dysphagia. Dysphagia describes any difficulties or pain in eating, chewing, drinking, or swallowing. The provider did not have a robust or effective system in place for monitoring and improving the quality of care people received related to this condition.
The premises and equipment was not visibly clean and infection control audits were not carried out and call bells were not always responded to in the most responsive and timely way.
The registered manager and staff did not involve people to make decisions about the service they received. Staff did not understand people’s needs and preferences well.
Accidents and incidents were appropriately recorded and investigated. Risk assessments were in place for people who used the service.
Staff did not take an active part in meeting people's social wellbeing and people were not encouraged to take part in the activities they wanted to pursue.
The registered provider did not work within the principles of the Mental Capacity Act and did not always follow the requirements of the Deprivation of Liberty Safeguards.
The registered manager did not have adequate systems in place to continually review the quality of the service being offered to people.