15 January 2019
During a routine inspection
People’s experience of using this service:
People were not protected from avoidable harm and known risks were not responded to or mitigated. Shortfalls in the service meant people had been exposed to immediate risk of significant harm. The registered manager had not recognised or acted on safeguarding concerns. Lessons were not learnt when incidents occurred and this placed people at risk of ongoing harm.
The provider had not ensured staff had received training in all people’s healthcare needs and as such staff had been providing clinical care tasks without the specific training or oversight. This had put people at serious risk of harm. The provider had not ensured checks were carried out on staff competencies to ensure they were providing safe care. Where concerns about staff practice had been noted through observations of care these had not been addressed by the provider.
People could not be assured that concerns or complaints would be dealt with. There were no robust systems to deal with complaints or for the provider to learn from complaints received. Whilst care plans had been reviewed they had not always involved the person. Care plan reviews had not been effective in identifying where care plans were incomplete.
The provider had not ensured they had robust and effective systems in place to monitor the quality and safety of the service and had failed to recognise the widespread shortfalls in safety. As a result people were exposed to significant levels of harm on an ongoing basis.
More information is in the full report
Rating at last inspection: Good (Report published 1 March 2017)
Why we inspected: We brought the inspection forward due to serious concerns we had received about an unexpected death at the service. Whilst the investigation into the death is on-going we carried out this inspection to check on the safety of the other people receiving care from the service.
Enforcement: As we have rated the service as inadequate, the service will be placed in ‘special measures’. Services in special measures will be kept under review. Following the inspection we took urgent action to impose conditions on the providers registration to restrict admissions to the service. In the meantime the provider submitted an application to deregister and we therefore withdrew any further enforcement. At the time of the publication of this report there are no longer any people using the service which is now closed.