1 May 2019
During a routine inspection
People's experience of using this service:
Quality assurance systems and processes were not effective. They had not identified that risk assessments and care plans had not been completed; non-compliance with health and safety guidance in relation to bedrails; incorrect and missing personal emergency evacuation plans (PEEPS); inconsistencies in the completion of Mental Capacity Act (MCA) documentation; inconsistent recording of people’s fluid intake in care records and an inaccurate record of staff training.
Risk assessments did not always accurately reflect people’s needs. Risks to people becoming trapped in gaps between bed rails, bed frames and their mattresses had not been identified or reduced.
The manager was not aware of all incidents and accidents that had occurred which meant they were unable to ensure appropriate action had been taken to safeguard people.
Documentation for use by the emergency services to identify people’s needs and their whereabouts to support a safe evacuation were inaccurate putting people at risk of an unsafe evacuation.
Confidential information was not always securely stored.
Activities were available for people to access, these were being developed and needed embedding into practice.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were able to personalise their rooms to their choosing. We have made a recommendation about personalising bedroom doors, so people are able to easily locate their rooms.
People were supported by staff that had been safely recruited. Staff knew how to report safeguarding concerns and had a good knowledge of infection control procedures. We observed the environment to be clean with a pleasant odour.
People were supported to access healthcare appointments and were referred to healthcare professionals as needed.
People received their medicines at the time they needed it, Medicines were safely stored.
People were supported by kind and caring staff, that knew them well and enjoyed their jobs.
Rating at last inspection:
This is the first comprehensive inspection of this location.
Why we inspected:
This was a planned inspection.
Enforcement:
At this inspection we found the service to be in breach of Regulation 12 Safe Care and Treatment, and Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014.
Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.
Follow up:
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. Should further concerns arise we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk