9, 10, 11, 12 June 2014
During an inspection looking at part of the service
Our inspection team was made up of two inspectors and we spent time in the home over the course of four days. We spoke with some of the people who used the service, the registered provider, the registered manager, care and ancillary staff. We also observed staff supporting people with their daily activities.
We considered our inspection findings to answer questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?
This is a summary of what we found. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people, the provider and the manager:
Is the service safe?
The service was not safe. Practices in the service did not protect people using the service and staff from the risk of harm.
The home's safeguarding policy did not include reporting procedures to ensure that staff knew what to do if they suspected that abuse was occurring. We witnessed an incident while we were in the home which we reported to the Local Authority Safeguarding team.
Systems were not in place to make sure that the registered provider, registered manager and staff learned from accidents and incidents, concerns, whistleblowing and investigations. Therefore risks to people were not recognised and acted upon.
Staff and management were not putting into practice the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that people were not subject to any form of restraint except as a last resort. The provider had not ensured that appropriate consultation had taken place with relevant health and social care professionals to make sure that people were only subject to restraint when it was in their best interest. Restrictive practices were not regularly reviewed and there were no risk assessments in place when these had been employed.
The environment was not well maintained and risks were not identified or managed to ensure the risk of potential harm to people who lived in the home was reduced.
Staffing levels were not assessed and monitored to ensure there were enough suitably qualified and experienced staff to meet people's identified needs and keep them safe at all times
Is the service effective?
The service was not effective. Our observations showed that people did not always receive the care outlined in their plan in the way it was agreed to be delivered. It was clear from what we saw and from speaking with staff that they did not always understand people's care needs.
Staff did not have effective support, induction and training to make sure they understood how to provide appropriate care for people who lived in the home.
Management did not have up to date plans to promote good practice and develop the knowledge and skills of their staff. Staff were not provided with appropriate training in the specialist needs of people who used the service such as nutrition or hearing and visual impairment training.
People were not provided with suitable food throughout the day and night. Meals were not flexible to meet people's individual needs or choices. People's identified needs in relation to nutrition were not monitored or managed effectively.
People's needs were not met because their independence was not promoted through the use of appropriate furnishings, signage, decoration and other environmental adaptations.
Is the service caring?
People and their relatives were encouraged to make their views known about their care and support.
There was evidence that staff who worked in the home cared about the people who lived there. Generally over the four days we were inspecting in the home we saw that staff treated people with kindness. However there were times when staff did not actively seek, listen to or act on people's views and decisions.
People's privacy and dignity was not always respected or promoted in the way that staff communicated with each other and with people who used the service.
Inadequate induction training meant that new staff did not know the people they were caring for and supporting, including their preferences and personal histories because they were not given time to read people's care plans.
Is the service responsive?
People were encouraged and supported to express what was important to them through regular resident's meetings with the manager. They were supported to be involved as much as they were able to, in the assessment of their needs.
People had access to activities. However these were not planned such a way as to ensure they were meaningful to them through the use of information about their individual interests, backgrounds and social histories.
Staff were not clear about their roles and responsibilities and who took accountability for people's individual care needs.
Shortfalls and risks in the environment were not addressed when a risk had been identified.
Where equipment was broken, it was not replaced or repaired in a timely manner.
Is the service well-led?
The service is not well-led. The provider and manager lacked an understanding of the risks that affected people in the home.
Management were not aware of the day to day culture in the service, particularly during the night shift when staff were routinely waking one person up early.
Resources and support had not been made available to the manager to develop or drive improvement.
There was no effective system in place to report accidents or incidents. For example we had not been notified about a recent accident that occurred in the home in accordance with current regulations.
The provider did not have a robust quality assurance system in place which could be used to drive continuous and sustainable improvement. We found that auditing processes did not identify areas of concern. This meant that these may not be picked up and dealt with in a timely manner.
We found that staff, particularly new staff did not know or understand what was expected of them because there was not an effective induction process in place.