The Care Quality Commission (CQC) has rated Dewi-Sant Residential Home in Plymouth, Devon, inadequate and placed it in special measures following an inspection in September and October.
The inspection was prompted due to concerns received about poor standards of care.
Dewi-Sant Residential Home is a residential care home providing accommodation supporting people living with dementia. At the time of the inspection, 26 people were living at the home.
Following the inspection, home’s overall rating has dropped from good to inadequate. It has also dropped from good to inadequate for being safe, caring, responsive and well-led. It has dropped from requires improvement to inadequate for being effective.
The service is now in special measures which means it will be kept under review by CQC and re-inspected to check sufficient improvements have been made.
Amanda Stride, CQC head of adult social care inspection, said:
“When we inspected Dewi-Sant Residential Home, we were disappointed that the standard of care had significantly dropped since our last inspection in February. People’s basic safety and wellbeing needs weren’t always being met, and risks weren’t effectively managed.
“There were indications that a closed culture may be developing at Dewi Sant. A closed culture is a poor culture that can lead to harm, including human rights breaches such as abuse.
“We found people were not being supported to have the maximum choice and control of their lives and staff using restrictive approaches to support them. Bathing and toileting needs were not based on individual needs but were carried out on a rota basis, and people and their loved ones told us of people being left in undignified states for long periods of time.
“However, we saw staff who were clear about their aim of providing person-centred care. They had a good knowledge of the service and they wanted to provide good quality care. But, the ability to deliver person-centred care was often hindered due to a lack of managerial oversight, staffing levels and ineffective training.
“As the service has been rated inadequate and placed in special measures, we will continue to monitor it closely to ensure people are safe. If we are not assured people are receiving safe care, we will not hesitate to take action.”
Inspectors found:
- The registered manager did not always report and investigate safeguarding concerns. As a result of this inspection 10 safeguarding referrals were made by inspectors to the local authority to investigate
- There were not always enough staff to meet people's assessed needs
- People had been identified by the service as displaying behaviours that may challenge others and themselves. But there was limited information within these peoples’ care records to determine what the behaviours that may challenge others were, and what staff should do to support people
- People's allergies to medicines were not recorded on their medicines’ administration record, as recommended in NICE guidance
- Some people had their medicines given to them hidden in food or drink, which is also known as covert administration. This should only ever happen when it is safe to do so and, in the person's best interest. There were no assessments of people's mental capacity to make decisions about their medicines, no records of best interest decisions and no evidence of pharmaceutical input to ensure that medicines were safe to be crushed and mixed with food or drink
- Institutionalised practices regarding bathing and toileting times had contributed to a potential closed culture
- People were left for long periods of time without much contact from staff. This was because staff were task orientated. Staff were continuously focused on their next duty and did not have time to spend quality time with people or deliver individualised care and support.