moderate“one person who had requested only female staff, had care given by male staff on occasions. Another person's plan said they liked to shower twice a week, but this was not happening.”
moderate“people who were cared for in their bed, or who spent all of their time in their room, were at risk of social isolation as staff were too rushed to spend meaningful time with them.”
critical“The registered provider was not providing person-centred, responsive care to people in order to meet people's individual characteristics and to avoid social isolation.”
governance
3 findings
moderate“the provider had systems in place to regularly review the care plans and although these were up to date, the provider had not identified these issues.”
critical
“the lack effective governance arrangements meant there was a continued breach of Regulation 17”
critical“The on-going lack of good governance and management oversight or commitment to improve people's care was a continued breach of Regulation 17”
consent capacity
2 findings
moderate“Some staff we spoke to told us they did not fully understand the Mental Capacity Act, even though they had training in this area.”
moderate“One person was determined as lacking capacity to make complex decisions, but there was no best interests paperwork to support any decision made on their behalf.”
other
2 findings
moderate“The service had recruited one activity coordinator, but more were required...Most people told us there was not enough for them to do and they mainly spent time in their rooms watching television.”
moderate“we again found this cupboard unlocked. We reported this to the registered manager.”
infection control
2 findings
minor“Sluice rooms (dirty utility rooms) were not being used correctly. We fed this back to the provider and recommended they seek further guidance in this area.”
critical“Sluice rooms on two floors were not being used correctly by staff and two smelled strongly of urine... There was also faecal staining on some of the equipment.”
leadership
2 findings
critical“management had created a cultural divide within the service, the provider remained in breach of Regulation 17.”
critical“In the last six years, this service has had 13 managers. All of whom had left after a short period of time and only two of those had registered with CQC.”
care planning
2 findings
critical“their risk assessment had not been reviewed for over a month and staff had not been monitoring this person's weight more frequently.”
moderate“People's care plans were not contemporaneous, and staff were not always able to tell us about people's individual care needs.”
safeguarding
2 findings
critical“One person was without their call bell. They told us, 'They took it away as I was a nuisance. I can wait ages. I have to scream to be heard.'”
critical“The lack of robust processes in place to help ensure people are safeguarded from abuse and improper treatment was a breach of Regulation 13”
staffing levels
2 findings
moderate“There is a shortage of staff and my concern is the time it takes for staff to get to her when she rings the bell.”
critical“The failure to provide a sufficient number of suitably qualified, competent and skilled staff in order to meet people's needs was a breach of Regulation 18”
communication with families
2 findings
moderate“It's a disappointment because she doesn't communicate with us. There are no residents/relative meetings.”
moderate“There is constant management change which is really quite worrying. We never receive any correspondence and there aren't any meetings.”
cultural competency
2 findings
moderate“There is a language barrier. I can't understand a word they are saying, it makes me feel anxious. They stand over you and talk in their own language every day.”
moderate“people reported staff continued to speak in their own language, rather than English. This was identified at previous inspections.”
record keeping
1 finding
minor“we found a lack of personal history in people's care plans. A staff member said, 'I don't know anything about his background, but it would be useful to know.'”
staff competency
1 finding
critical“The failure to ensure staff are sufficiently competent to provide care in a safe way was a breach of Regulation 18”
staff training
1 finding
moderate“where shortfalls or concerns had previously been identified at this service, training had not taken place with staff to help ensure they did not reoccur.”
incident learning
1 finding
critical“lessons had not been learnt as changes had not been made to the service to help ensure people were free from potential abuse.”
complaints handling
1 finding
minor“complaints... were not stored as a separate log and as such it was difficult to see what action had been taken, whether the complaint was resolved”