19 March 2019
During a routine inspection
People’s experience of using this service: At this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to person-centred care, safe care and treatment and governance.
The service did not consistently mitigate risks. People's risk assessments did not consistently cover all potential areas of risk, such as bed rails, and managing behaviour. We looked at the systems in place for medicines management and found they were not always effective.
People felt safe in the care of staff members and were happy with staffing levels. However, they told us staff did not always arrive on time and staffing was not always consistent. We asked the manager to explore this issue and to look at systems to improve staffing.
Care plans did not reflect people's preferences or routines in all cases.
Systems were in place to ensure that staff received appropriate supervision to support them in their roles. However, training records were not up to date and some specialist training could not be verified. Checks made on the ongoing competency of staff had lapsed from May 2018. We received feedback that some relatives had concerns over the competency of staff to support people effectively.
The provider’s systems and processes in place to monitor and audit had not identified the areas for improvement found. Records management needed improvements regarding medicines, risk assessments, care plans, staff records and quality monitoring of the service. People and staff members were asked their views via regular surveys.
The provider had appropriate systems in place to support staff to raise any safeguarding concerns. Staff had access to appropriate personal protective equipment (PPE) to help prevent the spread of infection.
People were supported to eat meals of their choosing and were supported to access healthcare professionals when necessary.
People told us care staff were caring and kind. Some people told us that timekeeping was an issue and also the consistency of staff that arrived to support people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection: At the last inspection the service was rated good (report published July 2016).
Why we inspected: This was a planned inspection based on the rating at the last inspection.
Follow up: We will monitor all intelligence received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.
More information is in the detailed findings below.