Archived: Autumn Care

We spoke with relatives who were happy with the care provided. They considered that staff were caring and that people's needs were met.

People who were living in the home were unable to talk with us about the care they received, due to their condition.

People did not have regular assessments of their care needs. We found that when their needs changed this was not identified. Care plans were not reviewed to ensure needs were met appropriately. People's care plans did not accurately reflect the care they needed or evidenced what care was given. People had been left in pain and discomfort and were at risk of serious harm. The service was not providing appropriate care and people were being neglected.

We noted that on occasion entries in the daily records had been falsified. The registered manager was seen writing an entry for a night shift when she was on the day shift. People did not experience continuity of care. Staff lacked leadership and did not have delegated roles. This meant that more than one care worker attended to each person. We saw that staff did not look at care plans and did not have a formal handover at shift changes.

We observed mealtimes on each of our visits. We noted that portion size was adequate and staff usually assisted people to eat and drink. However, this was not consistent. On occasion staff attempted to assist more than one person, which meant other people's food was cold by the time staff supported them. Some people did not receive any support by care workers to eat their meals; this was provided by visiting professionals and us.

Food available in the home did not indicate that a healthy balanced diet was available; we noted a lack of fresh produce such as fruit and vegetables. When people had specific dietary needs these had not been catered for. For example people with diabetes or requiring a soft diet.

There was a lack of choice for people in their daily lives and activities were limited to watching television. Staff did not always respect people living in the home and spoke over them, rather to or with individuals. Staff were task focused and failed to treat people as individuals. The majority of people spent their day in bed or in their rooms and were left for long periods with no social interaction.

There was a lack of infection control procedures and audits of the service provision.

Cleanliness of the home was visibly adequate, but there were a few rooms that smelt of urine. There were no systems in place to ensure that cleaning was carried out appropriately. Staff shared equipment between people, such as slings and slide sheets; they did not clean this equipment in between use. Staff did not use aprons or gloves when delivering personal care or doing other tasks. This did not protect people from the risk of cross infection.

The home did not have sufficient amounts of equipment to make sure needs could be met. For example, one hoist had to be carried upstairs so it could be used. We witness poor manual handling and moving of people.

Staff were not supported or suitably trained and supervised by the registered person. We found that training records were scant and people had not received mandatory training annually as required. Staff had not been recruited in a safe manner and we found that checks had not been made to ensure they were suitable to work with vulnerable people.

Staff were unaware of the need to notify us of safeguarding concerns. They were not aware that if people's needs were not being met this was neglect.

The registered person did not have suitable systems in place for monitoring the service provided. People and their representatives had not been asked their opinion on the running of the home. The registered provider said that they supervised the registered manager, but this was not recorded and he only visited the home on a monthly basis. He did not demonstrate a practice approach to the concerns raised.

All the people who lived in the home were moved to other locations in January 2012 by the commissioning local authorities following assessment. We have a voluntary agreement with the provider not to admit any more people to this location.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.