4 & 5 November 2015
During a routine inspection
We inspected 9 Grace Road on 4 and 5 November 2015 and the visit was unannounced. We last inspected the service in July and August 2015. At that inspection, we found breaches of legal requirements in four areas; the reporting of incidents and accidents, assessing risk, good governance and safeguarding people who use services from abuse. That meant the service was placed in special measures. We asked the provider to take action to make improvements however they had not time to send a dated plan by the time we re-visited in November. On this visit we found that there were continued breaches in assessing risk, protecting people from harm, providing safe care and good governance. There were further breaches in failing to provide statutory notifications, medicines administration and providing adequate infection control.
The service does not have a registered manager. Following our visit in July the Registered Manager resigned, a manager is now in post and intends to register with the CQC when the appropriate legal clearances have been received.
The provider has commenced sending us notifications about events happening to people living at the home. Notifications are changes, events or incidents the provider is legally obliged to send us within required timescales.
Risks to people’s health and safety was not overseen, managed or reviewed. We found a number of infection control issues throughout the home.
There were sufficient numbers of staff to keep people safe and meet their needs, and staff went through a thorough employment process and were recruited safely.
The legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) were now being followed. The MCA is designed to protect people who can't make decisions for themselves or lack the mental capacity to do so. The DoLS safeguards ensure that people are not unlawfully restricted.
Staff provided a varied response in dealing with behaviours that challenge, and not referring to people with their chosen name.
People’s privacy and dignity were not upheld or respected.
People were provided with meals that met their cultural and dietary needs. Nutrition was monitored by appropriate health professionals.
People were given greater choice on how they spent their time, as an activity co-ordinator had been employed and made improvements for people’s cultural and spiritual wellbeing.
People’s care plans included personalised information about their individual preferences and communication passports reflected how people could be communicated with on an individual basis.
The provider did not have effective systems in place to assess, monitor and improve the quality of care.
We noted a number of changes and improvements through the inspection, however the majority of these were reactive and limited to the deficiencies reflected in the last report.
There was limited information relating to people’s health needs and associated risks with diagnosed conditions. The health action plans which we saw at the last inspection had been removed from the care files.
At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.
CQC is now considering the appropriate regulatory response to resolve the problems we found.