26 April to 4 May 2021
During a routine inspection
Our rating of this location stayed the same. We rated it as inadequate because:
- The provider had not ensured the care premises, equipment and facilities were safe. Important checks relating to health and safety had not taken place. This meant staff, volunteers and clients were at increased risk of avoidable harm.
- Staff had not received basic training to keep themselves and clients safe. Leaders had not ensured that staff and volunteers had stayed up to date with their mandatory training in areas including first aid, fire safety and medication awareness.
- Staff did not always assess risks to individual clients thoroughly, meaning there were potential gaps in the way they managed and mitigated risks such as self-harm. At our previous inspection, there were similar issues that the provider had failed to address.
- Staff did not engage in clinical audit to evaluate the quality of care they provided. Some aspects of care planning were out dated and did not follow national, best practice guidelines.
- The service was not well led. Leaders had lost oversight of the service, meaning performance and quality were not well managed. We found significant failures in governance processes and systems. For example, some staff and volunteers had not been risk assessed in terms of their susceptibility to COVID-19. Audits completed on staff records did not identify this issue. As a result, the service could not be assured it had identified and protected individuals who may be at higher risk of contracting the virus.
- Some policies and procedures had not been fully adapted to the service, were outdated or had not been implemented effectively. This included the provider’s medication management health and safety and auditing policies and procedures. This meant staff did not always have clear guidance to inform them of how to carry aspects of their role safely and effectively.
- Leadership capacity and capability was insufficient to deliver high-quality, sustainable care. Leaders had lost oversight of the service, so performance and quality were not well managed. Where areas for improvement had been identified, the provider did not always act to rectify them.
- The provider had failed to complete the necessary checks required for directors to ensure they were suitable for their role. These checks are legally required under the fit and proper person requirement (FPPR) within Regulation 5 of the Health and Social Care Act 2008, (Regulated Activities) Regulations 2014. The need to complete these checks had been highlighted to the service at our last inspection in December 2020.
- Some staff and volunteers reported that the service had been under increased pressure, during the COVID-19 pandemic and since our last inspection in December 2020, and they did not always feel well supported to fulfil their roles.
However:
- The premises was clean.
- The team included or had access to a range of specialists required to meet the needs of clients under their care. Staff worked together as a team and with relevant services outside the organisation. Staff adapted the support they provided based on feedback from clients.
- Staff treated clients with compassion and kindness. They actively involved clients in decisions and care planning.
- The service was easy to access. Staff managed discharge well and directed people to alternative care pathways if the service could not meet their needs.
- The provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. This included supporting clients to find volunteering opportunities after discharge.