8 September 2021
During an inspection looking at part of the service
People's experience of using this service and what we found
People were not protected from avoidable harm because risk assessments and care plans were not up to date and did not always identify risk. Staffing numbers were not sufficient to meet people’s needs or keep them safe. Staff did not have time to monitor or supervise people who required this. Some people did not have enough to eat or drink and this was not identified, and no action was taken.
The premises and environment were poorly maintained, and this put people at risk of harm. Action required identified in the providers own fire risk assessment had not been taken. Staff had not had evacuation training and there were not enough staff to keep people safe in an emergency situation. Lincolnshire Fire and rescue service visited the service the day after our inspection and served a prohibition notice. This meant the fire service was of the opinion the use of the premises would involve serious risk to people and should not be used.
Infection control policies and procedures did not protect people from infection because government guidance was not always followed. Risks associated with COVID-19 had not always been identified or assessed.
There was a lack of formal oversight from the provider, who had failed to identify the concerns found during our inspection. Quality assurance audits were not always carried out or were ineffective. Staff had not received the training and support they required. People were not consulted about their care and support. People were not protected from the risks associated with receiving care and support.
Rating at last inspection
The last rating for this service was inadequate (published 20 May 2021). At this inspection, not enough improvement had been made and the provider was still in breach of regulations.
Why we inspected
This inspection was carried out to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We also received concerns in relation to staffing numbers and safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement
We have identified breaches in relation to safety, staffing numbers, quality monitoring and governance.
We cancelled the provider's registration.
Follow up
The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.