15 to 27 July 2021
During a routine inspection
Our rating of this location stayed the same. We rated it as inadequate because:
- Clients living at the service were at risk of avoidable harm and did not always receive the care and treatment they needed. Despite the provider’s attempts to improve, we found significant issues relating to the safety, effectiveness and leadership of the service.
- A clear model of care was not in place. Staff had not ensured they reviewed, assessed or responded to the changing needs of individual clients. For example, staff did not assess or manage risks such as falls, personal care or nutrition well.
- The service was not well led. Clear processes and procedures were not in place to ensure the service ran smoothly. Staff did not use audits effectively to identify issues and take action to rectify them in a timely way. The provider had faced delays in improving its information management system and the roll out of a new governance ‘quality framework’ for the service.
- Aspects of the environment were not well suited to client’s individual needs.
- The team did not have easy access to the full range of specialists required to meet the needs of clients under their care. Staff had not coordinated client access to additional community services such as memory clinics and advocacy in the local area.
- Staff did not always plan and manage discharge well. Some clients had remained at the service when it was no longer suitable based on their individual needs. The service did not have a clear admission criteria in place.
- Staff had not developed holistic, recovery-oriented care plans informed by comprehensive assessments of clients’ mental and physical health. Staff did not provide or ensure clients had access to a range of treatments they needed in line with national guidance about best practice around harm minimisation.
- Managers had not ensured the new staff team had access to adequate training to perform their role. Staff did not always work well together as a team.
- Staff treated clients with kindness but did not actively involve clients in decisions and the care planning process.
However:
- The service was clean.
- Despite challenges with the recruitment and retention of staff, the service ensured there were enough staff to support clients, using bank and agency staff where necessary.
- The provider had remained transparent and was cooperative in working with us to take enforcement action to rectify issues we identified.