Mr 'C's

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

The service was in breach of legal regulation in relation to people’s safe care and treatment, person-centred care, safeguarding, good governance and staffing.

This service scored 40 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always treat people with kindness, empathy and compassion, or respect their privacy and dignity.

The prolonged breakdown of the lift had a significant impact on some people, but individual needs were not always assessed or appropriately supported. One person with asthma and osteoarthritis was left to negotiate the stairs without assistance following a healthcare appointment, causing them considerable distress and discomfort. In addition, a relative raised concerns their family member, who did not smoke, was affected by cigarette smoke because another person was smoking near a fire escape due to being unable to access the outside smoking area while the lift was out of service. The relative reported they had raised these concerns with staff but felt their concerns had not been responded to sympathetically.

The provider also failed to respond appropriately to concerns affecting one person's dignity, health and wellbeing. Repeated incidents involving faecal incontinence were recorded over several months. A relative reported the person's access to showers had been restricted despite their wish to shower daily, and records did not demonstrate appropriate support arrangements had been developed to maintain the person's dignity while managing associated risks.

These failings meant the provider did not consistently demonstrate a person-centred approach or ensure people's dignity, comfort and individual wellbeing were promoted and protected.

Many people spoke positively about the kindness and compassion of staff. Comments included, “The girls are lovely. They would do anything for you. “and “I love the carers; they are so kind.” Despite this we found systems and practices did not consistently support people to receive dignified, person-centred care.

The provider did not always treat people as individuals or make sure people’s care, support and treatment met people’s needs and preferences. They did not always take account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

The provider did not consistently ensure people received care and support that reflected their individual needs, preferences, circumstances and aspirations. Care records varied in quality and did not always contain information about people's interests, preferences, personal histories or how they wished to be supported. As a result, staff could not always be assured they had the information needed to deliver truly person-centred care.

People and those important to them were not involved in developing or reviewing care plans, reducing assurance that care reflected people's wishes, choices and desired outcomes. Records also contained gaps in consent, mental capacity and best-interest documentation, meaning people's views and preferences were not always clearly evidenced within care planning.

Inspection findings demonstrated leaders did not always have a full understanding of people's individual circumstances. For example, one person who had lived at the service for four months told inspectors they did not have access to their clothes or personal possessions, missed hobbies such as watercolour painting and model aircraft building, and wished they could go outside to smoke. This information had not been identified through care planning or review processes and was not known to the manager.

The provider did not always promote people’s independence, so people did not always know their rights and have choice and control over their own care, treatment and wellbeing.

People were placed at risk because systems for monitoring who was in the building were ineffective. People were coming and going throughout the assessment. We observed members of the public entering the service unchallenged because access to the building was not monitored. This lack of oversight meant the provider could not be assured people were protected from unauthorised access or that accurate information was available regarding who was present in the building at any given time. One relative told us, “We visited [family member] and all the doors were open. We just walked in. We headed to their spot in the lounge, but they weren’t there. Staff told us [family member] was out, but they were in their room. If there was a fire, they would have had no idea [family member] was in the building.”

Following the prolonged lift breakdown, the provider failed to adequately assess and mitigate the impact on people's ability to move around the service, access facilities and maintain their usual routines safely. This had a significant impact on people’s independence and choice, as unless they could mobilise safely, they were unable to leave their room. One person, who was a wheelchair user, told us they would like to get out, and they had to cancel a health appointment because they couldn’t leave the building. We also received concerns from a relative whose frail family member had reportedly been sleeping in a recliner chair in the lounge for several days because they were unable to access their bedroom while the lift remained out of service. They told us, “The lift situation is ridiculous. It’s been 5 weeks. [Family member] was sleeping in a recliner chair downstairs or stuck in their bedroom which is very hot. They spent 10 days in the small lounge in a chair.” When we spoke with the management team about this they had a different interpretation of what happened.

The service did not always support people to maintain independence, choice and control in a consistent and well-planned way. Staff and leaders promoted some positive risk-taking and supported some people to make decisions about alcohol use, healthcare and community access. People were encouraged to maintain relationships and receive visitors, and several people accessed the community independently. Despite this, inspection findings demonstrated arrangements to support choice, control and independence were not always underpinned by effective risk management or oversight, placing people at increased risk of harm.

The provider did not listen to or understand people’s needs, views and wishes. Staff did not respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.The service did not consistently respond to people’s immediate needs or changing risks.

The provider did not consistently recognise, assess or respond to people's immediate needs and risks. Care plans and risk assessments lacked sufficient guidance for staff to identify, manage and respond to known health risks, and were not routinely reviewed following incidents, changes in need or deterioration in health. This was evidenced in the care of one person living with insulin-dependent diabetes and alcohol dependency who had experienced multiple hypoglycaemic episodes. Care records did not provide staff with sufficient guidance on diabetes management, recognising and responding to hypo- or hyperglycaemia, the impact of alcohol on blood glucose levels, or when medical intervention should be sought. Despite repeated incidents, including a fall linked to low blood sugar levels and alcohol use, risk management arrangements were not strengthened, and care plans were not updated to reflect the person's increasing needs.

When the person's health deteriorated significantly, staff did not have the knowledge, skills or guidance required to respond effectively and keep the person safe. Opportunities to identify escalating risks and intervene earlier were missed, resulting in a serious medical emergency. This demonstrated a failure to ensure staff were equipped to respond appropriately to people's immediate and changing health needs.

The provider did not consistently promote staff wellbeing or ensure staff were supported to deliver person-centred care. Despite the challenges they faced, staff remained committed to meeting people's needs and spoke positively about the people they supported. However, staff and relatives repeatedly raised concerns staffing levels were insufficient, affecting both staff wellbeing and the quality of care people received.

Staff reported they did not have enough time to spend with people, support meaningful activities or provide personalised care because they were focused on completing essential care tasks and covering additional duties, including kitchen responsibilities. One staff member described staffing as "the main issue" and said at weekends staff were often "hung out to dry." Staff told inspectors people were sometimes left waiting for support and concerns regarding staffing levels had been raised with the management team on multiple occasions without effective action being taken.

The provider did not always listen to or act on staff requests for additional resources and support. Staff described inconsistencies in staffing decisions, reporting requests for additional staff had been escalated but they had also been instructed to reduce staffing levels.

The provider also failed to ensure staff had the training, development opportunities and support necessary to perform their roles effectively. Inspection findings identified significant gaps in mandatory and specialist training, including training required to support people living with alcohol dependency and alcohol-related brain damage. Supervision was not being used effectively to support staff, assess competency, address performance concerns or identify development needs. Staff feedback also highlighted poor communication with the management team.

These concerns meant staff were not always adequately supported, developed or enabled to provide consistently safe, effective and person-centred care.