3 Beatrice Place

At our inspection on 20 May 2014 we found significant improvements had been made. The provider had put an accelerated programme in place in the service to bring the service up to standard. This included bringing in senior staff from within the trust to ensure improvement was sustained in the long-term.

Key policies related to the management of control and restraint had been reviewed and updated. A review of the provider's management of violence and aggression policy had been updated to provide staff with clearer guidance of how to de-escalate potentially difficult situations and how to carry out control and restraint if required. Additionally the provider had developed a local policy on physical intervention (restraint) for personal care developed specifically for older people.

The provider's governance arrangements for the service had been strengthened. The service had introduced regular meetings for management staff to consider issues of quality, safety and standards. Minutes from the inpatient safety and care quality meetings showed that a wide range of issues relating to the quality of the service were monitored and discussed. This included oversight of physical interventions, incidents such as falls, safeguarding and staff training. These were being monitored regularly by senior staff in the service. This helped ensure quality assurance systems were effective in identifying and managing risks to people using the service and others.

However we found that some physical risks were poorly assessed, monitored and did not include management or care, support or treatment plans. As a result people did not receive safe or appropriate care and support.

Overall, people who use the service were positive about staff who worked at Beatrice Place. Comments ranged from 'okay' to 'jolly and kind'. We observed staff interacting with people in a respectful manner. Staff had gained considerable knowledge about the early lives of the people who use the service and also knew about their important family relationships.

Whilst there was good information about people's life stories, the service had failed to use the information to ensure that people's needs were appropriately met. We found examples where the failure in linking people's early life experiences led to care that at times undermined people's safety and wellbeing.

The provider failed to respond appropriately to an allegation of abuse both in terms of how it was investigated and how it failed to protect the person who made the disclosure. Sometimes people had to be restrained in order to deliver care or to keep them safe. We found that half of the clinical staff had not been trained to restrain people appropriately and safely. This put people at risk of harm. Strategies to de-escalate potentially violent situations were inadequate.

We saw that the provider had invested resources and implemented systems to improve the service. This included auditing people's care arrangements and reviewing incidents in the service. However, we found that that these were not sufficiently robust to protect people from the risk of unsafe or inappropriate care and treatment.

Some people who lived at the service had difficulties in communication because of their levels of dementia and were not able to tell us about their experiences of the care they received. We undertook two short observational framework of inspections (SOFI) so we could closely observe how some people experienced their care. We found that mostly staff engaged positively with people who use the service and some were particularly warm and respectful in their interactions.

People were sometimes at risk because their identified physical health needs were not adequately met. They were also at risk because there were no de-escalation techniques in place for when people became highly anxious and distressed about their care intervention. Staff were not provided with directions or guidance on how to engage positively with people who had complex communication needs.

Staff were trained in their responsibilities on how to safeguard people who use the service. However there was a recent incident where staff failed to respond appropriately to an allegation of abuse. People were not always protected from the risk of excessive control or restraint and these incidents were not documented and reported properly.

Staff had been recruited into vacant posts and there was a low usage of bank staff. At the time of our inspection there were sufficient staff on duty. The service had recognised the need to improve the skill mix of its staff so that people's physical health needs could be better met.

The service had undertaken some monthly monitoring but there was little evidence the data would contribute to information on either the quality of the service or reduce the risks of unsafe care. People's feedback on their experiences of the care they received were not actively sought.