The inspection team was made up of an inspector and an expert by experience. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service, their relatives, the staff supporting them and looking at records.
If you wish to see the evidence supporting our summary please read the full report.
Is the service safe?
Some people told us they felt safe and we found that staff were knowledgeable and trained about safeguarding procedures so that they understood their role in safeguarding the people they supported.
There were some improvements since our previous inspection in August 2013 that showed that the manager and staff learnt from some events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The provider responded to the specific concerns that were identified from these and our previous inspection. They were not able to demonstrate how they would routinely identify and assess risks and put systems in place to minimise these risks as a matter of routine practice though. This meant there was an increased danger that the risk of harm to people may not always be identified and there may be a failure to ensure that lessons are learned from mistakes.
We found that there were times where people's needs were not always met appropriately by staff, with staff focusing on the task they needed to do but not engaging with people when they provided care and supported them. We were concerned that staff seemed less able to respond to people's needs during the morning period, with observation showing us that people had later breakfasts as staff did not get them up until mid-morning. We asked the manager about what sort of tools they used to measure people's dependency so they were able to plan how many staff were needed and how they should be deployed. They told us that they did not use one. This raised concerns as to whether there was sufficient staff, or whether they were deployed appropriately, so that people's needs were met and they were kept safe.
We looked at staff training records and saw that the provision of training to staff had improved in mandatory areas. Staff we spoke with presented as having better knowledge in some areas related to people's safety. There was still scope for improvement in areas relating to staff awareness of, for example, how to ensure people's dignity was consistently respected and the Mental Capacity Act.
We asked staff about people who may have a restriction agreed through a Deprivation of Liberty Safeguard (DoLS) (a restriction agreed with social services that is in the person's best interests), and there was a lack of understanding about one person's DoLS having ceased. Discussion with the same staff showed that the restriction was not being applied though, as these were not needed to promote the person's safety. Although this meant that restrictions were not applied inappropriately following the cessation of this DoLS it is important that staff are aware of the status of any DoLS in place to ensure that any restriction is not used unlawfully.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events, and ensuring there is sufficient staff available to ensure people's needs are met in an appropriate and timely manner .
Is the service effective?
People's health and care needs were usually assessed with them present, but they were not always involved in writing their care plans. Some people were not aware of what was in their care plans. Specialist dietary needs were assessed and included. We saw improvement in that all the care plans we looked at had been reviewed since our last inspection. Care plans identified people's health and care needs and staff showed an understanding of these. This meant that information was available to staff to allow them to offer support consistently to meet people's needs.
People's mobility and other needs were not always taken into account in ensuring people had equipment available to them to ensure they could be independent and be enabled to move around freely and safely.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in planning their care and promoting their dignity, privacy and independence.
Is the service caring?
People were not consistently supported by kind and attentive staff. We saw that although some care workers showed patience and gave encouragement when supporting people, others did not. People commented, 'They allow me to have a bath on my own. They just support me getting in and out, also in and out of my bed'. Another person said, 'Staff are always too busy to talk to me. I have to wait for staff to take me (to the toilet) and now they move me in a wheelchair'. A relative said, 'I'm not totally happy with the care in this home. Today (my relative's) shirt is all crumpled and scruffy and my relative has still got their pyjama bottoms on.'
People who used the service, their relatives, friends and other professionals involved with the service were able to complete satisfaction surveys. There were some shortfalls, and concerns had been raised by relatives. The registered manager was able to tell us what actions they have taken to address some of these shortfalls. Some people told us they would complain to the manager if they were not happy with the care, but one person told us they did not know how too, another that they were not confident in raising concerns. People were at risk of not having their concerns and needs properly taken into account.
People's preferences, interests, aspirations and diverse needs were recorded, although what we saw showed that care and support was not always provided in accordance with people's wishes, for example the times that people received their meals.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in planning their care.
Is the service responsive?
We looked at how the service worked with other health care professionals to ensure people's health care needs were addressed. We did see improvement in how the staff had responded to people's changing health needs to ensure appropriate health professionals were involved as and when needed. We saw that there was more regular assessment and review of people's care needs in place.
Is the service well-led?
All of the staff we spoke with said that if they witnessed poor practice they would report their concerns.
The service did not have a robust quality assurance system. Not all of the shortfalls identified by us at our previous inspection had been addressed. We saw that the provider had responded to some of the specific issues we identified during our previous inspection but had not identified other issues of concern that we observed during this inspection. This meant issues of concern were not routinely identified and responded to by the provider through continuous monitoring of the service.
The manager told us that the service worked in partnership with key organisations, including the local authority and safeguarding teams, to identify any concerns about care provision. The manager had informed us of any concerns about people's safety where this indicated potential abuse.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to developing their assessment and monitoring of the quality of the service so as to ensure they can learn from this.