22 March 2016
During an inspection looking at part of the service
This unannounced focused inspection was undertaken on 22nd March 2016. There were 59 people receiving care at the time of inspection.
The provider had received their first ratings inspection at this location in December 2015 and the service was found to be good in all key areas. However, since the previous inspection we had received intelligence that care practices had become unsafe. The registered manager had been dismissed and the service no longer had a registered manager in position.
There had been a number of changes at the service since their last inspection. The provider had also recently changed. We found that staff morale was low and that staff felt they did not have the right amount of safe and skilled staff to care for people in an individualised way. The service relied heavily on the use of agency staff who were often deployed to manage highly complex people's needs, often isolated away from regular staff. There had been some safeguarding incidents regarding agency staff and people at the service, however, managers had not assured themselves that agency staff had the appropriate skills.
The service had not learnt from incidents of falls, challenging behaviour and recent safeguarding, and reactively managed risk rather than identifying and managing common themes. There was a lack of strong leadership at the service and the deputy manager was covering the manager position as well as their own. However, on the day of our inspection a new manager had started at the service and had made the appropriate notification’s to register with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’.
The management team failed to monitor, assess, and take action to make any changes to improve the service based on feedback and incidents.
Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
You can see what action we told the provider to take at the back of the full version of the report.