Muriel Street Resource Centre

Muriel Street Resource Centre provides nursing care to men and women with a range of needs including physical disabilities, dementia and mental illness. The home can accommodate a maximum of 63 people over three floors. There were 35 people using the service on the day of the inspection.

People’s experience of using this service and what we found

People were protected from the risk of harm from preventable risks. Risks to people's health and wellbeing had been assessed and reviewed. Support that people needed to eat and drink was provided in a safe way. The environment was safe and clean. The service continued to follow safe infection prevention and control measures to ensure people were protected from risks of COVID-19. Visiting was allowed to people at the home and the manager explained how this was planned with people’s families.

Rating at last inspection and update

The last rating for this service was Good (Published on 21/04/2021).

Why we inspected

We undertook this targeted inspection to check how the home managed food and hydration for people due to a concern that had been raised. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Muriel Street Resource Centre our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service: Muriel Street Resource Centre provides nursing care to men and women with a range of

needs including physical disabilities, dementia and mental illness. The home is able to accommodate a

maximum of 63 people over three floors. There were 45 people using the service on the day of the

inspection.

People’s experience of using this service and what we found

Since our last inspection, the service had changed. There was a stable management team that with the help of the staff introduced improvements across all the areas of the service delivery. The five breaches identified during our previous visit related to dignity and respect, safeguarding people, nutrition and hydration, staffing and governance of the service had been met. The recommendations about comprehensive risk assessment and risk management planning and the Mental Capacity Act had been followed. Despite the adversities of the COVID-19 pandemic during the last 12 months, the service had managed well and received positive feedback from people using the service, their relatives and external health and social care professionals.

People were protected from the risk of harm and abuse. There was an effective safeguarding procedure in place and staff followed it. Risks to people’s health and wellbeing had been assessed and reviewed. There was a safe recruitment procedure and the managers effectively used the initial probation period and performance management procedures to ensure staff employed were suitable for their role. Medicines were administered safely.

The environment was safe and clean. The service followed safe infection prevention and control measures to ensure people were protected from risks of the COVID-19 pandemic. Accidents and incident as well and any safeguarding concerns had been analysed regularly and action was taken to ensure these had not happened again.

Staff received appropriate induction, training and supervision to help them to provide the most suitable care to people. Staff felt supported by their managers. They told us managers were appreciative of their work and were keen to involve them in the service improvement process.

The service provided effective care to people. People received food and nutrition that was appropriate for their health needs and personal dietary preferences. People’s health and wellbeing had been monitored. Staff took supportive action when people’s health had changed and they needed further attention from external health professionals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and their best interests; the policies and systems in the service supported this practice.

People and their visitors described staff as kind and caring. During our visit we observed staff engaging positively with people in a caring and respectful manner. We saw staff sitting with people and engaging them in discussions and activities. Staff offered people choices so people could make decisions about their care.

People received person-centred care. Each person had personalised care plans which included information about people’s life, their communication and their care needs and preferences. People and relatives were involved in care planning and reviewing.

The home’s lifestyle coordinator, with contribution from other staff involved people in meaningful activities. These were tailor-made for each person and had taken into consideration the drawbacks and benefits of living during the COVID-19 pandemic. People and their relatives had all told us that staff supported them to stay in contact throughout the pandemic.

The home was tastefully decorated in a way that met the sensory needs of people living with dementia. The atmosphere was pleasant, peaceful and everyone (people and staff) appeared settled and relaxed.

The management team together with the provider had introduced a range of effective quality monitoring and assurance systems. These included a mixture of managerial audits and feedback gathered from staff, people living at the home and their relatives. The systems helped to thoughtfully link various aspects of the service delivery, allowing its contemporaneous and seamless review. As a result, any shortfalls in the service delivery were highlighted and actions on improvements were introduced where needed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update: The last rating for this service was requires improvement (published 08 May 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this inspection to check if the service had followed their action plan and to confirm they now met legal requirements. This inspection has initially started as a focused inspection on the safe, and the well-led domain we were also planning to review breaches and recommendations in the effective and caring domains. During our visit, we observed significant improvements in the quality of the service delivered. Therefore, we extended this inspection to a five domain, comprehensive inspection to reflect positive changes across all the areas of the service delivery.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Muriel Street Resources Centre on our website at www.cqc.org.uk.

• Since our last inspection the home had undergone a major managerial change. There was a new registered manager who had worked at the home in different roles for over three years. Other members of the senior management team, including the deputy manager and the clinical lead, had joined the team in January 2019. The lack of a complete management team up to January 2019 was reflected in the running of the home. During our visit we identified shortfalls that needed to be addressed.

• People were not always protected from harm from others. Prompt action had not always been taken by staff when concerns about the lack of person-centred care were raised by people. The management team had investigated all known safeguarding concerns to ensure people were protected.

• Feedback about staff at the home received before and during our inspection was mixed. Alongside some positive comments, we received information suggesting that staff were not always kind or attentive to people. This had been confirmed by our observations during both days of our visit.

• Staff had not always received regular support to assess their skills and to help them to care for people effectively. Not all staff completed their mandatory training within the given time frame. Staff supervisions and appraisal were irregular and for some staff infrequent. Staff conduct had not always been properly managed.

• People were not always sufficiently supported to eat and drink. People needed to wait a long time for their meals and they had not always received appropriate assistance to eat their meals. People’s fluid intake had not been monitored closely as staff did not have guidelines on how much individual people should drink.

• Staff were knowledgeable about people’s individual dietary requirements. However, records related to nutrition had not always been updated promptly. It was possible that staff would refer to guidelines about people’s dietary requirements that were not current.

• Risks to people’s health and wellbeing had been assessed and reviewed regularly. The information about the level of risk had not always been checked to ensure consistency with information in other care documents. It was possible that staff would not have access to correct information about the risk.

• Regular health and safety checks of the premises and the environment had been done. Most of the equipment had been checked regularly. Recording of the airflow mattresses checks needed to improve.

• Quality assurance audits were effective in highlighting issues and shortfalls in care provided. However, the implementation of the improvement plans was not effective in addressing issues, which meant they happened again.

• Relatives said that they had been involved in making decisions about people’s care. However, when people lacked capacity to make decisions, there was not always clear evidence to show that people’s representatives had been consulted.

• Overall, medicines were managed safely. However, a small number of shortfalls were identified during our visit.

• Staff were recruited safely. Appropriate checks had been carried out to protect people from unsuitable staff.

• New staff received an induction to the home and their specific role. Staff felt supported by the management team and they said they could approach managers any time for additional supervision and support.

• People could choose what they ate. There was a selection of food to choose during each meal and throughout the day. Jugs of water and juice were always available to people across the home.

• Staff supported people to have access to external health professionals when needed. Appropriate referrals had been made to ensure people received support they needed.

• The home was clean and well maintained. The environment was bright and spacious, and the home’s decor was pleasant and helped safe movement of people with dementia and perception problems.

• People’s privacy was respected when staff provided personal care.

• People had individual care plans that set out their care needs and how staff should support them. The care planning system needed to be reviewed as information provided was not always consistent.

• The were some meaningful social activities which we observed. A new lifestyle coordinator had commenced further improvement work to ensure all people were provided with individual activities and an interesting activities programme.

• People and their relatives were encouraged to provide feedback about care at the home. This was done through residents and relatives’ meetings and periodic satisfaction surveys. People and relatives felt comfortable with raising any concerns with the registered manager. They felt the registered manager dealt with complaints promptly.

• The management team had received positive feedback from people using the service and relatives. All said they were approachable and responsive to any concerns raised. We observed that the management team was very knowledgeable about the people using the service, their needs and how they wanted to receive care.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have made two recommendation about comprehensive risk assessment and risk management planning and about the Mental Capacity Act.

Rating at last inspection: Requires Improvement (date last report published 26 March 2018)

Why we inspected: This was a scheduled inspection of the service; however, it was prompted in part by notification of an incident following which a person using the service died. The information shared with CQC about the incident indicated potential concerns about the management of risk related to choking and nutrition. This inspection examined if people were at risk related to eating and nutrition.

Follow up: We asked the provider to submit to the Commission an action plan to show how they will make changes to ensure the rating of the service improves to at least Good. We will continue to monitor the service and we will revisit it in the future to check if improvement have been made.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Our previous comprehensive inspection was undertaken on 25 and 26 January 2017 and we rated the service ‘Requires improvement’. During the inspection in January 2017, we did not find any breaches of The Regulations. At that time, the provider had been working on meeting the action plan submitted to the CQC following the focused inspection in September 2016. Although significant improvement had been observed in January 2017 more improvement were still required. At this inspection in January 2018 we observed ongoing progresses in improving the quality of the service delivery had been taking place at the home and more improvement were still needed.

Muriel Street Resource Centre provides nursing care to men and women with a range of needs including physical disabilities, dementia and mental illness. The home is able to accommodate a maximum of 63 people over three floors. There were 48 people using the service on the day of the inspection.

There was a registered manager in post. 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'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager with the support of the deputy manager and the clinical lead had worked continuously on addressing areas for improvement that had previously been identified at our previous inspections.. Our overall observation was that the safety and quality of the service provided had significantly improved.

At the previous inspection, we found that the provider had not managed the administration of topical creams appropriately. At this inspection, we found that this issue had been fully addressed and there were clear records when staff administered creams to people.

At the previous inspection, we found that staff had not received a yearly appraisal of their performance. At this inspection, we saw that the home was in the process of completing staff yearly appraisal and staff had received formal supervision.

At our previous inspection, we found that some people’s records were stored electronically and some in a paper form and it was difficult to find up to date information about people’s care. At this inspection, we saw that this issue had been fully addressed and it was clear which documents staff should look at for up to date information on people.

At the previous inspection, we saw that staff had not always acted in a caring way towards people. At this inspection, we saw the management team had been proactive in addressing any staff conduct issues. However, we observed that some staff practices during a handover process needed further improvements to ensure they supported people in a thoughtful and compassionate way.

There were limited meaningful social and leisure activities at the home. This area of the service provision needed to be improved. The management team were taking action to ensure the quality and the amount of meaningful activities for people would increase.

The provider had a range of systems to ensure the service delivery was continuously monitored and improved. However, a few of these had not been that effective because the provider had not identified the areas that we found during the inspection, as needing improvement. Whilst the service was rated ‘Requires Improvement’ at a previous inspection, improvements made by the provider had not been sufficient to rate the service ‘Good’. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. You can see what action we have asked the provider to take at the back of this report.

People told us they felt safe at the home. The management team had been working towards providing staff with additional training to increase staff awareness of their role in relation to safeguarding people.

Staff levels were maintained in relation to people’s needs. The registered manager was planning to increase staff numbers following new admissions to the service.

New staff received induction and they said it was helpful. We noted the home needed to improve how they evidenced the induction process for each individual staff member to ensure each staff member completed their induction as required.

There were regular service users meetings and satisfaction surveys carried out to encourage people to have their say about the service provision. However, there was no feedback mechanism in place to inform people about actions that had been taken following their comments.

People were involved in the planning and reviewing of their care and their care plans were person centred. However, some improvements were needed to ensure people were supported in understanding and for them to be more aware of the care planning and reviewing process.

We saw that medicines were managed safely and there were appropriate systems in place to ensure any errors in medicines administration had been identified and addressed.

The provider provided care that was safe. Risks to people’s health and wellbeing had been assessed and staff demonstrated a good knowledge on how to support people safely. Robust systems in place ensured people lived in the safe and clean environment. Accidents and incidents were monitored by the management team and actions were taken to reduce to possibility of them reoccurring. Correct infection control arrangements protected people from avoidable infection contamination. Appropriate recruitment procedures in place helped to protect people from unsuitable staff.

Staff received training and had the skills to support people effectively. The management team monitored staff competencies. Identified gaps in staff’s performance were managed through additional training or a performance management process.

People’s care and support needs had been assessed before they moved into the home. The deputy manager managed the referral process to ensure the home was able to meet the care needs and preferences of new people who would use the service.

People were supported to have a nutritious diet that met their nutritional needs and personal preferences. People received appropriate support during mealtimes and we saw they were dining in a peaceful and caring atmosphere.

Staff supported people in having access to community health professionals and services when required. Good communication between the staff team and external health professionals helped to address people’s health needs promptly.

The service had worked within the principles of the Mental Capacity Act 2005 (MCA). People were not unlawfully restricted. Any decisions on people’s behalf were made in their best interests. Staff asked for people consent before providing care and support.

The majority of people told us they knew who to speak to if they had any complaints about the service. We saw that the management team dealt with all received complaints appropriately.

The home had managed the end of life care of people with sensitivity. This matter had been discussed and recorded to ensure people’s wishes were known and respected, as required.

Staff were encouraged to contribute to the service development and they were committed to improving the quality of the service delivery.

There were quarterly service users and relatives’ surveys. The management team had taken actions to ensure the home addressed issues raised in these surveys.

External health and social care professionals spoke positively about the changes and improvement carried out at the home.

Muriel Street Resource Centre provides nursing care to men and women with a range of needs including physical disabilities, dementia and mental illness. The home is able to accommodate a maximum of 63 people over three floors. There were 49 people using the service on the day of the inspection.

The home did not have a registered manager. However, there was an interim manager in post at the time of our inspection that had begun the process of applying to the Care Quality Commission for registration. 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’. 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.

We conducted a focused inspection at Muriel Street Resource Centre on 29 September and 11 October 2016 as a result of concerns that we received and an increased level of safeguarding adult's notifications since April 2016. The concerns related to medicines management, falls management, skills and knowledge of staff in relation to supporting people with mental health conditions and dementia and the general quality of the care being provided at the home. We found significant shortfalls in the care provided to people and identified breaches of regulations 9, 12, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to infection control, monitoring of staff to ensure they remained fit to carry out their roles, staffing and person centred care.

We undertook this fully comprehensive inspection before the completion date of the action plan that resulted from the last focused inspection in September 2016, as we remained concerned at the level of issues being raised about the support being provided to people at the home. These included safeguarding concerns and complaints. We conducted a review of all the five domains, including safe, effective, caring, responsive and well-led to ensure the service provided was meeting people needs.

After the last inspection we received an action plan relating to the four breaches identified. The dates for completion of the actions were between the end of February and March 2017. At this inspection we found an overall improvement in most aspects of the care and support provided at the home. Management oversight of the home had improved as well as staff morale.

In the action plan, sent to us following the last inspection, it stated that improvements in relation to Regulation18, staffing, would be completed by March 2017. From evidence we saw, improvements had begun in relation to staff receiving supervision. As this inspection was in January 2017, the actions were not fully completed, particularly in relation to appraisals and training therefore the effective domain still required improvement. The manager told us it was envisaged that they would be completed by April 2017.

There had been a slight decrease in the amount of staff who had received face to face moving and handling training, although three staff had recently completed a train the trainer course and plans were in place for them to start delivering the training to staff in early February 2017. Other mandatory training was up to date and there were systems in place to flag up when refresher training was due.

People were supported to eat, drink and maintain a balanced diet. People received the support and supervision they needed to eat safely. However, we noted one person’ s eating and drinking assessment identified them as being at risk of choking and a recommendation was made for a referral be made to the dietician. Staff could not confirm to us whether this referral had been made since there was no record of a referral available for us to see. Action was taken by the clinical lead to address this immediately by ensuring an urgent referral was made.

There were systems for storing, administering and the monitoring of medicines and controlled drugs. Staff had the necessary competencies and were trained in medicine administration. However, staff were not always recording the administration of topical creams appropriately.

Staff attitudes were largely positive, however, on occasions some staff were observed to be responding insensitively to the needs of people they were supporting. The interim manager confirmed action would be taken in this area and be monitoring would be on going via the performance management systems at the home.

There was a mixture of care records stored electronically as well as hard paper file copies. However, the hard paper file copies were not always up to date with available information for staff and other health and social care staff to access. This may have led to confusion in terms of accessing up to date information regarding the care and support needs of people at the home.

At the last inspection, we saw there was a high use of agency staff and that staff deployment in the home was ineffective. Planning for people’s appointments did not always happen and staffing numbers at the home were often left short whilst staff accompanied people outside of the home. At this inspection, there were sufficient staff to support people at the home and rotas we saw confirmed this. Arrangements had been put in place to ensure staff were deployed effectively to meet people’s needs. We saw this requirement had been fully addressed.

At the last inspection the provider did not have in place on-going monitoring of staff to ensure they remained able to meet the Disclosure and Barring Scheme (DBS) requirements and they did not have appropriate arrangements in place to deal with staff who may no longer be fit to carry out the duties required of them. At this inspection we saw this issue had been fully addressed. The interim manager was able to show us the electronic system now used to monitor DBS checks as well as a flagging system that identified when new checks were due. There were also safe systems in place and recruitment checks carried out before staff started working at the home.

At the last inspection the provider was not ensuring that the required standards were in place in regards to assessing the risk of, and preventing, detecting and controlling the spread of infections, including those that associated with health care. At this inspection the issues had been fully addressed. We saw that hand sanitizers had been replenished and staff were washing their hands as appropriate. Clean, individual pots were used for each person for administering medicines and Infection control measures were in place. We saw staff using gloves and protective clothing appropriately.

Risk assessments formed part of the person’s agreed care plan and covered risks that staff needed to be aware of to keep people safe.

People had a Personal Emergency Evacuation Plan on their record (PEEP). Their PEEP identified the level of support they needed to evacuate the building safely in the event of an emergency.

People had access to a visiting GP at the home. We saw evidence on care records of multi-disciplinary work with other professionals.

There were systems in place to safeguard people from abuse and staff had a good understanding of the different types of abuse and how they would look out for signs.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).They were able to describe people’s rights and the process to be followed if people were identified as needing to be assessed under DoLS.

Aspects of peoples unique needs relating to this were included in peoples care plans, including ethnicity and religious beliefs. Staff told us this was an important part of supporting people and ensuring their needs were met.

We saw the system for recording complaints and compliments. There had been a total of twenty six complaints raised in the six months prior to our inspection. We discussed that high level of complaints with the interim manager who told us and we saw from records that there had been five unrelated complaints since she came to the home in November 2016. The remaining complaints were raised before November 2016 and were mainly in connection with staff practice issues and, as we have seen throughout this report, action is being planned and undertaken to address the issues and improve staff performance. Recent complaints had been followed up appropriately, according to the provider’s policy.

There was evidence of regular audits and checks undertaken by the management team. These included the checking of care records, medicine audits, infection control and the analysis of accidents and incidents. However these checks were not always fully effective.

At the last inspection, we saw from a recent completed survey from relatives that the general satisfaction level had declined in all areas since the previous survey in 2015. Although an action plan had been devised to target and monitor improvements in these areas, the service were waiting for a new survey to be completed in order to hear more current views of people and their relatives.

Muriel Street Resource Centre provides nursing care to men and women with a range of needs including physical disabilities, dementia and mental illness. The home is able to accommodate a maximum of 63 people over three floors.

The home did not have a registered manager. However, there was an interim manager in post at the time of our inspection. 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’. 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.

The previous registered manager had left the service in December 2015. Since this time, there had been one permanent and three interim managers at the home. One of the interim managers left after our first visit on 29 September 2016 and a further interim manager was in post on our second visit on 11 October 2016. We were advised that recruitment was underway for a permanent registered manager and that the provider was awaiting final recruitment checks.

Managers and staff were not always aware of people’s status in relation to methicillin-resistant staphylococcus aureus (MRSA) infections. Infection control procedures were not always in place or being followed to ensure the safety of service users and staff.

Disclosure and Barring Service (DBS) checks were carried out before staff commenced working with people to ensure their suitability for the role. However, effective systems were not in place to monitor that the rechecks took place as well as following up on positive DBS outcomes. A positive DBS is disclosure and barring check that may reveal a matter that might impact on the suitability of an individual to carry out their role.

Agency staff including nurses did not always have appropriate identification when working at the home. Managers on duty at the home were unaware if staff had the qualifications, competence, skills and experience to carry out their role safely.

People had an up to date Personal Emergency Evacuation Plan (PEEP) on their record. However not all staff were aware of the systems in place to safely evacuate people in the event of a fire.

Supervisions and appraisals for staff were not always consistent. Mandatory training was provided and 70% of staff were up to date with most of their mandatory training, however only 52% of staff had received the face to face fire safety training and 59% of staff received face to face moving and handling training.

Staff were not always appropriately deployed to meet the needs of people staying at the home.

Support was not always person centred and appropriate to people’s needs and preferences

A combination of a lack of day to day management oversight and the frequent change of managers within the home had led to an unstable management structure. Feedback received from a health and social care professional and relatives indicated that the lack of consistent management had impacted on communication with them.

There was a relative’s survey completed for 2016. The general satisfaction level had declined in all areas since the previous survey in 2015. Amongst the lowest scores were, making new residents welcome, the laundry service and making the most of residents capabilities at the home. An action plan had been devised to target and monitor improvements in these areas.

We identified four breaches of regulations relating to infection control, checks in relation to fit and proper persons employed, staff supervision and training and person centred care. You can see what action we have asked the provider to take at the back of the full version of this report.

We found that the provider was still failing to meet the requirements of regulations 10 and 20 and had failed to meet the requirements of the warning notices.

Care and treatment was not planned and delivered in a way so as to maintain people's welfare.

People were not protected against the risks associated with medicines because the provider did not have effective arrangements in place for the handling of topical medicines and the auditing of medicines.

People were at risk of unsafe or inappropriate care as the provider did not have effective systems to regularly assess and monitor the quality of service that people received.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

We spoke with four care workers and a nurse during our inspection who all demonstrated that they knew the needs of the people they provided care for. We also saw that people who use the service reacted positively to staff and that care workers and nurses that we observed were caring in their approach.

We found that people who use the service are at risk of unsafe or inappropriate care and treatment as the provider has not made sure that an accurate record in respect of each service user is maintained. We found that the provider had failed to address issues in relation to records that had been highlighted by the Care Quality Commission when we last inspected the service in February and March 2013.

We found that the provider worked in co-operation with others and carried out appropriate checks as to people's suitability before new staff commenced employment with the service.

We found that a range of care plans addressing people's health, personal and social welfare had been developed and were regularly updated. We visited each floor of the home at 8am and found that whilst some people who use the service were up, others remained in bed in accordance with their wishes.

We found that safeguarding concerns had been appropriately recorded, and that the necessary actions to safeguard people who use the service had been taken. However, we found that some staff required prompting to identify the different types of abuse people who use the experience may experience. The provider may wish to note that improvements to the design and layout of the premises may be needed to ensure they meet the needs of people using the service.

We found that the provider had not ensured that people who use the service were protected against the risks of unsafe or inappropriate care arising from a lack of proper information about them by maintaining accurate records that could be promptly located.