Two inspectors and a specialist advisor in the care of older people carried out this inspection. The registered manager was present throughout. The name of the previous registered manager also appears on this report. They are still on our register as they had not applied to cancel their registration at the time of this inspection. There were 36 people living at the home on the day of our inspection.The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.
We considered our inspection findings to answer questions we always ask:
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well-led?
This is a summary of what we found.
Is the service safe?
People's individual needs were not all adequately assessed, which meant they were at risk of receiving unsafe or inappropriate care. A person had swallowing difficulties, yet their care records contained no specialist swallowing assessment from a speech and language therapist. There were no records on file to show that the person had been referred for a swallowing assessment. The absence of professional guidance meant the person could be at increased risk of choking and aspiration.
People were not all protected against the risks associated with the inappropriate or unsafe use of bed rails because bed rail risk assessments were not always completed.
We found that two people had not received adequate wound care. One person's wound had been infected with maggots. We saw a second person sitting in their room with a bleeding leg wound.
We found that two people were at increased risk of pressure sores because their air mattresses were not set properly or were not functioning properly. We saw two people lying in discomfort on bare mattresses. This put them at risk of skin damage.
The home was generally clean but some aspects of the home's infection prevention and control were insufficient to ensure people were adequately protected against the risks of infection. For example, moving and handling slings were hanging together and were used interchangeably by staff, rather than being dedicated for use with one person only.
There were not enough qualified, skilled and experienced staff to meet people's needs. During the week of our inspection, rotas showed that the numbers of care workers rostered during the day were sometimes lower than the minimum stated by the registered manager. One person told us they liked the staff but there were not always enough of them and they often had to wait for assistance. A member of staff told us they had not been able to write in people's notes on the day of the inspection because they had been so busy; they said that this had been the case previously. Two members of staff commented that there was frequent staff sickness and that shifts were not always covered.
People's personal records were not accurate and fit for purpose. Care plans did not all provide sufficient detail for staff to provide safe and appropriate care for people. Some people's care plans were inconsistent and incomplete. Staff did not have access to complete, written details of people's dietary requirements. This meant there was a risk that people might not receive the diet they needed, particularly if staff who were not familiar with people's needs were involved in food preparation.
Is the service effective?
There was no effective system in place to assess people's pain. Records of pain assessments were missing or infrequent.
People were not protected from the risks of inadequate nutrition and hydration, because they were not supported to eat and drink sufficient amounts to meet their needs. We observed a person with swallowing difficulties reclined in bed repeatedly attempting, but not managing, to drink from a lidded beaker. Staff had not supported them to be able to drink by ensuring they were seated in an appropriate position. We saw they had had thickened drinks that had separated out, which indicated that the drinks had been there a while and that the person had not received the prompting or support they needed to consume them. One person's recorded fluid intake was very low and their care records showed that they had recently had a urinary tract infection. Inadequate fluid intake increases people's risk of acquiring a urinary tract infection.
Is the service caring?
Whilst at times we observed some staff talking with people respectfully, at other times staff were rushed and did not engage with people according to their needs. For example, we saw that one person was sat for the whole day of our visit facing the television. We did not see staff engage with them in any way except to give them meals and drinks.
Is the service responsive?
We observed that before some people received care and support they were asked for their consent and staff acted in accordance with their wishes. However, where people did not have the capacity to consent, the provider did not act in accordance with legal requirements. We saw no records of consent to the use of bed rails, or of decisions made in line with the requirements of the Mental Capacity Act 2005 that this would be in people's best interest. Care records did not all contain sufficient evidence of people's consent to their care, or, in the absence of consent, records of mental capacity assessments and best interest decisions.
Care and treatment was not always planned and delivered to meet people's individual needs. We observed staff did not provide the explanation and reassurance that a person required before and during hoisting. The staff did not take account of their visual and hearing impairments, which meant the hoisting process would have been particularly stressful and disorientating for them.
When people lost weight and were identified as at risk of malnutrition, this was not always adequately monitored or followed up with professional guidance.
People were not always able to request assistance when they needed it. The home had received three complaints from March 2014 onwards regarding call bells removed or left out of reach. We found two people were lying on bare mattresses who did not have access to call bells. We heard one of these people calling out for help for 15 minutes. Call bell analyses showed that many calls were answered promptly but some were left for long periods.
Is the service well-led?
The provider had systems for reviewing and monitoring the quality of service provided to people, but these had not been implemented effectively to ensure that people were not at risk of unsafe or inappropriate care.
We observed that the registered manager spent much of their time working and talking with people who lived at the home. The registered manager had held regular staff meetings to discuss staff morale and to set out improvements needed to their practice. A member of staff told us that staff morale had been low but was improving. Another staff member said they felt the registered manager was a good manager who communicated with staff about the changes that were needed.
We saw records of the registered manager's most recent audit in July 2014. This identified no major concerns and showed that all areas were compliant with company standards. However, it did not reflect the significant shortfalls that we identified during the inspection. For example, it stated that pressure-relieving mattresses were checked daily, whereas we saw that someone's air mattress was not inflated properly and that another person's air mattress was set incorrectly. Adequate daily checks should have detected this.