CQC Location ID:1-310212834
Dates of the assessments were 21 January 2025 and 03 February 2025. The service is a care home providing support to older people living with dementia, nursing needs, and physical disabilities. The manager investigated and reported safety events. Reflective reviews were carried out after events to support lessons learnt and improve. The provider did not always make sure there was continuity of care, including when people moved between different services. The provider did not always work well with people to understand and manage risks. We identified some people’s needs were not met in respect of management of their skin integrity, continence and mobility. This had not always been identified in audits carried out by the service putting people at risk of being harmed and their health and wellbeing deteriorating. People told us they did not always feel safe with the care received. The provider did not always detect and control potential risks in the care environment. The provider did not make sure there were enough qualified, skilled and experienced staff. During our assessment we observed that staffing levels were insufficient which impacted on people. The provider did not always assess or manage the risk of infection. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The provider mainly promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing. We found care plans and risk assessments were mainly person-centred, ensuring independence, choice and control was appropriately detailed. The provider valued diversity in their workforce. The provider did not always have clear responsibilities, roles, systems of accountability or good governance.
During this assessment we spoke with 8 people and 5 relatives. People told us the transitions to and from the home were not always good. One person told us, “My [relative] was admitted to hospital, and we did not know, and my [relative] also went with no contact details, so the hospital were unable to contact us” and “When my [relative] arrived here, they required a 72-hour continence test they were very delayed in doing this.” People told us they did not always feel safe with the care received. Some comments were, “My [relative] is supposed to have one to one as they have a specific way to go to the toilet and the agency staff don’t know how to do it correctly” We got mixed feedback in relation to the environment, but most people told us they were unhappy with the environment. Some comments included, “The maintenance here is rubbish”, “The double socket in my [relative] bedroom was hanging off and wires were exposed, and it took a week to mend after reporting it”, “The bath has been broken for two years”. We got mixed feedback in relation to staffing but most people were not happy with the number of staff or the regular use of agency staff. Comments included, Staffing levels are not adequate”, “They need to review staffing”, “The regular staff are good, not good agency staff they are terrible”, “The regular staff are good, but they are so busy they do not have time to spend with the residents”, “The staffing needs reviewing”. We got mixed feedback from people in relation to infection, prevention and control but most people were dissatisfied with the cleanliness of the home. Some comments included “My [relative’s] room could be cleaned better, and their bathroom could be cleaned better, staff leave stuff in the sink”, “There has been soiled underwear left in their bathroom”, “It could be cleaner here”. We received good feedback in relation to independence choice and control. Comments from people were, “I can do what I want”, and “You can make your own choices”.