10 November 2014
During an inspection looking at part of the service
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?
The service was not safe. We found concerns about the way medicines were managed at the home. Overall, we found that appropriate arrangements for the obtaining, recording, handling, using and safe administration of medicines were still not in place and this put people at risk of harm. People's insulin was still not always appropriately managed and medicines were not always offered at appropriate times.
The provider had failed to act in the best interests of a person who had refused personal care. As a result their health and welfare had been compromised. Appropriate referrals to the relevant health professionals had not been made when the needs of another person had changed. This put a person at risk of harm.
Is the service effective?
The service was not effective in meeting the needs or upholding the rights of people who lacked capacity. Although some improvements had been made since our last inspection, the provider still had little regard for the Mental Capacity Act 2005. Some staff had still not received any training to assist their understanding of the Mental Capacity Act.
Improvements had been made to make the home more dementia friendly. However, there was still a risk that people could become disorientated and confused because the provider did not ensure that doorways to people's personal space were personalised and easily identifiable.
Is the service responsive?
When people's needs changed or new risks emerged, the service was not always responsive and people were put at risk of harm.
The provider had sent the Commission numerous action plans following previous failings that had been accepted by the provider. However, they had not taken sufficient actions that ensured people received good care.
Is the service caring?
We observed that the staff were caring during most of our observations. Staff spoke to people in a caring and compassionate manner. When people became confused and upset, staff dealt with the situation calmly and were attentive to people's needs. However, people's dignity was not always promoted.
Is the service well-led?
The service was not well-led. Although systems were in place to monitor the quality of the service provided, these were not effective and failed to pick up the most of the concerns we had found. Where their checks had identified concerns, action was not taken to ensure they had been addressed and systems put in place to prevent them from happening again. The provider's visits to the home had not been documented and concerns we had found had not been identified by them.
This was the third inspection since May 2013 where we have identified the service had failed to provide us with notifications and therefore it was clear that lessons from past failings had not been learnt.