In August 2011 we carried out an inspection of the service and made several compliance actions. We carried out this unannounced inspection to ensure the provider was compliant with those actions. The people who use the service that we met and talked with were very positive about the staff and the way they were supported by them. We asked one person if they thought that there were enough staff on duty including at weekends. They told us that they thought there were sufficient staff. One person told us "The staff are really nice girls".
People said that they appreciate having their own rooms, and being able to choose how
they are decorated. One person told us "I choose the things I like to have in my room".
People told us that they liked living at the home. One person said "I'm really happy here it's my home".
When discussing personal choice, one person told us "I can get up when I like. If I don't
feel very well I go back to bed ". Another person told us "It's lovely. There is nothing
wrong with the place. I've got lots of freedom".
Four people who use the service told us that they felt safe at the home and that staff are "kind and considerate".
People told us that the food was "lovely" and that there was plenty to eat at times that
suited them. One person said "I can't fault the food".
Staff members we spoke with told us that knew about the whistle blowing policy. One
person said "There is a lot of whistle blowing going on at the moment. It's caused a lot of tensions in the staff team ".
From December 2011 to February 2012 we attended three safeguarding meetings
regarding concerns raised about the care of people living in the home. The subsequent
investigations and actions taken to discipline staff showed us that people had not always received safe care. As a result of the safeguarding concerns, in December 2011, the local authority stopped the placements of people into the home.
The issues, raised at the safeguarding meetings, included concerns about the manual
handling assessments and risk assessments for the use of specialist equipment such as a slide sheets or rotunda. Risk assessments did not provide enough information to support staff members in assisting people with safe movement and transfers. We read in one persons care file that they were concerned about the way staff had transferred them onto their bed. During our visit we saw a staff member transfer a service user in a wheelchair. We saw that they did not put the wheelchair foot plates down for this person. This person was put at risk of injuring their feet during the wheel chair manoeuvre.
There were also issue about unsafe staff practices in relation to the administration of
medication. We looked in the manager's personal file and did not see any evidence that
the manager had undertaken additional training in the administration of medication to
ensure they understood safe practice.
Members of the safeguarding meeting were concerned that the manager and the provider did not always inform the appropriate agencies about safeguarding incidents.
Following our visit a health professional told us they had visited the home and had been
concerned about aspects of medication safety, as they had seen that the keys to the
mobile medicine cabinet were in the lock of the cabinet. They were concerned that the
cabinet was unattended by staff members.
At our visit we saw that staff members were not properly trained or supervised. Some staff members have not received an induction when starting work at the home. The manger had not received any supervision, appraisal or induction. Staff members did not receive additional training after poor practice has been identified.
We have issued a Warning Notice about Regulation 23 (1) (Outcome 14) which requires
the registered provider to take action by 16 April 2012 to meet the regulatory requirements. If this is not achieved further enforcement action may be taken.