Our inspection team was made up of two inspectors. We considered our inspection finding 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.
The rights of people who used the service had not been safeguarded because consent was not appropriately obtained for those who lacked capacity to make decisions about their care and treatment. People were deprived of their liberty without appropriate authorisation and staff had limited knowledge and understanding about the Mental Capacity Act and Deprivation of Liberty Safeguards.
People's care had not been assessed and planned for, which meant staff did not have all the information they needed to ensure people received safe and effective care and support.
People who used the service were put at risk of abuse because staff lacked knowledge about safeguarding procedures and failed to report safeguarding incidents to the local authority safeguarding team for investigation. The practice of restraint was being used at the home without the proper legal processes being followed therefore putting people at risk of abuse.
People were not fully protected from the risks associated with the spread of infection because staff failed to follow infection control procedures.
Parts of the premises were unsafe and posed a hazard to people's health, safety and wellbeing.
Is the service caring?
The service was not caring.
Staff did not always treat people with respect, for example staff shouted across the path of people who used the service and people were served food without plates.
Staff did not take into consideration people's individual needs, choices and preferences when providing care and support. For example people were not consulted about their meals and where they sat.
Is the service effective?
The service was not effective.
There was a lack of person centred care and support. We observed one member of staff assisting three people with their meal during the same sitting. People's care records had not been updated to reflect changes to their care need requirements, which meant people did not always receive effective care and support.
There was a lack of effective record keeping and a lack of appropriate reporting of incidents, which put people's health safety and welfare at risk.
Is the service responsive?
The service was not responsive.
People did not receive person centred care and support because staff followed general routines and did not respond to people's individual needs, preferences and choices.
Staff did not always respond appropriately to people's needs because care records had not been updated with changes which had taken place.
Staff did not respond to people's requests for assistance which compromised peoples, dignity and independence.
People told us they had raised complaints however, one person told us their complaint was not properly resolved and another person told us that their complaint was investigated but they did not receive any feedback. Complaints records did not include any information about the provider's response.
The provider failed to respond to concerns identified at our previous inspection, putting people's health safety and welfare at risk.
Is the service well-led?
The service was not well led.
The home did not have a registered manager. A new manager had been recently appointed but had not started work at the home at the time of our inspection visit. We were told that the deputy manager had been managing the home and that a named nurse was in charge of each shift in the absence of the deputy manager. Senior staff were not clear of their roles and responsibilities and they were unable to provide us with information and locate records, which we requested about the running of the home.
The service did not have a quality assurance system in place to show that identified shortfalls were identified and addressed. The provider failed to identify risks to people's health, safety and welfare, including the lack of appropriate care planning, the risk of the spread of infection control and environmental hazards. The provider also failed to respond to complaints and appropriately report safeguarding incidents for investigation.
We identified a lack of acknowledgment and improvement of issues found during our previous inspections.