Margaret Roper House

The service was purpose built and accommodation was over 2 floors. People had access to a communal lounge and kitchenette on each floor, in addition to a dining room and conservatory located on the ground floor.

Practices at the service placed people at risk of harm. Systems in place to monitor, assess and improve the safety and quality of the service were not robust.

Risks to people were not always managed safely, as care plans did not always assess risks consistently or provide adequate information on how risks should be minimised and mitigated.

Although accidents were recorded, there was no evidence that risks had been analysed or that safety related themes and trends had been considered, meaning there were missed opportunities to identify and mitigate risks.

People's care plans lacked detail, provided inconsistent information and did not always reflect people's current needs, meaning people were at risk of receiving inappropriate care. There was a lack of management oversight to ensure records were maintained accurately.

Management of medicines was not always safe. The service did not always follow best practice guidance to ensure medicines were managed safely. Policies and procedures relating to medicines lacked sufficient information to help guide staff. Not all staff had an up-to-date competency assessment to ensure they were safe to administer people's medicines.

The environment posed risks to people as it was not safely maintained. For instance, some internal doors were not fire safety compliant. Infection prevention and control procedures were not always effective as some communal toilets were visibly dirty. Some of the communal baths were damaged, which compromised effective cleaning.

The principles of the Mental Capacity Act were not always adhered to when seeking and recording people's consent to their care and treatment, therefore people were not supported to have maximum choice and

control of their lives.

We were not assured people's nutrition and hydration needs were met adequately. Advice from professionals regarding people's intake was not always evidenced as provided. Any support from staff regarding these needs, was not properly documented within care plans. We have made a recommendation for people who require support with their dietary needs, that their care plans are updated to include proper guidance for staff to follow.

Although staff were competent in their roles, some refresher courses for core training, such as first aid and moving and handling, were overdue. However, people told us they thought staff were trained and competent in their roles. We have made a recommendation that the provider ensures training for staff is provided in line with best practice guidance.

We received positive feedback from people regarding their treatment from staff. People told us they were treated and supported well and enjoyed living at the home. People appeared calm and at ease in their surroundings.

Both the provider and quality compliance team responded in a positive and proactive way to the findings at our inspection and began to work to action and address the shortfalls immediately, demonstrating their dedication to improve standards in the safety and quality of care being delivered to people living at Margaret Roper House.