Inspection Report on

Snowdon Care Home

PLAS GARNEDD RESIDENTIAL HOME LLANBERIS CAERNARFON LL55 4LF

Date Inspection Completed

22/11/2019 Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Description of the service Snowdon Care Home is situated within its own grounds above the village of Llanberis, near Caernarfon. Care and support can be provided for up to 27 people. Plas Garnedd Llanberis Limited is the registered provider, with Ross Butler as the responsible individual (RI). There is a manager in post, who is registered with Social Care Wales (SCW), the work force regulator.

Summary of our findings

1. Overall assessment

People are happy with the care and support they receive and they get on with the staff who support them. Activities are provided and people have choices available to them in terms of their day to day routines. Care is delivered within a homely environment; however routine health and safety checks are not fully evidenced and the cleanliness within some people’s own rooms requires attention. Significant risks to people’s safety are not adequately managed and people are placed at risk of harm. Personal plans do not always record in detail people’s individual care and support needs and staff do not always follow the guidance contained within the plans. Generally, staffing levels enable staff to respond to people’s needs as required, although some people say they sometimes have to wait. Information to evidence staff’s suitability to work at the service is not always available and staff do not always receive training at a suitable level to support them in their roles. Quality assurance processes are not evidenced and are not effective in monitoring the service provided.

2. Improvements

This was the service’s first inspection since its registration under The Regulation and Inspection of Social Care (Wales) Act 2016. Improvements made at the service will be considered at the next inspection.

3. Requirements and recommendations

Section five of this report sets out the areas where the service is not meeting the legal requirements and our recommendations to improve the service. These include the following:

 Personal plans and risk assessments;  the environment;  quality of care report;  official RI visits;  staff recruitment information

Page 1  staff training;  safeguarding processes and  staff use of language.

Page 2

1. Well-being

Our findings

Inadequate arrangements are in place to manage known risks to people’s safety. Insufficient action was taken in response to the challenging behaviour of an individual using the service. There was a delay in seeking professional advice regarding the suitability of the person’s placement at the home because the manager told us they were not aware of the extent of the incidents which had occurred. Additionally, there was a lack of risk assessments in place to evidence how identified risks were to be managed or monitored. The available risk assessments were not always updated following a change in people’s needs so they were not always effective in managing the identified risks. People are not always protected from risks to their health and safety.

People like the staff who support them, are happy with the assistance they receive and can participate in activities. We saw people were offered the opportunity to take part in baking and decorating a Christmas tree, other people spent time colouring in and reading magazines. Some people preferred to spend their day in their own rooms watching television and others sat in a communal lounge watching television. People and a relative told us they got on with the staff working at the service and we saw people were relaxed in staff’s company. Some choices were available in terms of what people had to eat, where they sat to have their meals and in terms of people’s daily routines. Staff were friendly in their interactions with people; however, we saw some of the language used by staff did not protect people’s privacy or dignity, this needs improving. People are happy living at the service and can do things they enjoy.

The care and support people require is not always documented within their personal plans and the care provided is not always in line with the information recorded within personal plans. Personal plans lacked specific details in terms of people’s individual care and support needs and how they should be met. Records we saw indicated staff were not always following the guidance provided within personal plans, which could mean people receive inconsistent care and support. We found staff had not received training to promote their understanding of the mental health needs of the people they supported. Dementia training was not at a sufficient level to support staff to provide well-informed, proactive support to people living with dementia. People do not always receive the right care and support.

People are supported within a homely and personalised environment but health and safety checks are not always consistently completed. We saw people’s own rooms were furnished with their own items of importance, which promoted a sense of being at home. Efforts had been made to make the dining room a pleasant space for people to enjoy meal times. Health and safety checks, including fire safety, were not always recorded and we were unable to evidence all the required documentation. The level of cleanliness in relation to

Page 3 people’s bedding was unsatisfactory, which would negatively affect people’s dignity. Improvements are required to enable people to live in a home which always supports them to achieve their well-being.

Page 4 2. Care and Support

Our findings

People may not always receive the care and support they need or as described within their personal plans. We reviewed people’s personal plans and found they did not always contain individualised information regarding people’s needs and desired outcomes and how they would be met. Personal plans for people living with dementia did not record specific information in relation to interventions known to be effective with the person, which would guide staff in how to best support people who were not always aware of their own care needs. Other records we saw indicated staff were not providing people with the care and support they required in line with their personal plan. For example, one person’s personal plan stated they needed assistance with their personal care; however, staff recorded on several occasions the person had independently attended to their own care. The manager told us they believed staff had supported the person to undertake as much of their own personal care as possible, independently, and they considered it was the staff’s use of language, when recording the care delivered, which needed attention. However, they had not addressed this issue. We saw staff assisting a person to get up from their chair by using unsafe moving and handling practices and not in accordance with the guidance provided within the person’s moving and handling plan. The manager intervened which reduced the potential risk of harm to the person. Another person told us of an incident which involved staff using unsafe moving and handling practices whilst supporting them to have a bath. The manager was not aware of this incident until we informed them. They told us face to face moving and handling training would be provided to all staff in the next few weeks. People cannot be confident there is an accurate and up to date plan for how their care is to be provided.

Risk assessments are not always in place to manage identified risks to people’s own health and safety. We saw no risk management plans were in place to support one person at risk. Some personal plans and risk assessments we saw were generic in their content and included references to “he” and “his” rather than “she” and “her”, when appropriate. The wrong person’s name was recorded within one diabetes personal plan. We saw risk assessments were not always updated following a change in people’s needs. This meant, there was no review of the measures in place to manage the identified risks and, therefore, the measures in place may no longer be effective. We saw staff were not always providing support in line with people’s risk assessments; on one occasion, we had to intervene when a person attempted to lift a large, heavy object, which could have caused them harm. We discussed personal plans and risk assessments with the manager and they told us they accepted they were “not quite there yet” and told us this was because they were working on producing a new format to improve the personal plans. People cannot be confident risks to their safety are considered, documented or managed adequately.

Page 5 Risk assessments are not always in place to manage identified risks people may pose to other people who use the service. The impact of one person’s behaviours on other people had not been fully explored, and there were no preventative plans in place. The information provided was not sufficiently detailed or robust to support staff in managing or reducing the person’s distress responses or behaviours; this, in turn, affected the safety of other people who used the service. The manager had not maintained sufficient oversight in relation to the changing needs of people who use the service or ensured the delivery of care was consistent with personal plans. People are not always provided with a service which protects them from risks to their safety.

Safeguarding arrangements in place in the home are unclear and require clarification. We saw a safeguarding referral to the local authority should have been considered for one incident. The manager was unclear under what circumstances a referral might be made to the safeguarding authority by the home. We recommended the arrangements in place to safeguard vulnerable people require improvement. People would benefit from management clarification of the safeguarding processes in the home.

People are happy with the care they receive. We spoke with people who use the service and they confirmed they were happy with the support they received. The feedback we received included “gofal anhygoel o dda” (“unbelievably good care”), “dim byd yn anhwylus iddynt” (“nothing is too much trouble”), “staff are kind”, “sometimes have to wait”. We saw the manager and staff speak to people in a kind manner however, some of the staff used inappropriate language which infantilised people and did not sensitively protect their dignity. We spoke to a relative who told us they were very pleased with the care their family member received. They told us, “When I leave I know my (relative) is safe and I don’t need to worry about them”. We saw people enjoying decorating a Christmas tree with staff support and other people taking part in baking fairy cakes with staff support. People were offered choices during the course of the day in relation to what they would like to eat, where they would like to sit to have their meals and whether or not to take part in activities. People confirmed they were mostly able to choose when they get up and go to bed. We provided examples of this to the manager and they told us the matter would be addressed. Overall, people have positive relationships with staff and are happy living at the service.

Page 6 3. Environment

Our findings

People are supported within a homely environment. The home has benefited from some investment with new carpets in some rooms. The tables within the dining room were laid with fresh linen and fresh flowers and music was playing in the background. This created pleasant surroundings and orientated people to the meal time experience. Fresh fruit and other snacks and drinks were provided within the communal areas, and we saw the manager replenish the stocks to ensure there were sufficient supplies. All the rooms viewed had been personalised with items of importance to each individual person. Some people’s rooms had their photo on their door which helped to orientate people to their own room. Within one bathroom we found an uncovered disposable razor blade which posed a risk to the safety of people with memory problems and potentially an infection control risk. We found two bedrooms had an unpleasant odour. Within these particular rooms and two others, we found stained bed linen, and other areas requiring cleaning. People are supported within comfortable and suitable surroundings but their dignity is affected by the lack of attention to the cleanliness in some areas.

Safety checks within the environment are not routinely carried out and this places people at risk of harm. We saw there was a lack of hand towels in people’s own rooms. The manager told us hand towels had been removed from people’s rooms because they were being laundered. We informed the manager replacement hand towels should therefore be provided. We saw an oxygen container stored within one person’s own room, however there was no sign on the door to highlight this for fire safety purposes. The manager told us they were unaware where they could purchase a sign but we advised a sign was required. We reviewed health and safety documentation and found records were not always available to show measures were in place to protect people from harm. We saw the legionella risk management was not robust and this potentially placed people’s health at risk. The manager was unable to evidence a recent inspection of the electrical system or up to date servicing records for the passenger lift and moving and handling equipment.

We looked at records relating to fire safety and found they were incomplete. We could not evidence that weekly fire alarm tests had been carried out between 24 March 2019 and 11 June 2019. We discussed this with the manager but we were unable to confirm whether or not weekly fire alarm tests had been carried out during this period. We saw no evidence the emergency lighting had been tested on a monthly basis as required by the service’s own procedures. We saw no records of any fire drills undertaken at the service. We saw a North Wales Fire and Rescue Service report, dated February 2019, which stated staff fire training was out of date. We discussed fire safety training with the manager and they told us staff had recently received fire safety training. We saw fire safety was included within a day programme which included 24 other subjects, which suggests the training may not have been in-depth. The manager also told us fire safety training had been booked with a

Page 7 specialist company, to be held at the service. We asked to see written confirmation of this arrangement but no record was provided for us to verify this information. People cannot be confident consistent arrangements are in place to identify and mitigate environmental risks to their health and safety.

Page 8 4. Leadership and Management

Our findings

Sufficient numbers of care staff provide support to people living in the home most of the time. We saw staffing levels were appropriate, although, some people told us they sometimes had to wait for assistance from staff “because they were busy with other people who were ill”. We spoke with a relative, who told us they found staffing levels to be acceptable during their visits, but a visiting health professional told us “staffing levels not as good, staff are always busy”. Overall, people benefit from a service that provides adequate staffing levels.

Improvements are required to the vetting systems in place as part of staff pre-employment suitability checks. We looked at staff files and found not all of the required documentation was available to evidence a rigorous process had been followed to determine staff’s suitability to work with vulnerable people. We found two references were not always obtained and full employment details were not always dated. We saw a Disclosure and Barring Service (DBS) check had not been fully completed for one staff member. We asked the manager during the inspection and the responsible individual following the inspection to provide us with a record of a fully completed DBS check for this staff member; we did not receive this information. However, we did not see any evidence to suggest people using the service had been negatively affected by this. People’s safety would benefit from more complete and improved checks being completed prior to the employment of new staff at the service.

Staff receive training at an introductory level, however this may not fully provide staff with the right skills to care for people living at the service. The manager provided a supervision matrix which indicated staff were receiving formal supervision every 2 months. We saw some, but not all, staff completed an induction when they started working at the service. We viewed training records and saw staff had recently attended training which consisted of 25 individual subjects within a day, which included dementia. We did not consider this level of dementia training to be sufficient in preparing staff in how to best support people living with dementia, in view of the needs of some people living with dementia at the service. We discussed this with the responsible individual who told us one member of staff had a degree in dementia, and there were plans to utilise this by introducing further in-house dementia training to all staff. We saw people with mental health conditions were using the service, however, according to the training matrix provided to us, none of the staff had received training in relation to supporting people with mental health conditions or understanding the specific mental health conditions presented. We saw some staff had recently received moving and handling training which was provided as part of a training day consisting of 17 other subjects. We discussed with the manager the examples of unsafe moving and handling practice we saw and were told of by a person using the service. We asked how staff competency was tested following completion of training. The manager told us they

Page 9 were an accredited moving and handling trainer and intended to provide all staff with further in-house manual handling training in the near future. We recommended the manager undertake a review of the training requirements of the staff team with consideration given to the identified needs of the people who use the service. People are not always supported by staff who receive the correct level of training to enable individuals to achieve their personal outcomes.

There are a lack of formal arrangements in place for the oversight of the service provided. Although the RI said he is in the home 3 or 4 days a week, there was no evidence to reflect their monitoring of the performance of the service provided. We asked to see evidence of the RI’s official visits to the service during and following our visits but no documentation was made available to us. We asked to view the quality of care report, during and following our visit. This document should be available to view during inspection, however we did not receive a copy to view. People and relatives told us they felt able to speak to the manager and the responsible individual regarding any matters, or concerns, they may have. However, we did not see people had been consulted with as part of an official quality assurance process to assess, monitor, review and improve the service provided. During the inspection we found several areas of the service which did not meet the regulatory requirements, some of which had not been identified by the registered persons themselves as areas which required attention. People do not benefit from effective quality assurance processes or oversight of the service.

Page 10 5. Improvements required and recommended following this inspection

5.1 Areas of non compliance from previous inspections

None – this was the service’s first inspection under RISCA.

5.2 Areas of non compliance identified at this inspection

During this inspection we identified areas where Plas Garnedd Llanberis Limited is not meeting the legal requirements and this is resulting in potential risks and poor outcomes for people using the service. Therefore we have issued non-compliance notices in relation to the following:

Regulation 15 (1) (a) – Personal plan. The service provider has not prepared plans for individuals which set out how on a day to day basis the individual’s care and support needs will be met.

Regulation 15 (1) (c) – Personal plan. The service provider has not prepared a plan for the individual which sets out the steps which will be taken to mitigate any identified risks to the individual's well-being.

Regulation 15 (7) (f) – Personal plan. In preparing the personal plan, the service provider has not taken into account any risks to the well-being of other individuals to whom care and support is provided.

Regulation 57 – Health and safety. The service provider has failed to ensure that any risks to the health and safety of individuals (within the premises) are identified and reduced so far as reasonably practicable.

Regulation 73 (1) (3) - Visits: This is because we did not see evidence or documentation of the responsible individual’s official visits to the service at least every three months. There were no evidence to show the responsible individual had undertaken formal visits to the service which consisted of talking to individuals using the service and staff

Regulation 80 (1) (2) (3) (4) - Quality of care review: This is because we did not see any evidence to indicate the responsible individual had suitable arrangements in place to establish and maintain a system for monitoring, reviewing and improving the quality of care and support provide. No report was available to evidence a review of the quality of care and support had taken place, at least every six months.

Page 11 Recommendations for improvement

We recommend the following:

 Discussions should be held with staff in relation to ensuring the use of language which protects people’s dignity.

 Full information and documentation, as specified in Part 1 of Schedule 1 of the RISCA regulations, should be obtained as part of staff pre-employment suitability checks.

 Staff should receive training related to the specific conditions which affect the people who they are supporting. Training should be provided at a sufficient level to fully prepare and enable staff to support people to meet their identified outcomes.

 The processes and arrangements in place to safeguard people from harm and abuse require clarification.

Page 12 6. How we undertook this inspection

This was a full inspection undertaken in response to two concerns we received regarding the service and as part of the CIW dementia thematic review. Two inspectors visited the home on the:

 21 November 2019 (unannounced) between 9:13 am and 6.30 pm.  22 November 2019 (announced) between 09:00 am and 4:42 pm.

We provided feedback regarding the findings of the inspection to the manager at the end of our visits to the service and to the responsible individual on the 29 November 2019.

The following regulations were considered as part of this inspection:

The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.

The following methods were used:

We spoke with:

 six people using the service;  one relative of people using the service;  three staff working at the service;  the manager and responsible individual and  a visiting health professional.

We looked at:

 four people’s personal plans;  the statement of purpose;  three staff files;  training and supervision matrix (undated) and  fire safety documentation.

We undertook a tour of the premises and viewed:

 the main lounge;  the dining room;  bathrooms and  the majority of people’s own rooms.

Page 13 We used the Short Observational Framework for Inspection (SOFI). The SOFI tool enables inspectors to observe and record care to help us understand the experience of people who cannot communicate with us.

Further information about what we do can be found on our website: www.careinspectorate.wales

Page 14 About the service

Type of care provided Care Home Service

Service Provider Plas Garnedd Llanberis Limited

Responsible Individual Ross Butler

Registered maximum number of 27 places

Date of previous Care Inspectorate This was the service’s first inspection under The Wales inspection Regulation and Inspection of Social (Wales) Act 2016.

Dates of this Inspection visits 21/11/2019 & 22/11/2019

Operating Language of the service English

Does this service provide the Welsh This service is working towards providing the Language active offer? Welsh language active offer.

Additional Information:

Date Published 16/03/2020 Care Inspectorate Wales

Regulation and Inspection of Social Care (Wales) Act 2016 Non Compliance Notice

Care Home Service

This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the timescales specified.

The issuing of this notice is a serious matter. Failure to achieve compliance will result in Care Inspectorate Wales taking action in line with its enforcement policy.

Further advice and information is available on CSSIW’s website www.careinspectorate.wales

Snowdon Care Home

PLAS GARNEDD RESIDENTIAL HOME LLANBERIS CAERNARFON LL55 4LF

Date of publication: 05/03/2020 Welsh Government © Crown copyright 2020. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Care and Support Our Ref: NONCO-00008842-RHFJ

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 15 (1) (c) The service provider has not prepared a plan for the individual which sets out the steps which will be taken to mitigate any identified risks to the individual's well- being. Evidence - The registered person is not compliant with regulation 15 (1) (c) - This is because we found several examples where risks had been identified to people's health, safety and well-being but no plans were in place to record how the risks would be managed. No risk assessments were available to show consideration had been given to the likelihood of the risk and the possible severity. - The evidence:

- We saw records which documented a person had fallen and as a result had sustained an injury, which required paramedic attention. Their falls risk assessment and personal plan had not been updated to reflect this incident, therefore there was no reassessment of the person’s risk of falls or consideration given regarding the possible measures which could reduce their risk of further falls .

- The person’s personal plan recorded staff should ensure the person was “visible most of the time”. However we saw the person was often not within staff’s vision and on one occasion we had to intervene when the person attempted to lift a large, heavy object which could have caused them harm should they drop the object or lose their balance.

- We saw several significant risks had been identified in relation to people’s risk of harm to themselves but no risk assessments were in place to record how these risks would be managed and monitored. Records evidenced recurring incidents where a person’s behaviour placed themselves at risk of harm.

- We saw a person who had previously tried to harm themselves did not have a risk assessment or risk management plan in place to record how this particular risk would be managed at the care home .

- We saw a person who had previously been reported as being missing to the Police did not have a risk assessment in place for this possibly occurring again. The manager told us they were not aware of this incident, as it had occurred prior to their appointment at the service. However, the incident was noted within a professional’s assessment stored within the person’s care records, therefore we would have expected the manager to have been aware of this incident.

- We saw a person with dementia had repeatedly attempted to leave the building, without staff assistance, through fire doors. This happened on five occasions between 29 September 2019 and 7 November 2019, during the day and night. There was no risk assessment document in place to record how this risk to the person’s safety was managed or the action taken following each incident as to how to reduce the risk. We saw no evidence to indicate these incidents were reported to the professionals known to the person or any further guidance sought regarding how to best manage this behaviour. No record was available to indicate the manager had contacted the relevant local authority to escalate their request for a Deprivation of Liberty Safeguards (DOLS) authorisation from a standard to an urgent request.

- A person with dementia had repeatedly been found in other people’s rooms, during the day and night, mistaking the people in the rooms for their own close family relatives. There were six instances recorded between 3 November 2019 to 9 November 2019. This behaviour could place the person at risk of harm, as well as other people living in the home. There was no risk assessment in place to document how these identified risks would be managed, despite the repeated occurrences.

- We saw records which indicated a person refused their medication on occasions but their medication risk assessment did not record this or provide any guidance for staff how to respond or what action to take if this occurred .

- The impact on people using the service is they are not always protected from known risks to their safety and are at risk of harm. Care and Support Our Ref: NONCO-00008843-YSTC

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 15 (1) (a) The service provider has not prepared a plan for the individual which sets out how on a day to day basis the individual’s care and support needs will be met. Evidence - The registered person is not compliant with regulation 15 (1) (a) - This is because we found people's personal plans did not contain specific information in relation to their care and support needs or did not record accurately their identified needs. - The evidence: - Personal plans for people living with dementia did not record specific information in relation to interventions known to be effective with the person. No written information was available to guide staff in how to best support people who were not always aware of their personal care needs and would often refuse offers of assistance from staff. - Other records we saw indicated staff were not providing people with the care and support they required in line with their personal plan. For example, we saw a personal plan recorded a person, with dementia, required assistance with their personal care or they were at risk of self neglect. However several times staff had recorded the person had attended to their own personal care independently, with no reference made as to whether or not staff had observed or checked this was indeed the case. One incident which reflected the person’s dignity was negatively affected following their attempt to attend to their own personal care. - One person’s personal plan stated they were able to attend to their own personal care and only required the support of staff with bathing. However, their records referred to a potential for the person to over wash themselves at times, but there was no mention of this behaviour within the plan or how staff could best support the person when this occurred. - One person’s personal plan for diabetes recorded another person’s name within it. This did not preserve the person's dignity, nor did it provide the assurance that the plan was specific to that person.

- A person’s falls risk assessment stated the person did not use a walking frame but records completed by staff recorded they were using a walking frame. Their mobility personal plan did not reflect their mobility was variable, which could lead to incorrect care being provided.

- We saw one person’s moving and handling risk assessment stated the person could walk short distances with a frame and two staff either side of them with the use of a handling belt. We saw staff assisting the person on two occasions but no handling belt was used.

- The impact on people using the service is they do not benefit from having their specific individual care needs recorded which leaves them at risk of their needs and desired outcomes not being met. Specific, individual care and support information would assist staff to provide people with the care and support they require. Care and Support Our Ref: NONCO-00008845-DMSF

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 15 (7) In preparing a plan the service provider has not taken into account any risks to the well-being of other individuals to whom care and support is provided. Evidence - The registered person is not compliant with regulation 15 (7) (f) - This is because we found several examples where risks to the well-being of other individuals to whom care and support is provided but insufficient action had been taken to mitigate or manage these risks. - The evidence:

- We saw records which documented a person living with dementia had physically abused other people using the service between August 2019 and November 2019. Staff had requested a GP out of hours doctor visit on more than one occasion, due to their concerns regarding the behaviour of the person towards other residents. A GP had been contacted on three separate occasions, (27 August 2019, 12 October 2019 and 18 November 2019) for support and advice because of staff concerns regarding the person’s behaviour towards other vulnerable people. This suggested there were ongoing and known issues regarding the person’s behaviour towards other people using the service. However there were no records to evidence the manager had contacted the professionals known to the person for a review of their placement during this period or sought guidance on how to best manage the person’s needs and distress responses.

- The risk assessment created by the manager for these distress responses / behaviours was dated 20 and 22 October 2019 and focused primarily upon what staff should do following an incident of physical abuse made by the person. Very limited information was recorded in terms of preventative strategies which staff could utilise to reduce the risk of future incidents. - The risk assessment did not include information in terms of possible signs or indicators displayed prior to an incident which could be used as a way of preventing further incidents.

- There was no analysis of the incidents as to why they had occurred, potential triggers or learnings taken from the incident in terms of risk management.

- No risk assessment was in place regarding the identified potential risk posed by an individual using the service to other vulnerable people at the service or to persons visiting the home. - The impact on people using the service is people are not fully protected from risks to their well-being and safety. Environment Our Ref: NONCO-00008970-WGCS

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 57. The service provider has failed to ensure the premises are free from hazards to the health and safety of individuals and any other persons who may be at risk, so far as is reasonably practical. Evidence - The registered person is not compliant with regulation 57 - This is because we found insufficient arrangements were in place to ensure risks to the health and safety of individuals within the environment are identified and reduced so far as reasonably practicable.. - The evidence:

- We looked at records relating to fire safety and found they were incomplete. The fire log book evidenced a record of a weekly fire alarm test which was completed on the 24 March 2019 during which the system panel indicated a fault. Records viewed indicated a company was called out to attend to the fault identified, however the next weekly fire alarm test recorded was the 11 June 2019. We discussed this with the manager but we were unable to confirm whether or not weekly fire alarm tests had been carried out during the period between 24 March and 11 June 2019.

- We saw the emergency lighting system had been tested by an external company in April 2019; however no records were available to evidence the emergency lighting had been tested monthly, as this section of the fire log book was blank.

- We saw no records of any fire drills undertaken at the service.

- We saw a North Wales Fire and Rescue Service report dated February 2019 which stated staff fire training was out of date. We discussed fire safety training with the manager and they told us staff had recently received fire safety training. We saw fire safety was included within a day programme which included 24 other subjects on the same day which suggests an overview of the subjects rather than in-depth training.

- Safety checks within the environment are not routinely carried out and this places people at risk of harm. We saw there was a lack of hand towels in people’s own rooms. The manager told us hand towels had been removed from people’s rooms because they were being laundered. We informed the manager replacement hand towels should therefore be provided in the meantime, so people could still wash and dry their hands in their room whilst the other hand towels were being laundered. - We saw an oxygen container stored within one person’s own room, however there was no sign on the door to highlight this for fire safety purposes. We advised a sign was required but the manager told us they were unaware where they could purchase a sign.

- We saw the manager had tested the water temperature monthly, as part of the legionella monitoring process, however there was no record of action taken when the temperatures recorded were out of the safe range. We asked the manager about the issue but they were unable to provide any further information in relation to this. We saw recommendations were made by a company who had undertaken a legionella risk assessment but no records were available to evidence what action had been taken in response.

- We saw records which indicated the electrical system within the building had been inspected in 2008 and the manager informed us another inspection had recently been carried out to bring the inspection up to date. We asked to see a record of this to verify the information and to confirm whether any work was required to the electrical system; however this information was not provided.

- In relation to the testing of the passenger lift and moving and handling equipment, we saw servicing tests had been carried out in April 2019, therefore the equipment was overdue for testing. We discussed this with the manager and asked if records were available regarding further tests undertaken; however no records were provided.

- The impact on people using the service is they are not fully protected from potential risks to their safety within the environment. Leadership and Management Our Ref: NONCO-00008971-GBKJ

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 73 (1) (3) The responsible individual has not provided documentation to evidence they have undertaken visits to the service to monitor the performance of the service which include talking to people who use the service, their representatives, the staff, inspecting the premises and a selection of records of events. Evidence - The registered person is not compliant with regulation 73 (1) (3).

- This is because we saw no documentation to evidence the monitoring systems used by the responsible individual to formally monitor the quality of the service provided.

- The evidence:

- We found there was a lack of official arrangements in place for the oversight of the service provided such as formal visits undertaken by the responsible individual during which they should be meeting with people who use the service and staff.

- During the inspection visits and after the visits, we asked to see evidence of the RI’s official visits to the service but no information was made available to us, so we were unable to evidence that such visits had taken place.

- During the inspection, we found several significant areas of the service which did not meet the regulatory requirements. We have issued non-compliance notices in regard to these. Robust systems to monitor the quality of the service might have identified the areas of non- compliance identified by us, enabling improvement action to be taken in a timely way.

- The impact on people using the service is people do not benefit from effective quality assurances processes or oversight of the service provided. Required improvements are not identified or carried out in a timely way. Leadership and Management Our Ref: NONCO-00008972-RFLD

Non-compliance identified at this inspection

Timescale for completion 02/03/20

Description of non-compliance/Action to be taken Regulation number

Regulation 80 (1) (2) (3) (4) The responsible individual has not put suitable arrangements in place to establish and maintain a system for monitoring, reviewing and improving the quality of care and support provided by the service. Evidence - The registered person is not compliant with regulation 80 (1) (2) (3) (4)

- This is because we saw no evidence suitable arrangements were in place by the responsible individual to monitor, review and report upon the quality of care and support provided by the service.

- The evidence:

- We asked during and after the inspection to see the quality of care report but no report was provided to us and the responsible individual could not confirm that a formal system was in place for monitoring, reviewing and improving the quality of care and support provided in the home.

- No report was available to evidence a review of the quality of care and support had been undertaken, at least every six months, in accordance with the requirements of this regulation.

- At the inspection we found areas of significant non-compliance with regulations in the areas of personal plans, management of risks to people's health and safety, cleanliness of bedding within some people's own rooms and inconsistent health and safety checks. The responsible individual was aware the manager was working on improving people's personal plans and risk assessments; however they were not aware of the other areas of concern we found, or the areas of the service which were not meeting the regulatory requirements. An effective quality monitoring system would have helped to identify such areas so that robust action could be taken to address the issues.

- The impact on people using the service is they do not benefit from effective quality assurances processes or oversight of the service.