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Inspection Report onPontcanna House

PONTCANNA HOUSE RESIDENTIAL CARE HOME128-132

LLANDAFF ROADCARDIFFCF11 9PW

Date Inspection Completed 21/10/2019

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.

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Description of the servicePontcanna House is situated in the residential area of Landaff, Cardiff. The home is owned by Pontcanna House Limited and registered to provide personal care and support, for up to 28 people from 18 years of age. The responsible person known as the RI, has the responsibility for strategic oversight and the daily operational management of the home. The RI is suitably qualified and registered with Social Care Wales.

Summary of our findings

1. Overall assessmentWe found that the RI was visible, supportive and approachable. They provided clear leadership to the staff team, which was evidenced through observations and discussions with staff. They were well-led through regular supervision and training to perform their role. We saw staff being kind, caring and attentive to people’s care and support needs. The people at the home benefited from a stable staff team that were knowledgeable of their care needs, and communicated with people in ways they understood. Both people living at the home, representatives and other professionals were complementary of the quality of service being provided at Pontcanna. However, we informed the registered person that we have concerns in relation to health and safety and how risks are reduced as far as reasonably practicable. During our inspection visit the registered person took the necessary action to remedy the issues raised. We have issued a non-compliance notice in this area (refer to section five of the report) Following our inspection the local authority has informed the registered provider that their performance is being monitored to ensure the improvements are achieved and sustained.

2. ImprovementsPontcanna House was recently re-registered under the new Registration and Inspection of Social Care Wales Act 2016 (RISCA) and this was their first inspection under the new legislation. Any improvements will be considered as part of the next inspection.

3. Requirements and recommendations Section five sets out areas in which the registered provider is not currently meeting legal requirements. These include:

The management of health and safety of individual’s should be identified and reduced so far reasonably practicable

1. Well-being

Our findingsOverall, people can be confident that they will receive information about what the service can provide, but further revision is required. The statement of purpose and user information are important documents that outline what the service can provide for any prospective person to make an informed choice. When we examined the documents we found that generally they were detailed but would benefit from further revision to fully meet the regulatory requirements. The RI informed us that both documents will be revised and a copy given to all individuals and submitted to the regulator. Additionally, we examined the service agreement that outlines the terms and conditions such as; fees and the notice period for termination of their agreement. We found that the document was detailed and fully informs people about what they can expect from the service. We conclude that people currently receive information about the service but this could be strengthened further.

This is a service that promotes an “Active Offer” of the Welsh Language. The statement of purpose documented its position in this regard, we are told that there was one individual living at the home that speaks through the medium of Welsh, and one staff member available that could speak Welsh. The RI informed us; that they are working towards providing some bilingual documents in the near future. Also, we saw bilingual signage available throughout the home. Furthermore, we met another individual living at the home who spoke a different language. The RI and staff have developed a communication tool to enable people to have a voice, express their views and communicate meaningfully. We saw that there was a pictorial book with useful phrases and questions. Additionally, there was information available about the individual’s country and places of interest. The staff told us; they use a website to play music in the individual’s language which helps them to engage. This was a good example of person centred care, tailored to promote engagement and a sense of belonging.We conclude that there are arrangements in place to assist people with their communication and language needs to ensure they are fully understood.

People are positively encouraged to build on friendships and share experiences. The home employs an activities coordinator, who is responsible to plan varied activities for people to enjoy. When we spoke to the activities coordinator they told us; how they consider people’s needs, interests and hobbies. We saw that on a daily basis they arranged different activities to suit people’s interests and abilities. The home promotes an intergeneration project, and the local school children visit on a weekly basis. We saw the children interacting through, chatting, singing, dancing and having fun. It was evident that people were benefiting from their relationships with the children and we saw displays of genuine affection on both sides. The home shares their experiences with relatives, friends and general public by taking pictures and posting on their home’s website. During our visits we saw staff reading with people, having good conversations, singing and arts and crafts. Also, the home was busy making Halloween decorations for the party planned with relatives. When we examined the

consultation questionnaire feedback, people and their relatives felt that they would like to have the opportunity for social activities in the future. The RI informed us that they will be working towards this area. We conclude that people engage with meaningful activities which gives a sense of well-being and self-worth.

People are encouraged to speak and express themselves. We saw staff having positive conversations with people who live at the home. We saw staff taking the time to explain fully, and offer choices available to encourage people to make an informed choice. We found that the RI has an open door policy and made themselves fully accessible to both people living at the home and the staff team. We saw people speaking freely to the RI. Additionally, the relative’s consultation questionnaire feedback confirmed “it’s good to see a manager that interacts with the residents.’Overall, people benefit from a service that respects their views and listened too.

2. Care and Support

Our findings

People are treated with warmth and compassion. We saw many positive examples of care and support when staff were interacting with people living at the home. We saw staff knocking people’s doors before entering to maintain their privacy. We observed staff having jovial conversations with individuals which indicated that they have a good rapport, and they felt comfortable in the staff’s company. Also, we observed staff communicating with them in ways they understood. Where people appeared anxious or unsettled, staff offered comfort and promptly offered reassurance to reduce their anxiety. Also, we saw that they were encouraged and supported to maintain regular contact with their relatives, friends and other significant people. We received questionnaire feedback from professional’s visiting the home which told us;

“The manager and staff are always respectful and supportive to people” “The staff are always engaging with people at the home” “The home is warm and friendly”

Based on our observations and feedback we conclude that people are supported by staff who are courteous, and treat people with dignity and respect.

Generally, people can be assured that there is a care and support plan in place, but they are not always fully updated to reflect changes. When we examined five care and support files, we found that the RI had completed an initial assessment, which identified the individual’s care and support needs, and determined that the home was able to meet their needs. However, we found that there was some disparity between the information recorded in the care plans to the information in the risk assessments, for example; an individual was independently mobile, but it was stated in some records that they required one to two staff for supervision when mobilising. We saw that the care plans were regularly reviewed on a monthly basis, but the risk assessments were not reviewed at that time to ensure the information was synchronised and amended, when there were changes. The daily care records were not always accurately completed such as; staff had recorded on a few occasions that an individual engaged in an activity, but they were in hospital at the time, therefore, was crossed out. Furthermore, we found the file difficult to navigate due to the number of documents within the personal file, and would benefit from being streamlined to make it easier for staff to access the relevant information. At our second visit to the home the RI showed us; that the care files had been streamlined so they were tailored to the individuals’ needs and reduced the amount of records that staff were required to be completed. This will increase the quality of time being spent with the individuals’ at the home. The RI intends to update all care files to the new format over the coming months.Furthermore, we recommended that the individual or their representative should evidence that they had the opportunity to contribute to their initial care and support plan, and be a part of their review meeting at least a minimum of a three monthly basis. This will ensure that they have a voice about how they would like to be supported and their preferences

respected. We conclude that generally there are care and support plans in place to meet people’s needs but they are not always revised when there are changes. We understand that the RI will be updating all personal care files, therefore we will consider further at the next inspection visit.

People cannot always be confident that risks are minimised. We examined five personal care files and found that generally risks were assessed at the time of admission to the home and assessments in place, which informed staff on how to support the individuals with the associated risks. However, based on the files examined, we found the risk assessments had not been regularly reviewed in accordance with the care plans, therefore, some information was inaccurate. Furthermore, we were aware that a number of falls had taken place at the home, yet, when we tracked to people’s files the risk assessments were not reviewed and updated at the time of the fall, to reflect; any description of injuries sustained, changes to support needs, pain management monitoring, increased observation checks, and to confirm if any further intervention is required. Additionally, there were missed opportunities when advice should have been sought from an appropriate professional to assist the provider with more successful reduction of risk. Also, we noted that there were some risk assessments in the file that were not always needed, if there were no risks associated to the specific individual. The RI agreed to review all risk assessments to ensure they accurately reflected people’s needs and reduce the amount of information, if not relevant to the individual. We found three beds had been modified, rather than advice being sought about sourcing safer and more appropriate beds. When we examined the care files we found that the rationale for making the adaptions (sawing off the legs) and the decision making process, had not been recorded. We informed the RI that furniture or equipment should not be adapted without advice from the manufacturer or from an occupational therapist, as this could compromise people’s safety, rather than reduce the risk, as was the provider’s well-meant intention.We conclude that the service has systems in place to assess and minimise the risk, but further development would be required to ensure risk assessments are appropriately reviewed, revised, and all options have been explored to manage the risk, to keep people safe. Therefore, we have issued a non-compliance notice in this regard, refer to section five of the report.

People can be assured there are arrangements in place for reporting accidents and incidents, but should be further strengthened to fully safeguard the individual. We saw that the RI audits the data on a monthly basis, and the information could be used to identify patterns and trends. The accident and incidents records do not evidence the RI’s analysis and decision making as to whether any further action would be required, therefore we recommended that the form includes an investigation.

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We examined completed accident and incident forms and found that staff had taken the appropriate medical action to safeguard the individual. However, we identified that following a fall, staff had not always completed the falls log or updated the risk assessment in place. We therefore recommended, that the accident and incident form included a prompt for staff to review the risk assessment. The RI agreed to revise the form following our visit. Furthermore, we examined people’s care files and any accident and incidents that had occurred, but found that there were missed opportunities when the registered person should have sought professional advice or explored other alterative options.Also, we noted that body maps were not always completed at the time of submission. When we spoke to staff they were able to confirm the accident and incident procedure in place, which indicated that staff are well-informed, therefore they should ensure the procedure is fully followed. We conclude that people cannot be fully assured that following an accident or incident at the home, appropriate action is taken to minimise the risk and fully safeguard the individual.

People are supported to stay well because they receive proactive care. There was evidence on the care files viewed of involvement from health professionals when needed. We found that people had good access to health services such as; optician, oral care, podiatrist, district nurse, clinical nurse, dietician and other health professionals. Additionally, we saw that people were supported to attend regular appointments to monitor their health. We conclude that the people’s health is promoted to maintain their well-being.

3. Environment

Our findings

People are encouraged to personalise their rooms. We saw that the bedrooms were spacious and people are encouraged to bring items to the home to personalise their space. We saw people had comfy chairs and their pictures and ornaments to make the house their home. People were able to adjust the heating in their room and lock their bedroom door, if they so wish. However, we found that there were up to seven bedrooms that were adjacent to other people’s rooms, therefore we recommended privacy coverings for the windows to ensure the bedrooms were not looking directly into each other. People can be assured that they are able to personalise their rooms to have items that are important to them.

The home provides people with the choice of a single bedroom or there are two shared rooms at the home. We saw that the shared rooms had a privacy curtain, and their own furniture and storage areas. We saw that infection control was being maintained as there were separate soap dishes and toiletries etc. We saw evidence of meetings that had been arranged with the individual and their relatives in relation to making the decision about having a shared room. However, there was no evidence of an individual care plan being in place for people living in the shared rooms and reviewed regularly, to have an opportunity to change their mind, if so wished. We conclude that the registered person offers a choice of rooms but written agreements should be in place and reviewed.

People living at Pontcanna Care Home cannot be fully confident that hazards are identified and robust arrangements are in place, to identify when equipment and furnishings should be repaired or replaced.During our visit we found safety issues such as; layers of blankets on beds that could increase the risk of entanglement, missing radiator cover, exposed wiring on two floor sensor mats, some alarm cords in a bathroom and toilets were broken, commode chairs were worn and rusted, and some mattresses and base of beds were worn and heavily stained. (Refer to section five of the report for further details). Discussions with the RI confirmed that they were unaware of these issues. Therefore, hazards have not always been identified or addressed. The RI assured us that immediate action would be taken to remedy the situation. When we attended the home on our second visit the RI had replaced a number of beds, commodes and sensor floor mats. We recommended, that the registered person reviews the arrangements in place to be fully assured that they have clear oversight of the overall environment to ensure the service operates safely and effectively for individuals to achieve their personal outcomes. We examined the staff training records and found that they had completed health and safety training and infection control training. Therefore, they should have the understanding of the importance of maintaining a hazard free environment, sufficient infection control standards and identify when furniture should be replaced. We recommended that the registered person reviews the arrangements in place to be fully assured that they have clear oversight of the overall environment, to ensure the service operates safely and effectively for individuals to achieve their personal outcomes.

We conclude that the environment is poorly maintained which could compromise people’s safety and therefore, should be remedied. We have issued a non-compliance notice in this regard, refer to section five of the report.

Generally, people cannot be confident that there is effective infection control arrangements at the home. At the time of our first visit we found that the hot water temperature in some areas of the home were below the required temperature to manage infection control and maintain hygiene levels. The RI informed us; that recently a new boiler had been installed at the home and was unaware that the water was not reaching the appropriate temperature. At the second visit we tested the temperature and examined the records and found that they had improved. We recommended that temperatures are monitored at different times of the day, to be fully assured that they are reaching the desired level. Additionally, we found that the water temperature in the 1st floor bathroom was over the recommended temperature and could pose a risk of scalding to staff or the individuals living at the home. In another bathroom, there was cold water running through the hot tap and hot water running the cold tap. The room was locked and the RI took immediate action and arranged for the matter to be rectified. Furthermore, we found that the bins in the en-suite bedrooms were being used for continence products. These bins should have a lid in place to manage cross contamination and reduce any unpleasant odours in the room. When we had a tour of the home we found some bedding and divans were heavily soiled and should have been sufficiently cleaned or furniture replaced. We informed the RI that this was unacceptable, but they confirmed that they were unaware of the situation and therefore, would take immediate action. By the second visit we saw that several beds had been changed, mattresses had been replaced and deep cleaning undertaken in relation to the base of the beds. Based on our observations, the registered person should monitor the infection control arrangements to be fully confident that people are protected from cross-contamination.

4. Leadership and Management

Our findings

People benefit from a RI that is visible and dedicated to the role. We saw the positive interaction between the people at the home, RI, visitors and staff, which was relaxed and friendly. When we spoke to people they were complimentary of the RI and some comments included;

“I am very happy here, both management and staff are very good” “We are always informed of any concerns regarding Mum’s health and welfare” “The management are always there for the staff” “The Management always go above and beyond to make sure the home is run to the

highest standard”Also, during our visits when we identified issues the RI took immediate action to ensure the matters were remedied. We conclude that people benefit from a RI that is experienced, approachable and responsive.

Deprivations of Liberty Safeguards are appropriately made. We examined the care and support files which evidenced applications being submitted to the relevant Local Authorities for people, which are restricted to protect their safety and well-being, due to their memory impairment. Therefore, we conclude that people’s rights are respected.

People benefit from staff that are safely recruited. We examined staff personal files and found that all necessary recruitment checks had been completed in accordance with the required regulations. Furthermore, we noted that staff had not commenced in post until all recruitment checks had been finalised. Additionally, we saw that people’s Disclosure Barring Service checks are being renewed on a three yearly basis. We saw that there were staff identity pictures available as a part of their documents submitted, but we advised that a picture of the staff member would be useful at the front of the personal file for identification purposes. The RI agreed that this would be undertaken. We conclude that people can be confident that they are safeguarded by robust recruitment processes.

People benefit from staff that are familiar to them and feel well supported in their role. We examined staff personal records which evidenced that the home generally retains the staff at the home. When we spoke to staff they confirmed that they felt supported by the RI and enjoyed their work. Furthermore, when we sampled staff supervision records and team meeting minutes, this evidenced that people were given the opportunity to meet on an individual basis and collectively as a team, to express their views and receive the appropriate advice and support. Throughout our inspection visit, we saw the RI encouraging staff involvement and providing recognition for their work. As a result of a consistent staff group they have had the opportunity of developing a relationship with the people at the home, which was based on trust. Staff told us; “The team at Pontcanna House works well together and have the residents’ best interests at heart”. We conclude that people receive consistency and continuity of care by a familiar staff team that are knowledgeable and well-led by the RI.

Overall, people receive care and support from a knowledgeable and well trained staff team. We examined the training matrix and personal files which confirmed that staff received an induction when they commenced post and generally received all core mandatory training to perform their role. When we spoke to the staff they confirmed “I always receive regular training for my role” and “It’s good to recap on training”.We received questionnaire feedback from a professional visiting the home which told us; “Pontcanna is a well organised home with trained and caring staff”. We identified some training gaps but the RI was able to show us that there was a plan in place to ensure all ongoing training requirements are met. We identified that the registered person should also consider other training areas to support people with specific needs such as; learning disabilities, epilepsy, catheter care, diabetes etc. When we spoke to the RI they told us; that arrangements will be made to ensure these areas are included in the training plan. Additionally, over 50% of the staff were suitably qualified to QCF level which has given them the competency based training for their role. The evidence concludes, that the team receives support in the way that improves outcomes for people living at the home, but further improvement is required to include other training areas to effectively support people with specific needs.

Generally, people can be confident that there is quality assurance arrangements in place to ensure they are consulted, but further development will be required. We saw that the registered persons have consulted with people using the service, relatives, staff and other stakeholders. Overall, the results were complimentary and rated that people were satisfied with the quality of care and support received at the home. Also, relatives felt fully involved and kept up to date with changes. Staff felt well supported by management as they were visible and supportive. The comments included;

“The residents all appear to be well care for by kind and attentive staff.” “My mum has settled into a happy family orientated environment.” “The staff are friendly, approachable professionals who work hard to maintain a high

standard of care and support.” “The staff at Pontcanna House have been extremely supportive since mum moved

in both with mum and myself.’ ‘Good to see a manager that interacts with the residents.” “I feel dad is very safe and happy here. I am so pleased he has a loving family

environment to live in. He is well looked after.” “The team at Pontcanna House works well together and do have the residents best

interests at heart.”From examining the annual consultation feedback report from the people receiving the service and their relatives, we found consistency regarding the need to offer more activities outside the home. The RI told us that they were regularly reviewing the activities in the home and will also explore the opportunities for social activities. During our visits we saw a good level of varied activities which were tailored to the needs of the people living at the home. We saw there were consultation reports available which had been analysed but an action plan was not included. This is important, as the people providing the feedback should

be informed of how the service intends to improve. We conclude that overall people have a voice, and their contribution is valued.

People’s confidentiality is anticipated and respected. When we arrived at the home we were asked for our identification and to sign the visitors’ book on arrival and departure. We found that all internal and external exits are alarmed to ensure people’s safety is maintained. We saw that other relatives and professionals visiting the home were also requested to sign the visitor’s book to protect the safety of the people at the home. We found that all confirmation was stored in a locked room which conforms to the Data Protection Laws. Therefore, people’s privacy and personal information is well protected.

5. Improvements required and recommended following this inspection

5.1 Areas of non-compliance from previous inspectionsThis was the first inspection following re-registration under the new Registration and Inspection of Social Care Wales Act 2016 (RISCA).

5.2 Areas of non-compliance at this inspection During this inspection, we identified areas where Pontcanna is not meeting the legal requirements and this is resulting in potential risk or poor outcomes for people using the service. Therefore, we have issued a non-compliance notice in relation to the following: Regulation 57: The service provider must ensure that any risks to the health and safety of individual’s are identified and reduced so far reasonably practicable

This is because we found that there were several issues of concern which could compromise people’s health and safety. (Refer to the issued non-compliance notice at the end of the report)

Furthermore, we identified additional areas where the registered person is not meeting the legal requirements:

Regulation 15 (6): When preparing a personal plan, the service provider must involve the individual and any representative.Regulation 16 (4): When carrying out a review under this regulation, the service provider must involve the individual and any representative. Regulation 21 (2): The service provider must ensure that care and support is provided to each individual in accordance with the individual’s personal plan – In relation to care plans and risk assessments working in parallel and updated when there are changes to people’s needs Regulation 44 (4), (e), (h), (i): Premises must be – (c) suitably furnished and equipped (h) properly maintained, (i) kept clean to a standard which is appropriate for the purpose for which they are being used

A notice has not been issued on this occasion as there was no immediate or significant impact for people living at the home.

5.3 Recommendations for improvementIn addition we made the following recommendation to improve the service:

Statement of Purpose and User Information to be strengthened further to inform people what they can expect to receive from the service

Accident and Incident document should be revised to include a prompt to review the risk assessments and evidence the RI’s analysis and decision making as to whether any further action would be required.

Care Plans should be in place to confirm people’s agreement to sharing a bedroom with another adult and plans are regularly reviewed and revised as necessary

Privacy window coverings should be provided in some people’s bedrooms Consultation reports should include an action plan for the service so developments

can be measured

Registered Person to consider providing other training areas which will increase staff’s knowledge and skill level to support people with specific needs

6. How we undertook this inspection

This was a full inspection carried out in accordance with the Care Inspectorate Wales (CIW)Inspection Framework. We considered all four themes; well-being, care and support,leadership and management, and the environment. Our visit to the home was unannounced and undertaken on 4 October and 21 October 2019. The following regulations were considered as a part of this inspection:The Regulated Services (Service Providers and Responsible Individuals) (Wales)Regulations 2017.

We reviewed the statement of purpose and user information guide and compared itwith the service we observed We met and talked with individuals living in the care home We observed care practices and interactions between staff and individuals living in

the care home We held discussions with the registered person and several staff during our visits We gave out questionnaire feedback forms to people living at the home, their

representatives, staff team and other professionals that visit the home. We received two completed professional’s questionnaire feedback forms

Examined the provision of the Welsh Language at the home We observed the activities at the home and examined the activity records We carried out a detailed examination of five personal files which included; care

and support plans, risk assessments, health care and daily recordings Examined the Deprivation of Liberty Safeguards were in place and appropriately

made We examined the falls protocol and the accident and incident records at the home We looked at a wide range of records, including accident and incidents, engagement

evaluation reports and quality assurance reports We viewed the minutes of staff team meetings We examined three staff personal files, to examine recruitment arrangements,

supervision notes and training files We examined the staff training matrix We examined the arrangements in place for the maintenance and servicing of the

home We had a tour of the environment and considered the facilities provided The registered person was present throughout the inspection therefore we fed back

and confirmed their understanding

We are committed to promoting and upholding the rights of people which use the care and support services. In undertaking this inspection we actively sought to uphold people’s legal human rights.https://careinspctorate.wales/sites/default/files/2018-04/180409humanrightsen.pdf

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

https://careinspctorate.wales/sites/default/files/2018-04/180409humanrightsen.pd

http://www.careinspectorate.wales/

About the service

Type of care provided Care Home Service

Service Provider Pontcanna House Limited

Responsible Individual Nasik Al-Mufti

Registered maximum number of places

28

Date of previous Care Inspectorate Wales inspection

Pontcanna was recently re-registered under thenew Registration and Inspection of Social CareWales Act 2016 (RISCA) and this was their firstinspection under the new legislation

Dates of this Inspection visit(s) 04/10/2019

21/10/2019

Operating Language of the service English

Does this service provide the Welsh Language active offer?

The service is actively working towards the Welsh Language Standards Active Offer

Additional Information:

Date Published 13/12/2019

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

Pontcanna House

PONTCANNA HOUSE RESIDENTIAL CARE HOME128-132

LLANDAFF ROADCARDIFF

CF11 9PW

Date of publication: Thursday, 12th December 2019

www.careinspectorate.wales

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.

mailto:[email protected]

Environment Our Ref: NONCO-00008582-NCXS

Non-compliance identified at this inspection

Timescale for completion 09/12/19

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

Regulation 57 - The service provider must ensure that any risks to the health and safety of individual’s are identified and reduced so far reasonably practicable

Evidence

This is because there was a lack of due regard to the management of health and safety to ensure people remain safe and protected.• We found three beds had been modified by the provider rather than advice being sought

about sourcing safer and more appropriate beds. When we examined the care files we found that the rationale for making the adaptions (sawing off the legs) and the decision making process, had not been recorded. We informed the RI that furniture or equipment should not be adapted without advice from the manufacturer or from an occupational therapist, as this could compromise people’s safety, rather than reduce the risk, as was the provider’s well-meant intention.

• We examined people’s care records and completed accident and incident forms, and found that there were missed opportunities when risk assessments should have been further revised and advice sought from an appropriate professional to assist the provider with more successful reduction of risk. We saw impact to people living at the home, as there were incidents recorded when people had sustained serious injuries.

• We examined the accident and incident records and found that falls had occurred at the home, but the risk assessments or care plans were not always revised at the time to reflect; any description of injuries sustained, changes to support needs, pain management monitoring, increased observation checks, and to confirm if any further intervention is required.

• The accident and incidents records do not evidence the RI’s analysis and decision making as to whether any further action would be required.

• We found three layers or more of sheets and blankets being placed on people’s bed which could limit the freedom of movement and increase the risk of entanglement. References were evident on accident forms of people being found on the floor wrapped in their bedding.

• When we examined the care files we found that there was a lack of reviewing arrangements in place to ensure that risk assessments are regularly reviewed to synchronise with the care plan, which would ensure any updated changes to people’s need are accurately reflected.

• We found evidence that falls logs (to audit and analyse incidents) were not always being completed by staff, therefore patterns or trends may not be accurately identified at the earliest opportunity, which would determine if further action should be taken.

• A number of sensor floor mats should be replaced due to exposed wiring, in two of the

bedrooms, and others should be replaced as they were heavily worn and discoloured or confusing for people who may have perception difficulties because of their dementia.

• We found a wire trailing across the floor from the call sensor to the bed in one bedroom, which could increase the likelihood of a slip, trip or fall.

• The radiator in one bedroom was not safely covered. The people living at the home may not always understand the level of risk and possible consequences, therefore, having access to hot surfaces could result in significant harm or injury.

• We found some alarm call cords tied up and some cords were broken, as a result people would be unable to call for staff assistance. In most instances, the only means for people to summon assistance was by getting out of bed to activate alarm mats.

• A wall alarm socket in one bedroom was loose, which could expose the electric wiring and pose a risk to an individual.

• There was evidence of insufficient cleaning and infection control measures as we found several beds and bedding were heavily soiled with bodily fluids.

• Some bases of beds were heavily stained.• We found several commodes should be replaced as they were rusted and worn or with

buckling legs.• The water temperature in the 1st floor bathroom was over the recommended

temperature and could pose a risk of scalding to staff or the individuals living at the home. In another bathroom, there was cold water running through the hot tap and hot water running through the cold tap.

The impact to people living at Pontcanna Care Home is that they cannot be fully confident that hazards are identified and robust arrangements are in place, to identify when equipment and furnishings should be repaired or replaced.Furthermore, we saw that whilst the service has systems in place to assess and minimise the risk, further action will be required to ensure risk assessments are appropriately reviewed, updated, and revised and all appropriate options have been explored to manage the risk, to keep people safe.We recommended that the registered person reviews the arrangements in place to be fully assured that they have clear oversight of the overall environment, to ensure the service operates safely and effectively for individuals to achieve their personal outcomes. Between the inspection visit date and the issuing of this inspection report, the provider had begun to swiftly address the remedial issues highlighted.

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