What the CQC found at Allonsfield House

People received their medicines as prescribed. Staff were trained and assessed as competent, and time-specific medicines were given according to people's schedules.

“The services used an electronic medicines system. This was well managed, and people received their medicines when they should.” from the report

Care plans recorded people's needs, wishes, backgrounds and risks. People, relatives and other professionals were involved in assessments where appropriate.

“People's care plans were person centered and detailed the care and support they needed or preferred.” from the report

Inspectors saw that staff protected privacy during personal care, knocked before entering rooms and used people's preferred names.

“Bedroom doors were closed so that people were not observed when having personal care.” from the report

Staff knew how to report concerns. Incidents were investigated, reviewed and used to share learning across the provider's services.

“The provider had an electronic system to monitor incidents and ensure lessons were learnt and shared should a concern arise.” from the report

People in the dementia unit were left for lengthy periods without supervision or interaction, even though staff were nearby doing other tasks. Staff were also not always available in dining rooms.

“We observed lengthy periods of time when people in the dementia unit lounge had no supervision or interaction with staff, although staff were in the unit carrying out other tasks.” from the report

People living with advanced dementia or who were nonverbal were not consistently offered meaningful activities. Some were left to occupy themselves with repetitive or self-soothing actions.

“People living with advanced dementia or who were nonverbal were not offered any form of structured or unstructured activity in the morning of our inspection visit.” from the report

The dementia unit had no suitable books, magazines or dementia-specific items, and its garden and dining room had not been adapted well. The Allonsfield Suite was also described as dark and tired.

“There were no books, magazines, or dementia specific items such as twiddle muffs.” from the report

There was no clear system to check the wellbeing of everyone throughout the day. The quality assurance systems had failed to identify all the issues found by inspectors.

“There were quality assurance system in place. However, these had not identified all of the concerns identified above.” from the report

Some people were not supported consistently or with full dignity before lunch. In one dining room, no staff member stayed after meals were served, so immediate help was not available if someone choked.

“In the Allonsfield suite no member of staff stayed in the dining room once people had been served their meal.” from the report