Aspen Hill Village on Church Street, Hunslet, is a care home that can accommodate up to 180 people who require support with nursing or personal care needs, some of whom were living with dementia.
At the time of the inspection in April, 123 people were living at the service.
Inspectors spoke with nine people using the service and eighteen relatives about their experience of the care provided as part of the visit.
People did not always receive safe care at Aspen Hill Village, inspectors found.
Medication was not always administered safely and risks to residents' care were "not always managed well".
In a CQC report published in June, inspectors said: "During this inspection, we identified and reported safeguarding concerns.
"During our first inspection visit, we identified concerns in relation to risk of cross infection of COVID 19 in one of the units.
"People and relatives told us agency staff did not always seem to be knowledgeable about people’s needs or communicated well with people.
"The provider failed to ensure people's nutritional needs were always met.
"Several people living at the home had lost weight and some had not been identified before our inspection. Some people living at the service told us the food was not always appetising; this feedback was known to the provider and actions were being taken to address this.
"We found staff were offered varied training, but this had not always been completed."
The provider had "developed systems to make sure agency staff were aware of people needs" according to the report.
Inspectors continued: "People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies in the service supported this practice.
"However, we found examples of inconsistent application of the policies.
"We saw relevant mental capacity assessments and best interest decisions had been completed in several occasions, but we also found examples where this was needed and had not been put in place.
"We made a recommendation for the provider to review this area.
"The provider did not always ensure people received person-centred care and treatment.
"Some people's care plans were inaccurate and lacked information about people's needs.
"We found concerns in relation to the provision of people's foot care and lack of evidence around oral care. There were activities happening at the home, but the provision wasn’t always consistent or dementia friendly."
Although people and relatives told inspectors staff were kind and they observed caring interactions between people and staff, inspectors said their overall findings did not indicate the home was consistently providing a caring service that always respected and was responsive to people's needs.
"We found widespread shortfalls in the way the service was managed, in particular a lack of management oversight", they said.
"There was a risk of people receiving inappropriate care.
"Quality assurance processes had not always been effective in identifying the issues found at this inspection and in driving improvements. Records were not always accurate and complete."
The registered manager collaborated with the inspection, was receptive to the inspection findings and acted on the issues found, inspectors said.
The last rating for this service was Requires Improvement (published May 28, 2021).
The provider completed an action plan after the last inspection to show what they would do and by when to improve, however new breaches have now been found.
"Inspectors identified breaches in relation to safe care and treatment, safeguarding, person centred care and good governance at this inspection", they concluded.
"We undertook this inspection to follow up on specific concerns which we had received about the service.
"The inspection was prompted in part due to concerns received about safeguarding incidents, management of medication, staffing, infection prevention control and management of the home.
"A decision was made for us to inspect and examine those risks.
"We will continue to monitor the service and will take further action if needed."
A spokesperson for the care home said: “We are disappointed with the outcome of the CQC report.
"The last 12 months have been an exceptionally challenging and difficult year to recruit qualified clinical staff with over 25,000 nurses leaving the profession nationwide.
"The lack of availability of skilled staff impacts directly on quality.
"This staff shortage has contributed and led to several improvements identified by CQC and we have taken proactive steps to recruit suitably qualified staff through the Home Office Tier-2 visa programme.
"Since the inspection in April, we continue to work closely with our staff, the CQC and other health partners to make the required improvements at Aspen Hill Village.”