Troubled Leeds care home Donisthorpe Hall has once again been rated as requiring improvement by the Care Quality Commission.
The latest CQC report found Donisthorpe as inadequate in terms of being well led and requiring improvement in the other four inspection categories - safety, effectiveness, caring and responsiveness.
It mirrors the CQC's findings from its last inspection in April. The previous three inspections graded it as inadequate and it has been in special measures since November 2015.
The newly published report notes that Donisthorpe is registered to provide residential and nursing care for a maximum of 189 people. There were 72 residents at the time of the inspection in November, at which the CQC found that "risks around falls were not well managed" and "accidents and incidents were not always responded to appropriately.
"One person had five falls recorded since the last inspection. However, there was no evidence in the person's file to show what had been done or followed up in relation to this.
"Another person had six falls since May 2017. Common side effects of one of their medicines included dizziness, lack of balance and feeling unsteady. There was no evidence this had been considered as a potential factor of the falls."
Donisthorpe is credited for further improvement in medicine systems and residents told inspectors that staff were kind and caring.
"However, there was very little evidence to show how people or their representatives had been involved in making decisions about their care. Care plans and risk assessments varied in quality and did not always show how to keep people safe and provide person centred care."
And although the environment was "clean, pleasant, well-maintained and spacious", it did not enable those with dementia "to maintain their sense of well-being".
Staff received training which equipped them with relevant knowledge and skills. Yet "variable" supervision meant staff and volunteers might not receive appropriate support regarding roles and responsibilities.
Meals were of a good standard with plenty to eat and drink. But inspectors observed that "not everyone had a good dining experience".
The CQC pointed out that the inspection was the fifth "where we have rated the well led section as inadequate. The provider's quality management systems were not effective; they did not always drive improvement, consistently identify trends or how they could learn lessons and prevent untoward events from recurring."
It did acknowledge that over the course of inspections, the provider had responded to findings and that some issues encountered were "not anticipated".