13 September 2017
During a routine inspection
This inspection was unannounced and took place on 13 September 2017
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Systems were in place to manage risk. The staff we spoke with knew the actions needed to protect people from the risk of potential harm. However, risk assessments were not in place for all risks identified. For example, moving and handling. While staff reported accidents and incidents the reports were not analysed to identify patterns and trends.
We found areas of the home needed repairs, flooring in some areas such as the foyer was heavily soiled and there was poor storage for equipment. Although the registered manager had reported the repairs, action was outstanding.
The principles of the Mental Capacity Act (2005) were not consistently followed by the staff. People’s capacity to make complex decisions was not assessed. We saw people were under continuous supervision and staff confirmed this but Deprivation of Liberty Safeguards (DoLS) were not considered or applied for. Staff had not considered that lap belts and bed rails were forms of restrictions and had not assessed this.
Care plans were generally person centred. For some people their life stories lacked detail such as education and the events that led to their admission. Person centred profiles for some people were brief and lacked detail. For example, future goals.
Systems in place to assess and monitor the quality of the service needed to improve. People’s views about the service or those people close to them were not gathered. While audits had identified similar shortfalls to the inspection findings action had not been taken to make improvements.
When we asked one person if they felt safe they agreed and said “yes”. However, people using the service at the time of the inspection were not able to tell us what feeling safe meant to them. Staff said they attended safeguarding of vulnerable adults training. Records confirmed this. The staff we spoke with knew the types of abuse and the expectations that they report abuse.
The staff we spoke understood the importance of developing positive relationships with people. Staff were knowledgeable about people’s likes and dislikes. We saw people accept staff support and there were good humoured interactions between people and staff.
Medicine systems were safe. Staff signed medicines administration records (MAR) charts to show the medicines that had been administered. Protocols were in place for medicines to be administered as required.
There was a system in place to determine the number of staff required for people on respite care. Staffing levels had improved with recruitment of new staff but there was a reliance on relief staff to cover absences and vacant posts.
Members of staff received effective support to meet their roles and responsibilities. New staff received an induction for the role they were employed to perform. Mandatory training set by the provider was attended by all staff to ensure they had the skills needed to meet people’s needs. Group supervision was monthly and staff had the opportunity to discuss work issues and changes in policies were shared. One to one supervision with the registered manager was on request by staff or by the registered manager to discuss performance.
Some people attended day care services during the week and at weekends, staff organised outings and in house activities.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
You can see what action we told the provider to take at the back of the full version of the report.”