Archived: Royal Mencap Society - 29 Firgrove Hill

Updated 24 March 2016

Start this section with the following sentence:

'We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.'

Say when the inspection took place and be very clear about whether the inspection was announced or unannounced, for example by saying:

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was an unannounced inspection which took place on 9 February 2016. The inspection team consisted of two inspectors.

Prior to the inspection we reviewed the information we had about the service. This included notifications, complaints or safeguardings. A notification is information about important events which the service is required to send us by law. This enabled us to ensure we were addressing potential areas of concern at the inspection. We reviewed information on the Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the visit, we spoke with two people who used the service who were able to engage in some conversations, the registered manager and two members of staff. We spent time observing care and support in communal areas.

We looked at a sample of two care records of people who used the service, medicine administration records, two recruitment files for staff, supervision and one to one records for staff, and mental capacity assessments for people who used the service. We looked at records that related to the management of the service. This included minutes of staff meetings and audits of the service.

The last inspection of this service was on 10 December 2013 where we found our standards were being met and no concerns were identified.

Updated 24 March 2016

This inspection was carried out on 9 February 2016 and was unannounced. Royal Mencap Society – 29 Firgrove Hill is a service for up to five people living with learning disabilities. Accommodation is a house with three floors. On the day of our visit three people lived at the service.

On the day of our visit there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

People’s needs were met because there were enough staff at the service. Accidents and incidents with people were recorded on the service computer with a written copy kept in a file. Staff had knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. Staff had undergone recruitment checks before they started work.

People’s medicines were administered and stored safely. One member of staff told us that they had been trained to support people with their medicines.

Risks had been assessed and managed appropriately to keep people safe which included the environment. The risk assessments for people were detailed and informative and included measures that had been introduced to reduce the risk of harm.

In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

People’s human rights were protected because the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS) were followed. There was evidence of mental capacity assessments specific to particular decisions that needed to be made.

People were supported by staff that were knowledgeable and supported in their role. Staff had received all the appropriate training for their role and their competencies were regularly assessed.

People were supported to maintain healthy lifestyles. Where people needed effective systems were in place to monitor their nutrition and hydration. Staff were regularly weighing people.

People had access to a range of health care professionals, such as the consultants, dietician and GP. It was clear to them that staff understood people’s conditions.

Staff interacted with people in a kind and respectful way. One member of staff said “I enjoy it here very much, I like that I’m needed and that I can help people.”

People were involved in planning their care. We saw that care plans had detail around people’s backgrounds and personal history and included people’s views on what they wanted. Staff knew and understood what was important to the person and supported them to maintain their interests.

People were supported by staff who understood their needs. Where it had been identified that a person’s needs had changed staff were providing the most up to date care. People were able to take part in activities which they enjoyed and were supported to live as independently as they could.

There was a complaints procedure in place for people to access if they needed to and this was in a pictorial format for people to understand. People were reminded at every meeting how they could raise a concern if they had one.

Staff said that they felt supported and valued. Systems were in place to monitor the quality of the service that people received. This included audits, surveys and meetings with people and staff.