Archived: Mencap (Chasewood Avenue)

As part of this inspection we spoke with three people who used the service and two staff. We also reviewed records relating to the management of the home which included the care records of three people who used the service.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The service had a policy and procedures in place to safeguard people from abuse. A whistle-blowing policy was also in place which described what kind of concerns staff were expected to report and how to raise their concerns.

We found people's care plans took into account any potential risks to their welfare and safety. A range of risk assessments were in place, which included the actions staff needed to take to manage the risks.

We looked at the accident and incident records and saw all incidents including those described as a near miss incident were recorded. Details of the incidents, follow-up actions and long term action plans were also recorded in order to avoid similar incident happening in the future. We saw appropriate actions had been taken in response to the incidents.

People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act (2005) and they aim to make sure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. There had been one person subject to the DoLS for a period of time since our last inspection on 16 July 2013. We found the appropriate process had been followed and therefore the person's freedom was restricted lawfully.

There were arrangements in place to deal with foreseeable emergencies. The service had an emergency plan and business continuity plans in place which contained the management plans for the different type of emergencies such as extreme weather or loss of accommodation. People who used the service had personal emergency evacuation plans in place.

Is the service effective?

People's needs were assessed and care was planned and delivered in line with their individual care plan. We looked at three people's care records during our inspection. The records contained people's personal profile and detailed care plans for every identified need including personal care, support with health, accessing the community, medication, communication and challenging behaviour. We found the care plans were person-centred and took into account people's individuality.

People's assessed needs, preferences and choices were met by staff who had the necessary skills and knowledge. Staff had effective support, induction, supervision, appraisal and training.

People's health was being monitored and they were supported to receive medical check-ups. People had 'hospital passports' which contained information to help ensure the continuity of support in case of hospitalisation. Health action plans were also in place and records showed people attended medical appointments, medication reviews, eye-tests and visited their GP and dentist.

Is the service caring?

Staff supported and involved people in planning and making decisions about their care and support through monthly one to one meetings and regular meetings. Records of these meetings showed people were asked about what they liked or didn't like in that month and planned activities for the following month. Staff told us they had weekly menu planning meetings where people made decisions about what would be on the menu.

People's diversity, values and human rights were respected. We found there was training and information provided to staff with regards to the Mental Capacity Act (2005). We saw people's mental capacity had been assessed with regards to managing their finances and people were supported accordingly. We also found that one person used a wheelchair and their room was adapted and equipped in order to appropriately care for and support the person. People who used the service were given appropriate information and support regarding their care. We saw the daily menu was displayed and information was visibly displayed to indicate which staff were on duty that day. Pictures were used to help people's understanding.

Is the service responsive?

People living at the home had varying levels of ability to express and communicate their views about the quality of the service due to having learning disabilities. We observed the care provided during our inspection and saw people were treated kindly and with respect. We asked three people for their views about the care and support they received. They said 'yes' when we asked if they liked living at the home and whether they felt safe in the home. One person said 'I feel alright' and 'I love to come back (from the day centre).' We observed during our inspection people were treated kindly and with respect. We saw staff knew people's needs and communicated with them calmly.

People were supported in promoting their independence and community involvement. We found people had monthly activity schedules and they participated in many different social activities in the community such as going to a day centre, cinema and shopping. People's activity schedules were different and reflected their personal interests and choices. Each individual had a plan with regards to the required support with their personal care. Staff told us they encouraged people to do as much as they could for themselves. We found people's autonomy and independence was promoted by enabling them to choose what they wanted to do in the home.

Is the service well-led?

We saw the quality of the service was being monitored through various audits and regular health and safety checks. We saw records of 'spot checks' on various aspect of the service for example medication and financial records. We saw that actions had been identified and acted upon in order to improve any shortfalls.

We found the views of people who use the service were regularly sought and were acted upon. There was also evidence that learning from accidents and incidents took place and appropriate changes were implemented.

We found the service used the provider's 'Shape Your Future' tool and guidance which is a particular way to manage staff's performance and plan their career. Records showed staff's individual performances were discussed and their annual appraisals identified objectives for the following year along with learning and development needs. This meant staff knew and understood what was expected of them.

Staff told us that they had been through a detailed recruitment process that included completing an application form and interviews. References were taken up from their former employers.

The provider had carried out a survey of people using the service and relatives. Regular audits had been carried out covering a range of areas such as medications management and care planning. The provider explained that they carried out a check of care plans and risk assessments on a regular basis.

The people who use the service had some communication difficulties and so we relied on observation, gesture and feedback from staff and relatives.. People indicated that they were happy in the placement and their relatives were positive about the standards of care and treatment experienced at the service. We looked at the records held about people which indicated that individual needs were being assessed and that reviews were taking place on a regular basis. We noted that issues of choice were appropriately recorded.

We found that the premises were of a suitable design and layout to meet the needs of people who used the service and appropriate security measures were in place. We also found that the provider employed suitable numbers of staff to meet the needs of people who use the service and that the provider had an accessible complaints process in place.

You can see our judgements on the front page of this report.