A single Inspector carried out this inspection. The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive and well-led?We used a number of different methods to help us understand the experiences of people using the service, because people using the service had complex needs which meant they were not able to tell us their experiences.
We observed the care provided and the interaction between staff and people who used the service. We also spoke with three care staff, the Registered Manager and Director of Services. We also read feedback from relatives.
Below is a summary of what we found. The summary describes what people using the service and 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?
People who used the service had support plans and risk assessments which helped to ensure their safety and welfare.
We found the home had safeguarding, whistle blowing and Deprivation of Liberty Safeguards (DOLs) policies and guidance in place. Training records showed staff had received training in safeguarding and DOLs. When speaking to them, they were able to provide examples of what constituted abuse and how they could identify abuse. They were aware of action to take and how to report allegations or incidents of abuse to the relevant authorities.
CQC monitors the operation of the DOLs which applies to care homes. While no applications have been submitted, appropriate policies and procedures were in place. When speaking with staff we found they had an understanding of the Mental Capacity Act (MCA) 2005 and the DOLs and how it applied to the people they were providing care and support to on a daily basis.
We found the home ensured people were cared for, or supported by, suitably qualified, skilled and experienced staff. We saw there were recruitment and selection procedures in place and found that the appropriate checks had been undertaken before staff began work. Staff were trained in areas of relevance to their job roles and demonstrated knowledge of people's individual needs and requirements.
Is the service effective?
We found the home had taken steps to ensure that people were included and involved as much as possible in their care and support. We found they used various methods of communication to engage and involve people who used the service as much as possible such as pictures, facial expressions, sign language, key objects and words and simple Makaton signs.
We looked at three care plans and saw that people's needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out. We found these were person-centred, very detailed and specific to each person and their needs.
Is the service caring?
One person who used the service told us 'it is nice here. I like it. It's my home'.
We found good feedback had been received about the home. Feedback from one relative read 'All the staff are very helpful and hospitable' and 'we are very pleased and satisfied'. Another relative commented 'we are very satisfied with [their relatives] care. Thanks to the very helpful staff'.
We saw people being treated with respect and dignity. Staff communicated well with people and explained what they were doing and why. We observed people were given a choice by staff and asked what they wanted to do. During the inspection, we observed people who used the service were relaxed and happy.
Is the service responsive?
We saw the home had a complaints policy and procedure in place and was easily accessible to staff and people who used the service. We found people and staff were aware of how to make a complaint and felt comfortable approaching the manager with any concerns they had.
We also found regular reviews were being held between people who used the service, their family or representatives, the Registered Manager and Director of Services, where all aspects of their care were discussed and any changes actioned if required.
People's health and medical needs were assessed and we viewed records demonstrating that they were supported and provided access to health and medical services when necessary.
Is the service well-led?
We found the home had a system in place to obtain feedback through surveys which showed good feedback had been received.
There were regular consultations and resident meetings with the people who used the service which gave them the opportunity to discuss any issues or concerns they had and if they had any complaints they wished to make.
We also found regular monthly staff meetings took place which ensured staff had the opportunity to communicate their views about the service and to discuss the care and support needs of people using the service.
We found the home had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. Checks had also being conducted on all electrical equipment and maintenance checks and service records were up to date.