Background to this inspection
Updated
12 February 2020
The inspection:
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team
The inspection was carried out by one inspector.
Service and service type
This service is a care home that accommodates people with mental health issues. It provides personal care to people living at the service.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
Inspection site visit activity started on 19 December 2019 and ended on the same day.
What we did before the inspection
We reviewed information we had received about the service since the last inspection and sought feedback from the local authority and professionals who commissioned the home's services. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.
During the inspection
We observed how staff provided care and communicated with people. We spoke with three people who used the service and two relatives. We spoke with three staff, the registered manager, the deputy manager and a care worker.
We reviewed a range of records. These included two people's care records and three records relating to staff recruitment, training and supervision. We also looked at information relating to the management of the service, including the provider's policies and procedures, people's medicine administration records (MARs) and quality assurance records.
After the inspection
We continued to seek clarification from the provider to validate the evidence found during the inspection.
Updated
12 February 2020
About the service:
16 Sylvan Road is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. 16 Sylvan Road accommodates 4 people in one adapted building. At the time of our inspection 4 people with mental health needs were living there.
People’s experience of using this service:
People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible and in their best interests; the policies and systems in the service did support this practice. There was an instance of consent documentation being completed incorrectly. Consent was implied in people's documentation.
We saw that some care records had been typed then written over by hand. We noted some audits were overdue and did not pick up on the error we found with respect to consent documentation. One audit which was overdue and therefore did not pick up a medicine recording omission we found. Quality assurance processes either did not identify or seek to remedy the issues we saw with decoration.
People’s needs were met with respect to building layout and design, however the service had not been decorated for some time.The provider told us they would seek people's input around this and agree a plan.
People told us they felt safe and there were safeguarding procedures to keep people safe from abuse. People were risk assessed to keep them safe from harm. There were sufficient staff at the service. Suitable staff were recruited to work with people. People’s medicines were managed safely.
People’s needs were assessed before moving into the service. Staff were trained how to do their jobs and were supervised in their roles. People were supported to access health care professionals. People were supported with their food and could choose what they wanted to eat.
People and relatives told us staff were caring. People and their relatives were involved with their care. People’s privacy was respected, and their independence promoted.
People’s care plans recorded their needs so staff knew how to best work with them. People were supported to attend activities they enjoyed. People’s communication needs were assessed, and staff knew how to communicate with them. People and relatives told us they knew how to make complaints, though there had been no recent complaints at the service. The service was not providing end of life care to people but staff had received training and people’s end of life wishes were recorded if they wanted.
People were happy with the management of the service. The registered manager was supported in their role by a deputy manager. The service had links with other agencies to the benefit of people using the service.
Please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection
This service was previously rated ‘Good’ at inspection in July 2017.
Why we inspected
This was a planned inspection that was part of our inspection schedule.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.