21 September 2016
During a routine inspection
At our last comprehensive inspection on 27 and 28 August 2015, we found several breaches of legal requirements. Staff were not supported through regular supervision and yearly appraisal in line with the provider’s policy, and some sections of people’s care plans did not reflect their current needs. We asked the provider for an action plan to address the breaches identified. The provider sent us an action plan telling us how they would address this issue and when they would complete the action needed to remedy the concern.
This unannounced comprehensive inspection took place on 21 and 22 September 2016. At this inspection we found the service provided an induction and training, and supported staff through regular supervision and annual appraisal to help them undertake their role. Staff prepared, reviewed, and updated care plans for every person. The care plans were person centred and reflected people’s current needs. The provider was now compliant with the regulations following improvements made in the areas we identified at our last inspection.
There was a registered manager 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.
People who used the service and their relatives told us they felt safe and that staff and the registered manager treated them well. The service had clear procedures to support staff to recognise and respond to abuse. The registered manager and staff completed safeguarding training. Staff completed risk assessments for every person who used the service which were up to date and included detailed guidance for staff to reduce risks. There was an effective system to manage accidents and incidents, and to prevent them happening again. The service had arrangements in place to deal with emergencies. The service carried out comprehensive background checks of staff before they started working and there were enough staff on duty to support to people when required. Staff supported people so that they took their medicines safely.
The provider had taken action to ensure the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were followed.
Staff assessed people’s nutritional needs and supported them to have a balanced diet. Staff supported people to access the healthcare services they required and monitored their healthcare appointments.
People and their relatives where appropriate, were involved in the assessment, planning and review of their care. Staff considered people’s choices, health and social care needs, and their general wellbeing.
Staff supported people in a way which was kind, respectful and encouraged them to maintain their independence. Staff also protected people’s privacy and dignity, and human rights.
The service supported people to take part in a range of activities in support of their need for social interaction and stimulation. The service had a clear policy and procedure about managing complaints. People knew how to complain and told us they would do so if necessary.
There was a positive culture at the home where people felt included and consulted. People and their relatives commented positively about staff and the registered manager. Staff felt supported by the registered manager.
The service sought the views of people who used the services to help drive improvements. The provider had effective systems in place to assess and monitor the quality of services people received, and to make improvements where required. Staff used the results of audits to identify how improvements could be made to the service. However, we found that the provider had not notified the Care Quality Commission (CQC) of the authorisations of Deprivation of Liberty Safeguards (DoLS) as required. As a result of the inspection feedback, the provider then notified the CQC. We saw there was no negative impact on the people who used the services.