Satash Community Care Project Limited

About the service

Satash Community Care Project is a residential care home providing the regulated activity of accommodation and personal care to up to 8 people. The service provides support to people with learning disabilities and autism. At the time of our inspection 7 people were using the service.

People's experience of using this service and what we found

The service was able to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture. However, improvements were needed to the systems and governance of the service to ensure people received safe care. We found concerns with the providers lack of oversight and poor recruitment practice.

Right Support:

Care and support were provided in a safe, homely, well equipped, well-furnished environment which met people's physical and sensory needs. People living at the service had adapted their bedrooms to their likings. People's independence was promoted.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right Care:

There was limited information in the support plans we reviewed relating to people's end of life wishes. We have made a recommendation about end of life wishes.

Care and treatment was planned and delivered in a way which was intended to ensure people's safety and welfare. There were enough staff to meet people's needs. There were systems in place to minimise the risk of infection and to learn lessons from accidents and incidents. Medication was dispensed by staff who had received training to do so and assessed as competent

Right Culture:

Support focused on quality of life and followed best practice. Staff involved people, their family and other professionals as appropriate to evaluate the quality of support given and obtain feedback to improve people's day to day quality of life. People living at the service made choices and took part in meaningful activities which were part of their planned care and support. Staff supported them to achieve their aspiration and goals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The rating at the last inspection was good (published 15 June 2021).

Why we inspected

We undertook this inspection as part of a random selection of services rated good and outstanding.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively

Enforcement and Recommendations

We have identified breaches in relation to recruitment practices, quality assurance and the notification of incidents. We have made a recommendation about the management of when required (PRN) medicines and end of life wishes.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we inspect next

We found the following examples of good practice.

With the exception of one corner of a communal lounge, the premises were clean and hygienic. Cleaning schedules were in place, including for touch points.

Personal Protective Equipment (PPE) and appropriate handwashing and sanitising facilities were available to staff.

The staff and residents were taking part in regular COVID-19 testing and had been given the COVID-19 vaccine.

The local authority provided training on the wearing of PPE and pictorial guidance is displayed.

People were supported to stay in touch with their families through visits that met current government guidelines.

The registered manager needed to put plans in place which considered the most effective way to cohort staff and zone the service effectively if there was an infection or an outbreak. We have made a recommendation about cohorting and zoning.

Satash Community Care provides accommodation and support for up to eight people who have a learning disability. On the day of our inspection the service had one vacancy.

The service had 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.

The service was remarkably responsive. Since our last inspection the service had continued to make further improvements that had a positive impact on people’s lives. Staff, relatives, professionals and people living at the service all felt that the care at the service was exceptional and people were enabled to have a good quality life. Staff cared for people in a very kind and compassionate way, they knew them well and people were happy and relaxed at all times. People’s diverse needs had been met and the service were seen to be proactive in looking for ways this could be supported and enhanced. Relatives were very positive about the care provided at the service and complimentary about staff and management.

Staff showed a good knowledge of safeguarding procedures and were clear about the actions they would take to protect people. People’s medication was well managed and this helped to ensure that people received their medication safely. They were supported to be able to eat and drink sufficient amounts to meet their needs and were offered choice. We found that people’s healthcare was good. People had access to a range of healthcare providers such as their GP, dentists, chiropodists and opticians.

There was a regular and consistent staff team. The provider had appropriate recruitment checks in place which helped to protect people and ensure staff were suitable to work at the service. There were sufficient numbers of skilled, well trained and qualified staff on duty. Staff told us that they felt well supported in their role. We saw that staff had received training and formal supervision had been regularly provided.

People were treated with dignity and respect and staff interacted with people in a kind, caring and sensitive manner.

We found that detailed assessments had been carried out and that the care plans were very well developed around each individual’s needs and preferences. There were risk assessments in place and plans on how the risks were to be managed. We saw that appropriate assessments had been carried out where people living at the service were not able to make decisions for themselves; to help ensure their rights were protected. People were supported with taking every day risks and encouraged to take part in daily activities and outings.

People were happy and relaxed with staff. Systems were in place for people to raise concerns and they could be confident they would be listened to and that appropriate action would be taken. The provider had an effective quality assurance systems in place. People had the opportunity to feedback on their experiences and staff tried to involve people in day to day decisions and the running of the service. The service was very well managed.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

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

Is the service caring?

People are treated with respect and dignity by the staff. People told us that the staff were kind, fun and responsive. One person told us, 'Everyone is good here. The staff are fun and I like them all. Everyone gets on well and I am always happy to come home.'

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People commented, 'I love it here, they are so nice. Everything I want they help with.'

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. The management team completed analysis of this information and took action if required.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. Encouragement was given to people to live as independently as possible.

Is the service safe?

People's health and care needs were assessed fully with them and their representatives, and they were involved in planning how care should be provided. Specialist dietary, mobility and behavioural issues had been identified in care plans where required. People said that they took part in making decisions about their care, their health and any changes. We saw that care records reflected their current needs.

People's needs were taken into account which enabled people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical impairments.

Systems were in place to assist managers and staff learn from events such as accidents and incidents and concerns. Procedures were in place which were robust and regularly updated. This reduced the risks to people and helped the service to complete analysis to look at service improvement.

The building in which the service is run from was safe and appropriate for the needs of those people living there. Daily checks and regular audits were in place. Contracts were in place for maintenance and annual checks.

Is the service effective?

The registered manager set the staff levels, the manager took people's care and dependency needs into account when making decisions about the numbers, qualifications, skills and experience of staff required. This ensured that people's needs were met. Staff employed had relevant experience and qualifications to enable them to complete their role. Training was encouraged and undertaken regularly.

Analysis of the service was completed by people who used the service, staff and management to ensure that the service remained appropriate and effective.

Is the service responsive?

People completed a range of activities in and outside the service regularly. People told us, 'I don't like doing craft so I don't go, I stay here on that day which is my decision', 'I go to Church, it's a church I've always gone to and I come back by myself when it is not cold,' 'We get to go on holiday where we want to go.'

People told us that they felt listened to and they felt able to talk to all staff if they wanted to do anything. Staff confirmed that they felt people were able to make choices, which were then responded to. One staff member told us, 'I think people have a great choice in what they want to do, we are here to support them, and check that they're safe, not to tell them what to do.' One person told us, 'I'm off to Rome next week, I've always wanted to go to Rome so for my birthday I am going there with one of the staff.'

When people's needs changed, we found that care records had been updated to reflect this. We saw that health professionals were involved in a timely manner.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. We saw evidence that the management team was proactive in managing the service and ensuring that care provided was relevant and that people who used the service were the central focus when planning.

The service had a quality assurance system; we saw very positive feedback had been received from people, representatives and professionals. Analysis of information was in place and as a result the quality of the service was continually improving.

We saw that staff were supported by management and encouraged to undertaken relevant training courses and qualifications to enhance their knowledge.

We spoke with five people using the service and three members of staff. We saw that interactions between people using the service and staff were positive and supportive. Staff had a good understanding of people's needs and preferences. They understood the best approach to take to meet people's needs.

People told us that they were asked for their consent before any support was given. We found that where they were unable to give consent there was evidence of a decision being made with the support of family and/or social services.

We saw that the premises were well maintained, safe and suitable for people to live in. Equipment in use was properly serviced and maintained.

People told us that they liked and got on well with the staff who supported them. We saw that staff were properly recruited to keep people safe. People told us that they were involved in choosing staff to work at the service. We found that there were enough staff provided to ensure that people had good support.

At the time of our inspection there had been no complaints made; however, people told us that they were aware of the complaints process.

We found that the support plans provided a very clear picture of people's needs and that they included information on their strengths and weaknesses and their hopes and dreams. We found that they addressed individual's cultural needs. The records showed that people had been supported to practice their faith. People told us that they attended their church meetings every week.

The provider had appropriate systems in place to address allegations of abuse. Staff had been trained and showed a good knowledge of the procedures. The training records showed that staff were well trained. The provider had been awarded the 2010 Skills for Care Accolades award. This award is given to an organisation that is doing well in developing a capable, confident and skilled workforce.

The provider had a system in place for monitoring the quality of the service. Regular checks had been carried out on the home's systems and practices and any shortfalls found had been addressed in a timely manner. People who used the service told us that they were happy with the quality of care provided at Satash Community Care Project.