The Mallards

Updated 18 July 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was undertaken by one inspector and one expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The inspection took place 21 May 2018 and was unannounced.

Before the inspection, we reviewed information we held about the service including statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. Statutory notifications include information about important events, which the provider is required to send us by law. We used this information to plan the inspection. We received a Provider Information Return (PIR) form. A PIR is a document that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We gave the provider an opportunity to provide us with information that was relevant to our inspection.

On the day of our inspection, we reviewed two care plans in depth and referred to others. We reviewed three staff files, spoke with three care staff, the registered manager, the deputy manager, three relatives, and seven people using the service. We looked at audits relating to medication, health and safety, fire safety and cleanliness.

Updated 18 July 2018

The last comprehensive inspection took place on 18 October 2016 and we rated the service as requires improvement in two key questions we inspect against including safe and responsive. This gave the service an overall rating of requires improvement. There were no breaches of regulation. We carried out our latest inspection on 21 May 2018.

The service is registered for up to eleven people with a diagnosis of autism, or a learning difficulty. On the day of the inspection there were eleven people using the service including one person having respite care. The accommodation comprised of the main house and the annex. The service provides both permanent accommodation and temporary, respite care. However, the registered manager said following our visit they were going to cease providing respite care because it is not financially viable.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

The service had a registered manager. 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.

At our inspection visit on 21 May 2018, we found people were happy at the service and were being supported to be independent and engage in different activities. The service was mostly well led but we found the registered manager had been off on extended leave and had only recently returned. In their absence, a number of things had not been fully addressed.

The service managed risk well but some areas of refurbishment and repair in the main house were overdue. Audits were not always identifying issues of concern, which could affect the safety and well-being of people using the service.

Staff felt well supported but there was a lack of recording around formal support, personal development, training and growth. Some staff training was overdue.

People were involved and consulted about their needs and preferences. Reviews established if people were unhappy about any part of the service. The service quality assurance system did not firmly establish how they consulted with health care professionals and other stakeholders or how as an organisation they identified common themes or areas of poor compliance across the services.

The registered manager was well respected by staff, people using the service and relatives spoken with. They were sensitive to the needs of people using the service and their staff. People received good care and had fulfilling lives.

Staffing levels were appropriate and people received support from regular staff who knew them well. This was a well-planned service where staff were adequately recruited, supported and trained for their job role.

Medicines were administered as intended and audits were designed to identify and address any shortfalls.

Risks were effectively managed for individuals and for the environment. Shortfalls identified were being rectified. Staff understood what constituted abuse and what actions they should take to report abuse and make people safe.

The Commission is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found people’s rights were being upheld and staff supported people in lawfully and in line with legislation around mental capacity and deprivation of liberties.

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People were supported to eat and drink sufficient to their needs and involved in meal preparation, menu planning and shopping. People had their health needs met and staff monitored long-term health conditions to help ensure symptoms were well managed.

People’s needs were assessed before moving into the service and a clear plan of care put into place. The same process should be followed for people coming in for respite care. People had sufficient occupation, activity and leisure activities.

The service gave people opportunity to comment on the service including having an established complaints procedure and regular reviews of care.