14 December 2016
During a routine inspection
There was a Registered Manager in post at the time of our inspection. 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 this inspection we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
Accidents and incidents were not always reported and documented by the management team and it was not always clear if action had been taken to resolve accidents and incidents or to reduce the likelihood of an incident occurring again. These omissions had not been identified in audits of care notes so audits were not always effective.
Medicine documentation audits were also in place however these had not always been effective in identifying when staff had not been completing them sufficiently.
Risk assessments were in place. However, the level of detail varied for different people so staff did not always have enough information available to them to support people safely.
People told us they were receiving their medicines. However, there were not always PRN protocols in place for people that had medicine that was taken ‘when required’. Recording of the administration of medicines was not always clear, which had not been identified through effective audits.
The principles of the Mental Capacity Act 2005 (MCA) had not always been followed. Assessments had not always been carried out to help determine if people were still able to make decisions and what type of decisions. Evidence of Lasting Power of Attorney (LPOA) had not been consistently sought and those who did have an LPOA did not always have the correct one in place regarding health and welfare.
People told us they felt safe. Staff were aware of different types of abuse and understood their responsibilities to report instances of suspected abuse.
People and staff told us they felt there were enough staff and they were not rushed. Safe recruitment practices were in place and staff had appropriate checks prior to starting work to ensure they were suitable to work with people who use the service.
Staff told us they felt supported in their role and they had sufficient training to support people effectively. Staff said they were supported to gain qualifications.
People had access to other health professionals in order to maintain their health and wellbeing.
People were supported to have food and drinks of their choice that were appropriate for their needs.
People felt staff were caring and that they were treated with dignity and respect, and people were encouraged to maintain as much independence as possible.
Care plans contained good personal detail so that staff could get to know the people they supported and people had their preferences documented and catered for where possible.
People and relatives were encouraged to provide feedback or complain if they needed to and it was recorded that this feedback was acted upon. We saw that complaints were recorded, investigated and responded to.
Staff all felt they could approach the registered manager and management team. There was an open door policy and staff all said they could raise things if necessary.
The registered manager had submitted notifications about the service, which they are required to do by law.