This inspection took place on 24 March 2015 and was unannounced. This meant the provider did not know we would be visiting. We last inspected the service on 17 December 2013 and found the provider was not meeting legal requirements in relation to safety and suitability of premises. The provider submitted an action plan and we found that appropriate improvements had been made.
Potensial Limited – 2 Belgrave Terrace is based in South Shields in a Victorian terraced house close to the town centre and local amenities. The service can accommodate up to eight people with learning disabilities. At the time of the inspection seven people lived at the home.
There was an established registered manager in post at the time of the 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.
Staff understood safeguarding procedures and policies were available for staff to refer to as needed. People received pictorial, easy read information on abuse and bullying and knew to tell someone if they were concerned.
Accidents and incidents were recorded and monitored. Records included potential triggers for any incidents and any behaviour strategies to assist staff to manage the situation.
Risk assessments were in place and included information on referrals to occupational therapy for mobility assessments or specialist equipment.
Emergency plans were in place and each person had a personal emergency evacuation plan which detailed plans should 2 Belgrave Terrace not be habitable. The fire brigade had been involved with the completion of the fire risk assessment.
Everyone we spoke with said they thought there were enough staff to support people and meet their needs. Everyone was aware that the local authority funded a specific number of one to one support hours for people and staff worked with people to ensure they received one to one support at times where it was of most value to people. For example at the weekend to go out on an activity or to attend social events.
Recruitment procedures were robust and people were involved in deciding who they wanted to support them. References and disclosure and barring service checks were completed before anyone was offered employment.
Staff were trained in the administration of medicines and appropriate care plans and risk assessments were in place. Where people had been prescribed ‘as and when required’ medicines protocols were in place and administration had to be authorised by the deputy or registered manager.
Staff told us they were supported very well and attended regular supervision and team meetings. Annual appraisals were held with people to review performance over the past year.
Training was provided to ensure staff were knowledgeable of the skills needed to support people. This included training in dementia and diabetes as well as infection control, risk assessment and challenging behaviour.
The registered manager and staff had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff had taken time to explain to one person what having an authorised DoLS in place meant to them and the person understood this and accepted the reasoning behind it.
People said the food was good and they were able to choose what they wanted to eat. We saw people were involved in deciding what shopping was needed and had been involved in the decision to move away from a set menu so people could be actively involved in decision making around choice of meals.
Health action plans and hospital passports had been completed with people which gave a record of healthcare professionals who were involved in people’s care. A community nurse told us, “They are good at referring people.”
People were encouraged and supported to be involved in decision making and we saw information was available for people in a pictorial format using plain English. This included individual charters which explained people’s rights and responsibilities.
Care records were individual to the person and everyone had a person centred plan which recorded their hopes and dreams for the future. People were encouraged to celebrate their achievements.
People were involved in planning their care and signed documents to say they had been included in reviews on a quarterly basis. Outcomes were recorded and people’s progress was noted as achievements.
A pictorial complaints policy was in place and people knew how to complain if they needed to.
The registered manager was seen working alongside care staff to support people and there was a genuine emphasis on team working. Local authority commissioners said, “Staff are very willing to share best practice and learn from others.”
A variety of audits were completed in order to drive quality and service improvement and the registered manager had a clear vision about the need to support people to be independent, active members of the local community.