Archived: The Regard Partnership Limited - Church Road

Updated 17 April 2015

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.

We visited the home on 11 December 2014. Our visit was unannounced and the inspection team consisted of one inspector.

Before our inspection we reviewed the information we held about the service, which included the Provider Information Return (PIR). This is a form in which we ask the provider to give us some key information about the service, what the service does well and any improvements they plan to make. We also reviewed other information we held about the service including safeguarding alerts and statutory notifications which related to the service. Statutory notifications include information about important events which the provider is required to send us by law.

On the day of our inspection to the home we focused on speaking with people who lived in the home and their visitors, speaking with staff and observing how people were cared for. A few people had complex needs and were not able, or chose not to talk to us. We used observation as our main tool to gather evidence of people’s experiences of the service. We spent time observing care in communal areas and used the Short Observational Framework for Inspectors (SOFI). This is a specific way of observing care to help us understand the experiences of people who were unable to talk with us, due to their complex health needs.

During our inspection we spoke with three people who lived in the home, two support workers, one visiting healthcare professional and the registered manager.

We looked at two people’s care records, two staff recruitment records, medication charts, staffing rotas and records which related to how the service monitored staffing levels, complaints and the quality of the service.

Updated 17 April 2015

The inspection took place on 11 December 2014. The Regard Partnership Limited - Church Road is a care home that provides accommodation and personal care and support for up to six people who may have mental health needs. There were five people who lived in the service when we visited.

At this inspection we found the service had not taken proper steps to ensure that each person was protected against the risks of receiving unsafe or inappropriate care. There were insufficient members of staff available to meet people’s care needs and staff were not appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to people safely. The service also did not assess and monitor the quality of service provision adequately.

People’s safety was being compromised and they were at risk of harm because on going care was not being assessed and delivered which met their changing needs. Assessments of risk to people had been developed but were not up to date. Staff had not completed essential paperwork.

Staff did not have the knowledge and skills they needed to carry out their role and responsibilities effectively. They did not recognise poor practice which might put people at risk of injury, for example when supporting people to move and transfer with a hoist. People were provided with sufficient quantities to eat and drink however meals were delayed at times due to a lack of staff available to help people who needed assistance.

People were not actively encouraged consistently to take part in activities that interested them and to maintain contacts with the local community due to staff constraints. Care records we viewed did not show that wherever possible people were offered a variety of meaningful chosen social activities and interests and hobbies.

Systems were not fully in place to gain the views of people, their relatives and health or social care professionals. The provider had quality assurance systems in place to identify areas for improvement, however appropriate action to address any identified concerns had not always been taken. Audits, completed by the provider and registered manager and subsequent actions had not all resulted in improvements and development of the service.

Staff interacted with people in a caring, respectful and professional manner. Where people were not always able to express their needs verbally we saw that staff responded well. Where people were not always able to express their needs verbally we saw that staff responded to people’s non-verbal requests and had a good understanding of people’s individual care and support needs.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

The provider had a robust recruitment process in place. Records we looked at confirmed that staff were only employed within the home after all safety checks had been satisfactorily completed.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions for themselves and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. Staff had followed guidance and were knowledgeable about submitting applications to the appropriate agencies. The service was meeting the requirements of the DoLS.

There were systems in place to manage concerns and complaints. No formal complaints had been received in the last year. Informal concerns received from people had been recorded and included the action taken in response. People understood how to make a complaint and were confident that actions would be taken to address their concerns.

You can see what action we told the provider to take at the back of the full version of the report summary.