11 April 2017
During a routine inspection
Accommodation for up to 25 people is provided in the home on two floors. The service is designed to meet the needs of older people living with or without dementia. There were 15 people using the service at the time of our inspection.
At our last inspection on 17 and 18 October 2016, we served warning notices on the provider in the areas of medicines and good governance. We also asked the provider to take action to make improvements in the areas of statutory notifications, person-centred care, dignity and respect, safe care and treatment, safeguarding people from abuse and improper treatment, premises and equipment, recruitment and display of rating. We received an action plan setting out when the provider would be compliant with the regulations. At this inspection we found that action had been taken to make improvements in all areas. However, while improvements had been made, more work was required in the area of good governance.
This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.
The service had not had a registered manager since January 2017. A manager was in post but had not started the application process to become registered with the CQC. They were available during 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 did not always safely manage identified risks to people. Staff knew how to keep people safe and understood their responsibilities to protect people from the risk of abuse. Sufficient numbers of staff were not always on duty to meet people’s needs during our inspection. Staff were safely recruited. Safe medicines and infection control practices were mostly followed.
Staff did not receive appropriate training, supervision and appraisal. People’s rights were not consistently protected under the Mental Capacity Act 2005. People’s needs were not fully met by the adaptation, design and decoration of the service. People received sufficient amounts to eat and drink and external professionals were involved in people’s care as appropriate.
Staff were kind and knew people well. People and their relatives were not fully involved in decisions about their care. Advocacy information was made available to people. People were treated with dignity and respect and their independence was promoted.
Activities required improvement. People received personalised care that was responsive to their needs. Care records contained information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.
There were systems in place to monitor and improve the quality of the service provided, however, they were not effective. Further work was required to ensure that people and their relatives were involved or had opportunities to be involved in the development of the service. The provider was not fully meeting their regulatory requirements.
We found one 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 this report.