The You Trust - 34-36 Shaftesbury Road

Updated 8 September 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was undertaken at this time as the last inspection was rated overall requires improvement. 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.

This inspection took place on 6 and 9 August 2018 and was unannounced. The inspection team consisted of two inspectors.

Before the inspection, we reviewed all the information we held about the service including previous inspection reports and notifications received by the Care Quality Commission. A notification is information about important events which the service is required to tell us about by law. On this occasion, we had not requested a Provider Information Return (PIR) is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We spent time observing interactions between staff and people within the communal areas of the home. We spoke with four people who lived at home. We also spoke the registered manager, deputy manager and two staff.

We looked at four people’s care plans, medicines records and other associated records, staff duty rotas, three staff recruitment and supervision records. We also looked at staff training records, records of complaints, accidents and incidents, policies and procedures, safeguarding and quality assurance records.

Following the inspection we requested feedback from an external health and social care professional but did not receive any.

Updated 8 September 2018

This inspection took place on 6 and 9 August 2018 and was unannounced. At our last inspection of The You Trust - 34-36 Shaftesbury Road in November 2017 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found people were not protected against the risks associated with unsafe management of medicines because staff did not always follow policy and procedures. We also found the provider had not implemented robust quality assurance systems to effectively improve the quality and safety of the home. Risks to the quality and safety of the service people received were not always identified and effective measures were not in place to ensure these were mitigated and addressed. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

The You Trust – 34 - 36 Shaftesbury Road is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. 34-36 Shaftesbury Road accommodates up to 13 people living with mental health needs. The service does not provide nursing care. At the time of the inspection there were 11 people using the service.

A registered manager was in post but was not working in the service. 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. Another manager was supporting the deputy manager with the day to day management of the service at the time of our inspection. Throughout this report we refer to this person as the manager.

Governance systems were being operated effectively and had identified areas for improvement. The work to make these improvements had taken place. Improvements had been made to the management of medicines. Audits of these were more effective and there were no unexplained gaps in records. Medicines storage was secure but temperatures checks needed to be done consistently.

People’s needs were assessed before they moved into the home, to ensure their needs could be met. Where it was appropriate for people, they were supported to transition to the home. People told us they made their own decisions and came and went as they pleased. Staff adhered to the principles of the Mental Capacity Act, 2005 (MCA) and understood people’s right to make unwise decisions. They supported people in the least restrictive way. Risks associated with people’s needs were well known by staff and new recording systems were being implemented at the time of the inspection. These provided comprehensive, person centred information about people.

Staffs knowledge of people was good and they provided person centred care. People were provided with appropriate mental and physical stimulation. People were treated with kindness and compassion. Observations reflected people were comfortable and relaxed in staff’s company. People were involved in their care and their independence was supported. People’s privacy and dignity was respected. People were encouraged to eat healthy balanced diets by staff who worked well as a team and supported access to appropriate healthcare.

There were sufficient staff to meet people’s needs and the provider demonstrated safe recruitment processes were followed. Staff understood their responsibility to safeguard people and had received training to do so. Various subjects of training were delivered to staff, in a variety of formats. The training subjects were based on the providers mandatory requirements and people’s specific needs. Staff received supervisions and felt supported. Following feedback from staff a new appraisal system had been developed and the provider aimed to roll this out in the coming months.

There was a process in place to deal with any complaints or concerns if they were raised. People told us they knew how to complain but had not needed to. The manager and deputy manager were accessible and operated an open-door policy. Staff and people were confident to raise concerns and felt listened to.

The provider was aware of their requirement to notify CQC of significant incidents and this was happening.