20 March 2017
During a routine 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. The service had a manager in post who was going through the registration process with Care Quality Commission.
We spoke with the area manager and the manager and they were very open and told us that they recognised that the service needed to improve. They told us they were committed to the work required and that they had in place an action plan for improvements on the employment of the new manager.
We found that recruitment practices were in place which included the completion of pre-employment checks prior to a new member of staff working at the service. However we found that some staff did not have references prior to employment that matched information included in their application form as was stated in the services policies. This meant the staff were possibly delivering care that the office were unaware of and that they were potentially untrained for and so putting the person at risk.
Care plans and risk assessments were in place for the care people required, however we identified that the service had an auditing system that had not been effective when checking the daily log sheets that recorded the care that was being delivered was what had been agreed in the care plan or had been risk assessed. This information did not always match and daily log sheets had not always been completed appropriately. The care records we looked at contained good information about the support people required and recognised people’s needs.
The service had not notified CQC of all notifiable occurrences which meant they had not always fulfilled their responsibilities in relation to their service and registration.
Some people using the service reported that staff were not always on time or did not stay the required time. Those who had regular care staff visiting were happy with the care delivery and told us that the staff were thoughtful and caring.
Staff had access to gloves and aprons and had received training about health and safety and food hygiene this meant the infection control standards of the service were of a good standard.
The provider had systems in place to ensure that people were protected from the risk of harm or abuse. We saw there were policies and procedures in place to guide staff in relation to safeguarding adults.
Suitable processes were in place to deal with complaints and people knew the phone numbers to ring and each person we spoke to had no complaints about the service from care staff.
The services policies and procedures had been reviewed by the provider and these included policies on health and safety, confidentiality, mental capacity, medication, whistle blowing, safeguarding, recruitment, complaints and lone working. This meant staff had access to up-to-date guidance to support them in their work.
People's care files were stored securely to protect their confidential information.