17 May 2018
During a routine inspection
This was the first inspection completed for the service that registered with CQC in May 2017. The service had newly appointed a manager who was due to commence the process of registration with the CQC. 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 previously been managed by two registered managers who had both left the organisation within the last 12 months. A third manager commenced the registration process, however withdrew their application. The current manager was appointed thereafter. The services had therefore not had consistent managerial overview of operations. The service employed three part time staff, one newly recruited staff and four bank workers. The management of the service consisted of a newly appointed manager, the service manager and a consultant.
The management of the service had been inconsistent over the last 12 months. This had led to overall issues with service performance and management.
The service was not always safe. The service had not ensured that all staff employed had been through a robust recruitment process. During this inspection we found a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service did not follow their recruitment procedure to carry out checks before new staff were employed to work with people. They did not gather necessary information to ensure staff were suitable for their role. You can see what action we have asked the provider to take at the end of the full version of this report.
Risks were appropriately assessed with details provided on how to mitigate risks where possible. These focused on people retaining their independence as far as possible such as outings, excursions with the family and accessing the internet.
Medicines were generally managed safely. Audits indicated that there had been no recent medicine errors. However, the paperwork did not clearly illustrate if staff had been appropriately assessed as competent prior to administering medicines. The service reassured us that all staff would be assessed prior to completing this task moving forward.
Staff were aware of signs of abuse and how to safeguard people from abuse. The service also spoke with people and taught them to understand how they should keep themselves safe.
Care plans were person centred and very detailed. They provided comprehensive step by step guidance to staff on how people needed to be supported. Reviews took place as required and involved people and their families.
The service worked effectively with external agencies and families in ensuring people received the best support possible.
Staff were described as caring, and as maintaining people’s privacy and dignity. Staff spoke with people in a caring manner, helping them make choices for themselves. People were encouraged to maintain their independence and where possible measures were taken to assist with this.
A comprehensive complaints system was in place that ensured an appropriate response to poor practice was taken in line with legislation. Concerns were thoroughly investigated and responses provided to complainants in line with company policy.
Audits were in place and new action plans had been developed to focus on the path the new manager wished to take with the service. Staff were appropriately supported and supervised to ensure they felt involved in the vision of the service.