27 March 2019
During a routine inspection
People’s experience of using this service:
¿ People who used the service did not raise any concerns with us about their safety when staff were supporting them. Safeguarding procedures were not always followed effectively.
¿ Medicines were not always being managed safely.
¿Risk assessments were in place but did not include risks associated with medicine management.
¿ Staff were not complying with the infection control policy.
¿ Staff were recruited safely and there were enough staff to meet people’s needs. Staff told us the training they received was good but we identified some issues in relation to induction of new staff. Staff were supported by the registered manager and received formal supervision.
¿ People using the service were complimentary of the care and support they received. Staff demonstrated a caring and respectful approach to people.
¿ We recommend the service reviews policy, practice and staff knowledge in relation to requirements of the Mental Capacity Act.
¿ Staff knew what to do if people needed support from healthcare professionals.
¿Care plans did not always reflect the needs of people identified during their initial assessment. People told us they received the care and support they needed.
¿ We recommend the service reviews policy and practice in relation to managing complaints. Compliments were recorded and celebrated at staff meetings.
¿ There was a registered manager in place. Systems for auditing the safety and quality of care were weak. There was no overview of accidents, incidents and complaints and audits in relation to medicines management were not robust. There was no evidence of auditing by the provider.
Rating at last inspection: This was the first inspection of this service since their registration in March 2018.
Why we inspected: This was a planned inspection based on the date of registration.
We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.
Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk