About the service: This service provides care and support to people living in specialist housing. At the time of the inspection, people lived in an adapted household accommodation in a shared site or building. The accommodation is rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate the premises used for this type of housing; this inspection looked at people’s personal care and support service. At the time of the inspection five people were being supported with personal care. People’s experience of using this service:
A relative and a person told us they were happy with the care provided by Southways Group. However, standards relating to the quality and safety of the service needed to be improved. The registered provider had not always recorded areas of risk comprehensively. Staff knew how to keep people safe from harm, but the registered manager had not always raised a safeguarding concern to the appropriate bodies.
Staff had been trained in medicines, however the way the service managed people’s medicines needed to improve. Staff told us they were well supported. Staff had received some training, which included additional training relating to mental health, however, there were some core subjects that staff had not been trained in.
Care plans did not contain information about how to reduce the risk of infection and staff needed to have training in infection control. Accidents and incidents were recorded, however, the registered manager needed to introduce a system to enable them to monitor when accidents and incidents occurred.
People spoke positively about the registered manager. However, the registered manager needed to develop the governance systems to ensure they had audits and governance systems in place.
The registered manager and staff needed to develop their understanding of their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. However, people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way.
Assessments and care plans needed to be reviewed to ensure all aspects of personal care was reflected, and that there was relevant guidance available for staff.
Staff supported people to maintain a healthy diet, in line with their assessed needs and to access health care if this was needed. People's health information was recorded. We have made a recommendation about hospital passports.
The accessible communication standard (AIS) had not been embedded into the service, we have made a recommendation about AIS.
The registered provider complaint process needed to be developed in line with current best practice guidelines. Processes were not in place to support people to plan for the end of their life. We have made a recommendation about end of life care.
Staff were kind and had developed positive relationships with people. Staff cared for people in an intuitive, empathetic and kind manner, they had a good understanding of people’s preferences.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection: This service was registered with us on 10 October 2018 and this is the first inspection.
Why we inspected: This was a planned comprehensive inspection.
Enforcement: We have identified breaches in relation to good governance.
Follow up: You can see what action we have asked the provider to take at the end of this full report.
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Whilst improvements to the service are needed, we found no evidence during this inspection that people had sustained harm. Please see the Well-Led domains sections of this full report.