Background to this inspection
Updated
22 December 2015
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. 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.
The inspection took place on the 26 November 2015 and was unannounced. The inspection was carried out by two inspectors.
We checked the information we held about the service and provider. This included the notifications the provider had sent to us about significant events at the service and information we had received from the public.
On this occasion we did not ask the provider to send us a Provider Information Return (PIR). This 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. However we offered the provider the opportunity to share information they felt relevant with us.
We spoke with eight people who used the service, three friends and relatives, five members of staff, the registered manager and the provider. We also spoke with a visiting health professional. We did this to gain people’s views about the care and to check that standards of care were being met.
We spent time observing care and support in the communal area. We observed how staff interacted with people who used the service. We looked at the care records for three people. We checked that the care they received matched the information in their records. We also looked at records relating to the management of the service, including quality checks and complaint records.
Updated
22 December 2015
We inspected this service on 26 November 2015. This was an unannounced inspection. Our last inspection took place in March 2014 and we found no concerns with the areas we looked at.
The service was registered to provide accommodation for up to 26 people. At the time of our inspection, 21 people were using the service.
The service had a registered manager in post. 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.
When people were unable to consent mental capacity assessments and best interest decisions were not completed. The provider had not considered that some people were being restricted and that deprivation of liberty safeguards referrals were needed.
People told us they felt safe and staff demonstrated they knew how to recognise and report potential abuse. The provider had procedures in place to report concerns. Equipment was checked and maintained to ensure that it was safe to use.
People told us medicines were managed in a safe way. There were effective systems in place to administer; store and record medicines to ensure people were protected from the associated risks. We saw there were enough staff to meet people’s needs.
People could access sufficient amounts of food and drinks and when people had specialist diets they were catered for. People were referred to health professionals for support when needed.
People were treated in a kind and caring way and their privacy and dignity was promoted by staff. They were able to make choices about their day and participated in hobbies and pastimes they enjoyed. People and families were involved with reviewing their care and staff received training to offer support. People were supported to maintain relationships with friends and family and they could visit the service.
Quality monitoring checks were completed by the provider and this information was used to bring about changes to the service when needed. The provider sought the opinion of the people and relatives who used the service and used this to make improvements. Staff felt they were listened to and were given the opportunity to raise concerns. People knew who the manager was and felt they could approach her if needed. There was a complaints procedure in place and people knew how to complain.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.