29 September 2016
During a routine inspection
This unannounced inspection took place over two days, 29 September and 4 October 2016. At the time of the inspection there were 16 people living in the service.
There was a registered manager in post who also co-owns the service. 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.
Improvements were needed in fire safety and the storage of hazardous fluids. The service needs to ensure that the checks in place to monitor the safety of the environment are effective enough and meets current guidelines and that staff are competent in the use of fire extinguishers and evacuation equipment. Further work is needed to ensure identifying and acting on any potential risk is embedded in staff practice.
People told us they felt safe. Staff understood their responsibilities to ensure people were kept safe from abuse and knew who to report their concerns to within the service. However, if the need occurred, not all were aware of the external safeguarding agencies to contact.
People and their visitors spoke about the caring staff and friendly atmosphere of the service. Staff had good relationships with people who used the service and spoke about them in a caring and compassionate manner. However, improvements were needed in the staffing levels and knowledge in supporting people with dementia, to ensure all interactions with people are meaningful and caring. Also in the range of activities offered to prevent the risk of social isolation. We have made recommendations to support the service in identifying how many staff they need and in improving staff’s knowledge of dementia care, and arranging simulating activities.
People were supported by staff to take their medicines as prescribed. Health care needs were met through developing good working relationships with external health care professionals.
The service was in the process of implementing new care plans. Improvements were needed in how people’s ability to make decisions were assessed and recorded. We have made a recommendation to support the service in ensuring any restrictive practices are lawful.
People told us that the ‘home cooked’ food was good, and that they were supported to have enough to eat and drink. Dietary needs and nutrition were being monitored and advice sought from appropriate health professionals as needed. However, improvements were needed in people’s dining experience.
A complaints procedure was in place to ensure people’s comments, concerns and complaints were listened to and addressed in a timely manner. There were systems in place to seek the views of people using and working for the service. However we have made a recommendation to further build on the work being undertaken. This is so people and staff can be more influential in driving improvements.
The service had checks in place to monitor the running of the service. But improvements were needed to ensure they were able to independently identify any shortfalls in the quality of service being provided as part of driving continuous improvements.
We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.