During our previous inspection in January 2014 we identified concerns in relation to infection control and the management of medicines and set compliance actions. During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We spoke with four people who use the service, three family members of people who were unable to communicate with us due to their mental frailty and six members of staff. We looked at three care plans and records relating to the management of the service. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.
We looked at the areas of respecting and involving people who used the service, care and welfare, infection control, management of medicines, staffing and quality assurance. We used the information to answer the five questions we always ask;
' Is the service safe?
' Is the service effective?
' Is the service caring?
' Is the service responsive?
' Is the service well-led?
This is a summary of what we found:
Is the service safe?
We found not all aspects of the service were safe.
Infection control guidance was not always followed. The sluice room and some bedding were not clean. Not all staff were aware of how to process dirty linen safely and one of the cleaners had not received training in infection control.
Medicines were not always managed safely. The provider was unable to account for the use of some medication. The use of creams and ointments was not always recorded and there was no system in place to ensure they were not used beyond their shelf life.
The provider ensured there were sufficient staff with the right skills to meet people's needs. Risks were managed effectively and equipment required to manage risks, such as walking aids and pressure relieving cushions, was readily available.
CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service had policies and procedures in place in relation to Deprivation of Liberty Safeguards (DoLS). The registered manager was in the process of seeking a DoLS authorisation in respect of one person. This would ensure their human rights were protected.
Is the service effective?
The service was effective because people were cared for by staff who were knowledgeable about their needs and had the skills to provide appropriate care and support. People told us their needs were met consistently. One person said, 'I'm very happy with the care, they'll do anything for you.' A family member told us 'The care is very personalised; [the person] gets all the help they need.' Care records showed people had access to appropriate medical care, including GPs and chiropodists. People's needs were clearly known and met.
People had access to a choice of suitably nutritious meals. We spoke with the chef, who was aware of people's dietary needs and those who required their meals preparing in a specific way. For people at risk of malnutrition, we saw food and fluid charts were maintained and their weights were monitored appropriately.
A range of activities was provided by an activities coordinator and we saw people enjoying a ball game and a quiz. The home's garden had been made accessible to people with limited mobility. We saw this being used during our inspection.
Is the service caring?
We found the atmosphere at the home felt friendly and people were supported in a kind and caring way. One person said of the staff, 'They're very kind and they've helped build up my confidence.' Another person told us how staff prepared them for bed in a particular way that gave them 'great comfort'. They said, 'The staff are wonderful, they're more like friends.'
We observed care and support being provided in communal areas. Staff interacted positively with people, using people's preferred names and speaking with them in a calm and respectful way. They took time to sit and engage with people and understand their needs.
Is the service responsive?
The service was responsive to people's changing needs. We saw assessments were carried out before people moved to the home and their care plans were updated monthly. We spoke with a community health care professional who said of the staff, 'They're very good; they provide good, reliable information and follow through on recommendations we make.'
However, we found that decisions made in respect of people's ability to manage their own medication were made by staff based on information provided when the person was admitted to the home. No person living in the home at the time of our inspection was managing their own medication. Records did not show whether people had consented to these arrangements or that decisions had been taken in accordance with the Mental Capacity Act, 2005.
Is the service well-led?
We found not all aspects of the service were well-led.
There was a clear management structure in place, including a registered manager; the home benefited from an experienced management team and a low level of staff turnover.
We saw the provider obtained people's views by completing an annual survey. We looked at the questionnaires used for the latest survey, conducted in April 2013. Family members had also provided feedback. We saw people's comments had been used to make changes to the environment. The registered manager told us this survey was due to be completed again soon.
The provider took account of complaints and comments to improve the service. Records showed complaints were recorded, investigated and resolved in a timely way. Systems were in place to ensure lessons were learned from incidents.
The registered manager told us they monitored the service informally by working with staff and reviewing care plans. However, the provider was unable to demonstrate the effective operation of systems designed to monitor the quality of services provided. Audits of infection control and medication had not identified the concerns we found during our inspection. This meant people were not protected against the risks of inappropriate or unsafe care.