22 February 2017
During a routine inspection
The service did not have a registered manager. 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. The provider had recruited a manager who had been working at the service since January 2017. They told us they were in the process of applying to register with us.
At our last inspection on 10 February 2016, we issued requirement notices in relation to reducing environmental risks for people and the need for consent. The provider sent us an action plan on 12 April 2016 that told us about the improvements they would make. At this inspection, we found that some improvements had been made, but further actions were required.
The provider had made improvements within the home that meant people who used the service were no longer at risk from the environment they lived in. However, we found that the provider could not ensure that people’s medicines were managed in a safe and proper manner.
We had also told the provider to ensure that when people were not able to make decisions for themselves, this had been assessed and decisions made in people’s best interests were evidenced. These required improvements had not been made. However, when people who lacked capacity were being restricted, the applications to ensure this was being done legally had been submitted.
People were safe and protected from harm by staff who understood how to recognise signs of abuse and knew how to report concerns. Risks to people were assessed, managed and reviewed. The environment had been improved so risks associated with this were minimised. There were enough staff to meet people’s needs and keep them safe and there were safe recruitment processes in place.
Staff received an induction and training to give them the knowledge needed to carry out their roles. People enjoyed their food and were supported to maintain a balanced diet. They were able to access healthcare services when needed and changes in people’s health were responded to.
People were supported by staff who were kind and compassionate. Positive relationships had been developed and staff knew people well. People’s independence was promoted and they were enabled to make day to day decisions about their care. People’s privacy was respected and staff treated people in a dignified way. Visitors were made welcome and people were able to maintain relationships that were important to them.
People were involved in the planning of their support, and the care they received was individual to them. There were opportunities for people to take part in activities they enjoyed. People knew how to raise any concerns and were encouraged to provide feedback about the care they received.
There was an open and positive culture within the home and communication was effective. Staff were supported to carry out their roles. The manager had systems in place to assess, monitor and review the quality of the service. These were used to drive improvements.
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.