Background to this inspection
Updated
18 June 2016
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 16 March 2016 and was unannounced.
The inspection team consisted of one inspector.
Before the inspection took place, we looked at the information the Care Quality Commission (CQC) held about the service. During the inspection, we spoke with two people that used the service and one relative of a person. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We spent time observing care and speaking with the deputy manager, Head of Northern services, Nurse on duty and two support workers. We looked at three people’s care record documentation, three staff files as well as documentation relating to the management of the service such as training records, policies and procedures and information we had received about the service and statutory notifications we had received from the home.
We received 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. We reviewed all other information we held about the provider and contacted the local authority to ask for their views on the service.
Updated
18 June 2016
On the 16 March 2016 we inspected 1 - 2 Cuthberts Close. This was an unannounced inspection.
The service was last inspected in December 2014 and was fully compliant with the outcome areas that were inspected against.
Saint John of God Hospitaller Services situated at 1 and 2 Cuthberts Close is registered to provide care for a maximum of 12 people with learning disabilities. The accommodation compromises of two bungalows each with six single rooms. The service is located in the residential area of Queensbury, close to Bradford and Halifax.
There was a registered manager in place. A registered manager is a person who has registered with the CQC 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.
Medicines were not managed safely and appropriately and medicine audits were not robust enough to identify the concerns we raised.
There were safeguarding adult’s policies and procedures in place to protect people from possible harm and incidents and accidents were recorded and acted on appropriately.
Assessments were conducted to assess levels of risk to people’s physical and mental health. Care records contained guidance to provide staff with information that would protect people from harm.
There were safe recruitment practices in place and appropriate recruitment checks were conducted before staff started work. There were appropriate levels of staff on duty and deployed throughout the home to meet people’s needs.
There were arrangements in place to deal with foreseeable emergencies and there were systems in place to monitor the safety of the premises and equipment used within the home.
People were supported by staff that had appropriate skills and knowledge to meet their needs and staff received regular supervision, training and an annual appraisal of their performance.
Staff demonstrated good knowledge of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s right to make informed decisions independently was respected.
People were supported to eat and drink suitably healthy foods in sufficient quantities to meet their needs and ensure well-being. People had access to health and social care professionals when required.
Interactions between staff and people using the service were positive and staff had developed good relationships with people. People were supported to maintain relationships with relatives and friends. Care records documented people’s involvement in their care and where appropriate relatives were involved.
Staff were knowledgeable about people's needs with regards to their disability, race, religion, sexual orientation and gender and supported people appropriately to meet their identified needs and wishes.
People were supported to engage in a range of activities that met their needs and reflected their interests.
There were quality assurance and governance systems in place to monitor the quality of the service provided. Concerns raised from audits fed into action plans to rectify problems or issues.
Relatives told us they knew who to speak with if they had any concerns. There was a complaints policy and procedure in place and management was aware how to deal with complaints in line with the provider’s policy.
The provider took account of the views of people using the service and their relatives through annual residents and relative’s surveys.
We found one breach of the Health and Social Care Act (2008) Regulated Activities Regulations 2014. You can see what action we asked the provider to take at the back of this report.