Background to this inspection
Updated
14 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 23 June 2015 and 12 August 2015 and was unannounced.
The inspection team consisted of one inspector and one specialist advisor. The specialist advisor was a pharmacist.
We looked at three peoples care records. We spoke with two people that used the service. 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 manager and staff. We asked for feedback from the City of Bradford Adult Protection Unit. We looked at care plan documentation as well as documentation relating to the management of the service such as training records, policies and procedures
On this occasion we did not ask the provider to complete 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. Before the inspection, we reviewed all the information held about the provider.
Updated
14 December 2015
On the 23 June 2015 and 12 August 2015 we inspected 8, 10 and 11 Bedes Close. Both days of inspection were unannounced. The pharmacist attended the inspection in 23 June 2015, and due to high risk work being undertaken at the time, the lead inspector was unable to attend the remainder of the inspection until 12 August 2015.
8, 10 and 11 Bedes Close provides accommodation for persons requiring nursing and personal care to a maximum of 18 people who are living with learning disabilities. All the accommodation is in single rooms and the service is located in the residential area of Thornton, close to Bradford city centre. The Service is split between three, six bedroom bungalows.
There was not a registered manager in place. The last registered manager deregistered with the Care Quality Commission (CQC) in 2013. The service had an acting manager who was in the process of registering with the CQC. 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.
Staff were recruited in line with the provider’s policy. Relevant background checks had been completed and were monitored.
People were protected from the risk of abuse as staff had received training in safeguarding people and had good understanding of their roles and responsibilities if they suspected abuse was happening. The manager also shared information with the local authority and the Care Quality Commission when required.
People received their medicines as prescribed and the management of medicines promoted people’s safety. Medicines were audited regularly to maintain a high standard.
Staffing was maintained at appropriate levels to provide people with effective support. Staff had received appropriate training to maintain their competency. Staff felt supported however there were gaps in supervisions and appraisal meetings.
People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We saw best interest meetings had been held when required.
Staff encouraged people to be as independent as possible. Staff spent time getting to know people to provide a more person centred service.
Staff were aware of the basic principles of the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.
People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when required.
People’s care records were person-centred to ensure people received support in a planned and responsive way. People that used the service, or their representatives, were encouraged to contribute to the planning of care records.
People had unrestricted access to their families and their friends. They also had opportunities to participate in a variety of social and leisure activities to help them lead a fulfilling life.
Systems were in place to monitor the quality of service provision. We saw regular audits had identified shortfalls which had been remedied.
People that used the service or those acting on their behalf felt they could report any concerns to the management team and they would be taken seriously.