Salroyd Villa is a detached property located in a quiet residential area of Low Moor in Bradford. The home is registered to care for up to 16 older people, some of whom are living with dementia. The home includes lounge and dining facilities and there is a garden and a patio area to the front of the house. The inspection was unannounced and took place on 19 and 26 April 2017. The management team were not available on the first day of our inspection, so we returned a week later to check documents which only management were able to access. On the days of the inspection, 15 people were living in the home.
Although the home had been operating for many years, in September 2016 changes were made to the partnership running the home meaning the home was re-registered with the Commission in its current form. As a result the service had not been previously inspected under this registration.
The current registered manager, who was also a partner in the business, and several other staff had also been at the home for many years under the previous registration. 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.
We rated the provider ‘Requires Improvement’ overall. This was because we found several areas of concern relating to the ways medicines were managed, a lack of working to the Mental Capacity Act (MCA), a lack of evidence people’s nutritional needs were being met and lack of robust governance systems. We also identified some good areas of practice. People, relatives and health professionals spoke positively about the home. They said that that the home provided good quality care in a friendly environment. Care was personalised and staff knew people well.
Medicines were not always managed in a safe and proper way. We were unable to confirm people had consistently received their medicines as prescribed as records were not consistently completed and a full balance of medicines in stock was not always kept.
People said they felt safe living in the home. Staff understood how to keep people safe from abuse.
Overall staffing levels were appropriate within the home, although staff were stretched when management were not present within the building. Safe recruitment procedures were in place to help ensure people were of suitable character to work with vulnerable people.
Risks to people’s health and safety were assessed and control measures such as specialist equipment were sourced to protect people from harm.
The premises were homely and kept clean and personalised to people’s individual requirements. We found some risks associated with the premises which the provider had rectified by the 2nd day of our inspection.
Staff received a range of training and support relevant to their role. People said staff had a good knowledge of them and how to provide effective care.
The service was not consistently compliant with the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) as DoLS conditions had not been met.
We concluded people’s nutritional needs were not always met, as appropriate action had not always been taken when people were losing weight.
Staff were kind and caring. Good, positive relationships had developed between people and staff. Information on people’s past lives had been obtained to help provide personalised care and support.
People were encouraged to remain independent and help out around the home where possible.
People felt listened to and their views and opinions were used to shape care and support arrangements.
People’s needs were assessed and plans of care put in place. People, relatives and health professionals said care met people’s individual needs.
A programme of activities was in place. These included regular visitors such as entertainers, regular events and trips out into the community.
A system was in place to log, investigate and respond to complaints. No recent complaints had been received about the service and people were very satisfied with the home.
We found a positive, caring and person centred atmosphere within the home. The management team were ‘hands on’ and people and relatives spoke highly of them.
Audits and checks were carried out. Some of these needed to be more robust to prevent some of the concerns we identified from occurring.
People’s feedback was used to make changes to the service for example around activity provision.
We found four breaches of the Health and Social Care Act (2008) Regulated Activities 2014 Regulations. You can see what action we asked the provider to take at the back of the full version of this report.