22 November 2017
During a routine inspection
There was a manager in place who was in the process of registering with the Care Quality Commission (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.
People who used the service felt safe with the people who supported them. Staff recruitment was robust and staffing levels were satisfactory.
There was a safeguarding policy and staff had undertaken training and were confident about the procedures around safeguarding issues. Accidents and incidents were logged and addressed appropriately. An appropriate medicines policy was in place and medicines were managed effectively.
The induction procedure was thorough and on-going mandatory and refresher training was undertaken by all staff. Staff supervisions and appraisals were undertaken regularly. Care plans included appropriate information around health and support needs.
The service was working within the legal requirements of the Mental Capacity Act 2005 (MCA). We saw evidence of consent being sought where appropriate.
People who used the service and their relatives the service told us staff were polite and kind.
There was a policy on equality and diversity and the service was committed to ensuring equality and diversity were respected.
There was a service user guide which included relevant information about the service. Satisfaction surveys were sent out on a twice yearly basis to gain people’s views and suggestions about the service. We saw evidence of people’s involvement in care planning and reviews.
Care files we looked at were person-centred and included information about people’s backgrounds, likes and dislikes. The service was using a new electronic system for call monitoring. This enabled the service to better monitor timings of visits and to address any issues of lateness or missed visits promptly.
The service had an appropriate compliments, suggestions and complaints policy and procedure in place. Complaints had been addressed appropriately and in a timely way. The service had received a number of compliments via telephone and e mail and these were also logged and analysed.
Staff said they were well supported within their roles and the management team were accessible and supportive. Regular staff meetings provided an additional forum to supervisions for staff to raise any issues.
The service undertook quality audits, monitoring and analysis. All audits included follow up actions where required.