Archived: Box Tree Cottage

Updated 12 October 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.

This inspection took place on 5 September 2016 and the inspection was announced. The provider was given 48 hours’ notice because the location provides a domiciliary care service and we needed to be sure that the registered manager was available. The inspection was carried out by one inspector and a specialist advisor.

We used a number of different methods to help us understand the experiences of people who used the service. We spent time observing support being delivered. We looked at three people’s care records, medicines administration records (MAR) and other records which related to the management of the service such as training records, staff recruitment records and policies and procedures.

We spoke with four people who used the service. We also spoke with the registered manager, the deputy manager, the area manager, three project workers and the cook.

Before our inspections we usually ask the provider to send us 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 did not ask the provider to complete a PIR on this occasion.

Updated 12 October 2016

The inspection took place on 5 September 2016 and was announced.

Box Tree Cottage is a specialist service offering short stay hostel accommodation for up to seventeen males who have either offended or who are at risk of offending. The service is staffed 24 hours and meals are provided on site.

There was a registered manager in post at the time of the inspection. 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.

Staff received training to protect people from harm and they were knowledgeable about reporting any suspected harm. There were a sufficient number of staff available for operational purposes and recruitment procedures ensured that only staff suitable to work in the caring profession were employed. Risk assessments were in place where risks to people’s health, safety and welfare had been identified and action had been taken to reduce these risks.

The registered manager demonstrated a good understanding of their responsibilities under the Mental Capacity Act 2005 (MCA) and staff showed a good knowledge of the people they supported and their capacity to make decisions.

The staff we spoke with were able to describe how individual people preferred their support to be delivered and the importance of treating people with respect.

The support plans we looked at were person centred and were reviewed on a regular basis to make sure they provided accurate and up to date information. The staff we spoke with told us they used the support plans as working documents and the information provided enabled them to carry out their role effectively and in people's best interest.

Medicines were administered by competent and trained staff and people received their medicines as prescribed and in a timely manner.

There was a complaints procedure available which enabled people to raise any concerns or complaints about the support they received.

There was a quality assurance monitoring system in place that was designed to continually monitor and identify shortfalls in service provision. Audit results were analysed for themes and trends and there was evidence learning from incidents took place and appropriate changes were made to procedures or work practices if required.

Members of the senior staff team were accessible and provided staff with leadership and direction. There were clear lines of communication and accountability within the staff team which meant the service was managed effectively and in people’s best interest.