18 January 2017
During a routine inspection
This inspection took place on the 18 and 19 January 2017 and was unannounced. The inspection team consisted of one inspector.
The last inspection we carried out at this service was in December 2015 at which the provider was found to be in breach of three of the regulations that we inspected which included safeguarding people from abuse and improper treatment, staffing and good governance. The provider submitted action plans linked to each of these breached regulations, stating how and by when they would meet the requirements of these regulations. At this inspection we found improvements had been made in all three of the aforementioned areas.
A registered manager was in post at the time of our inspection who had been registered with the Commission to manage the carrying on of the regulated activity since August 2016. 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.
People who could told us they felt safe living at the home. Their relatives confirmed they had no concerns about the way their family member was treated by staff. The provider had a safeguarding policy and procedure in place that gave staff information about how to appropriately safeguard people in their care from harm or abuse. Historic safeguarding or potential safeguarding matters had been dealt with promptly and correctly.
Risks that people were exposed to in their daily lives had been assessed and were regularly reviewed. Environmental risks within the building were also well managed to protect people's safety. Emergency planning had been considered and measures were in place to support people appropriately in the event of unforeseen incidents taking place. Accidents and incidents were documented, analysed and measures put in place to prevent repeat events.
Recruitment procedures were robust, as was the management of medicines within the service.
People's needs were met and staff were very knowledgeable about how to support people in line with their needs. People's general healthcare needs were monitored and they were supported to maintain their health and wellbeing. Where people were ill, medical attention was sought promptly. Staff and people enjoyed good relationships and there was a calm and happy atmosphere within the home.
People's dignity, privacy and independence was protected and promoted. Staff involved people in their care and they chose how they lived their lives. People were heavily involved in a range of different activities within the community and staff supported and encouraged this.
CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty safeguards. The Mental Capacity Act (MCA) was appropriately applied and the provider had submitted applications to the local authority to deprive people of their liberty lawfully, to prevent them from coming to any harm where they lacked capacity. The service understood their legal responsibility under this act and they assessed people’s capacity when their care commenced and on an on-going basis when necessary. Decisions that needed to be made in people’s best interests had been undertaken and related records were available for us to view.
Staff support and training had improved since our last visit and staff had received training in key areas which had previously not been completed. Supervisions and appraisals took place. The induction programme had been developed to include the Care Certificate.
Care records were well maintained and regularly reviewed to ensure they remained up to date. Monitoring tools were used to ensure continuity of care. Handovers between shifts took place and a diary system was used to pass messages between changing staff teams.
The registered manager was organised and focused. We received positive feedback about her approach and the improvements that had been introduced since our last inspection. The provider's oversight of the service had improved and quality assurance systems were effectively applied. The provider's compliance team monitored the service well and this meant that any shortfalls which were identified were promptly addressed. Staff and the registered manager were accountable for their actions.