St Audrey's

Updated 26 October 2017

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 met 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 under the Care Act 2014.

This inspection took place on 11 September 2017 and was unannounced. The inspection was carried out by two inspectors.

We reviewed information we held about the service including statutory notifications that had been submitted. Statutory notifications include information about important events which the provider is required to send us. Prior to the inspection we also reviewed information received from the local authorities commissioning and safeguarding teams.

During the inspection we observed how staff offered support to people who used the service. We spoke with four people who used the service and two relatives, two staff members, the registered manager and deputy manager. We also spoke with one visiting health professional.

We also 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 reviewed care records relating to four people who used the service and other documents central to people’s health and well-being. These included staff training records, medication records and quality audits.

Updated 26 October 2017

St Audrey's is registered to provide accommodation and personal care for up 38 older people. At the time of our inspection 10 people were living at St Audrey's. This was due to extensive renovations to the home in order to meet fire safety regulations.

We previously inspected St Audrey's on 05 August 2016 and found improvements were required in relation to how the service was monitored, and how people’s records were accurately maintained, including how the registered manager identified and responded to incidents that may put people at risk of harm. At this inspection we found the required improvements had been made.

The home had a registered manager in post who had been registered since September 2015. A registered manager is a person who has registered with the Care Quality Commission (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.

At this inspection people told us they felt safe and staff were aware of how to maintain people’s safety. Staff had reported incidents that required review and investigation to keep people safe from the risk of harm. Risk assessments were in place and regularly reviewed to ensure safe and effective care was in place to manage those identified risks. There were sufficient numbers of staff deployed to provide care safely to people living in St Audrey's. People were supported by staff who had undergone a robust recruitment process to ensure they were of good character to provide care to people. People's medicines stored safely and managed well and people received their medicines as the prescriber intended.

Staff felt supported by the manager who enabled them to carry out their role effectively. Staff received training relevant to their role and new staff received a comprehensive induction. Staff were aware of how to support peoples to make decisions who may lack the capacity to make those informed decisions, and people consent was recorded in line with their wishes. People's nutritional needs were met and their food and fluid intake along with their weight was robustly monitored. People were able to choose what they ate from a varied menu with support from staff to eat their meals independently. People we spoke with told us they had access to a range of health professionals.

Staff spoke to people in a kind, patient and friendly way, and staff and people and their relatives have developed a clear rapport and understanding of one another. People's dignity was maintained, and people were assisted promptly when required to protect their dignity. People's privacy was maintained.

People received care from staff that was responsive and met their needs. Staff were aware of people's individual needs and how to meet these, and were knowledgeable about how people chose to spend their day, and accommodated this. People were provided with a range of activities based on their preferences, and were actively encouraged to spend time away from the home with family and staff. Complaints had been responded to by the Registered Manager in a robust manner.

People, staff, relatives and health professionals felt the management team were visible around the home and sought their views and opinions about how the home was run. We were told that the management team responded positively to feedback and proactively encouraged people to do so. People's personal care were records were regularly reviewed to ensure they were complete and actions that were identified were addressed. The registered manager completed a range of audits in relation to areas such as infection control, medicines, health and safety, training and development, and where they identified areas for improvement they took action to ensure these were completed. Notifications that are required to be submitted to CQC were made when required.