Pauline Burnet House is registered to provide accommodation for up to eight people who require nursing or personal care. At the time of our inspection there were eight people living at the service. Accommodation is provided on both floors of the two storey building and all bedrooms are single rooms.
At our previous inspection on 11 April 2014 the provider was meeting the regulations that we assessed. This unannounced inspection took place on 8 September 2015.
The service had a registered manager. The registered manager also managed four other locations registered by the provider. 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.
The provider’s recruitment process was robust. This helped ensure that only those staff who were deemed suitable to work with people using the service were offered employment. There was a sufficient number of suitably qualified and experienced staff working at the service. An induction process was in place to support and develop new staff.
Staff’s competency to safely administer medicines was assessed regularly to ensure they adhered to safe practice. This was after staff had successfully completed medicines administration training. However, not all medicines were recorded accurately or stored as safely as they should have been. This was in contravention of the provider’s policy and put people at risk of unsafe medicines administration.
Staff had been trained in protecting people from harm. They were knowledgeable about reporting suspected or actual harm and had a good understanding of what protecting people from harm meant.
The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service’s manager and staff were knowledgeable about assessing people’s ability to make specific decisions about their care needs. Staff were aware of the circumstances and conditions when an application to lawfully deprive any person of their liberty was required.
People’s care was provided with compassion and in a dignified and private manner. People were encouraged to be as independent as practicable with their day to day living skills, choices and preferences.
People’s care records were reviewed regularly and kept up-to-date by staff. This was to help ensure that people were provided with care and support based upon the person’s latest and most up-to-date care information. People were involved in their care planning and were supported by relatives, staff and social workers. An advocacy service was available if people required, or were identified as needing, this support.
People were supported to access a range of health care professionals including speech and language therapists, GP and opticians. Advice and guidance provided to staff by health care professionals was followed and adhered. Prompt action was taken in response to the people’s changing health care needs. Risk assessments were in place to help manage each person’s assessed health risks.
People were encouraged and supported to eat a healthy balanced diet which was appropriate for their needs. People were supported to have sufficient quantities of the food and drinks that they preferred.
People, their relatives and staff were provided with information and guidance about how to raise compliments or concerns. Staff knew how to respond to any reported concerns or suggestions. Not all complaints were recorded. This limited the registered manager’s and provider’s ability to respond effectively to concerns.
The provider, registered manager and the service’s manager had audits and quality assurance processes and procedures in place. However, not all audits were effective in identifying the issues we found.
Staff were supported to develop their skills, increase their knowledge and obtain additional care related and management qualifications.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take in the full version of the report.