Archived: Avenues South East - 6 Coleman's Stairs

Updated 15 January 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 22 December 2015 and was unannounced. The inspection was carried out by one inspector. This was because the service was small and it was decided that additional inspection staff would be intrusive to people’s daily routines.

The provider did not complete a Provider Information Return (PIR) because CQC did not request one before the inspection. 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 asked these questions during the inspection. We reviewed information we held about the service. We looked at previous inspection reports and notifications received by CQC. Notifications are information we receive from the service when a significant events happen, like a death or a serious injury.

We looked around all areas and grounds of the service. We met the two people living at the service. We spoke with four members of the care team and the registered manager. During our inspection we observed how the staff spoke with and engaged with people.

People were not able to communicate using speech because of their health conditions so we 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. Some people used their own form of sign language or body language to express themselves.

We looked at how people were supported throughout the inspection with their daily routines and activities and assessed if people’s needs were being met. We reviewed two care and support plans and associated risk assessments. We looked at a range of other records, including safety checks, staff records and records about how the quality of the service was monitored and managed.

We last inspected Avenues South East – 6 Coleman’s Stairs in May 2014 when no concerns were identified.

Updated 15 January 2016

This inspection took place on 22 December 2015 and was unannounced.

Avenues South East – 6 Coleman’s Stairs provides residential care for up to four people with a learning disability, autistic spectrum disorder or physical disability. At the time of the inspection there were two people living at the service.

A registered manager was in post. 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. The registered manager was present on the day of the inspection.

Staff understood the importance of keeping people safe. Staff knew how to protect people from the risk of abuse. Risks to people’s safety were identified, assessed and managed appropriately. People received their medicines safely. Accidents and incidents were recorded and analysed to reduce the risks of further events.

Recruitment processes were in place to check that staff were of good character. There was a training programme in place to make sure staff had the skills and knowledge to carry out their roles effectively. People were consistently supported by sufficient numbers of staff who knew them well.

People were provided with a choice of healthy food and drinks which ensured that their nutritional needs were met. People’s health was monitored and people were referred to and supported to see healthcare professionals when they needed to.

The registered manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. DoLS applications had been made to the relevant supervisory body in line with guidance.

People and their loved ones were involved with the planning of their care. People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. Staff were kind, caring and compassionate and supported people to keep occupied with a range of meaningful social and educational activities to reduce the risk of social isolation.

The registered manager led by example and coached and mentored staff through regular one to one supervision. The registered manager worked with the staff each day to maintain oversight of the service. Staff were clear about what was expected of them and their roles and responsibilities and felt supported by the registered manager.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service. CQC check that appropriate action had been taken. The registered manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines. Complaints were responded to and used as a learning opportunity to improve the service.