The inspection took place on 16 March 2017 and was unannounced. The service was last inspected in January 2015 and met with legal requirements.261 Passage Road is a care home that is registered to provide personal care for up to 5 people. There were 5 people at the home on the day of our visit.
Two people told us a staff member was "bossy" in their manner towards them. Some action had been taken to address these concerns after people had raised their views to senior staff in the home. At our inspection these concerns were repeated to us. We bought this matter to the attention of the registered manager who took action to ensure that people were safe.
Fire drills had not been regularly carried out. This put people at risk as in the event of a fire it would not be clear if people knew what actions to take to be safe.
The governance system that was in place for auditing and monitoring quality and safety was not being used effectively. The failings identified at our visit had not been picked up by recent audits.
There was a registered manager for the service. 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.
There were systems in place to minimise risks to people and to protect them from abuse. People who lived at the some engaged in a positive and warm way with the staff that provided them with personal care and other support.
People were assisted with their care by staff that understand their needs and knew how to provide effective support. The staff we met had a kind and caring manner toward the people they supported. The staff also knew how to ensure that privacy and dignity was maintained when they were supporting people with their care.
People were well supported to eat and drink enough for their health needs. Menus were planned with choices available which reflected the likes and preferences of each person at the home.
People were supported by a team of staff who were properly trained to provide effective care The staff had been on regular training and were developed and supported in their work. This helped them to improve and develop their skills and competencies. Staff were properly supervised in their work and this helped to ensure they were competent in their work. Staff spoke positively about working as a team and the team support that existed among them.
There was a system in place in the home so that the requirements of the Mental Capacity Act 2005 were implemented when needed. This legislation protects the rights of people who lack capacity to make informed decisions.
People were being well supported to take part in a variety of social and therapeutic activities both in the home and the community. These activities were planned based on what people wanted to do each day.
There were recruitment and training processes in place that helped to ensure that staff were properly checked and were knowledgeable. This meant staff were be able to support people effectively.
The staff told us they could address any concerns or raise any matters informally with senior staff and the registered manager. The staff had received formal supervision meetings. At these meetings areas for improvement were regularly addressed with them.
Care records were detailed explained what to do to effectively assist people with their personal care needs. People were well supported with their physical health care needs. Staff consulted with external healthcare professionals to get specialist advice and guidance when it was needed.
The provider had systems in place to support people to make their views known and to make complaints about if they needed too.
Staff understood the provider’s visions and values that they expected staff to follow. One key value was to provide personalised care. The staff told us they put these into practice in the way they supported people at the home.
We found two breaches of Regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we have taken at the back of the report.