13 November 2017
During a routine inspection
At the last inspection on 19 October 2015, the service was rated Good. At this inspection, we found the service remained Good. This inspection took place on 13 and 22 November 2017 and was unannounced.
At the time of our inspection, 30 people were using the service and there was a registered manager in post. 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.
We found best interest meetings did not always include all relevant people and did not always consider least restrictive options. We have made a recommendation for the provider to use the Mental Capacity Act 2005 code of practice to inform their policies and procedures regarding best interest decision-making.
People told us they felt safe living at the service. Staff were clear about their responsibilities to protect people from the risk of harm and abuse, and had completed training in safeguarding vulnerable people.
People received their medications as prescribed. However, the provider had recently identified issues in the recording of medicines and had put steps in place to reduce the reoccurrence of this.
People’s nutrition and health needs were met. Referrals to healthcare professionals were completed in a timely manner and people were involved in making decisions regarding their own treatment and care where possible.
Although some care plans were not fully up-to-date, staff were responsive to people’s needs and we found no detrimental impact on people. Pre-admission assessments enabled staff to provide care for people from the day of their admission and assessments were person-centred.
We found staff were recruited safely and received an induction, which was linked to the Care Certificate. Staff received training, supervision and appraisal as required, and there were sufficient staff on duty to meet people’s individual needs. Staff were trained in infection control and the service was safe, clean and tidy. Business continuity plans and personal emergency evacuation plans (PEEPs) gave staff clear guidance on how to keep people safe in the event of emergencies.
The environment supported people who were living with dementia and catered for people’s individual needs. We saw the décor, activities and many communal areas enabled people to spend time as they wished. Activities were tailored to people’s needs and preferences. Newsletters kept people updated with relevant information.
We found people were supported by staff who were caring, patient and compassionate. People were treated with dignity and respect, and were enabled to be independent. There were no restrictions on visits, and accessing the community was encouraged. Local community groups, such as schools, were invited to the service and there had been a recent open day where the community could attend the service.
We found the culture of the provider to be open and inclusive. Comments regarding the provider and registered manager were positive, and everyone said that they were approachable. People told us any complaints would be addressed and we saw the provider had responded to feedback. The registered manager understood and fulfilled their duty to report notifiable incidents to the Care Quality Commission as required under legislation. The provider had developed quality assurance and governance systems to highlight shortfalls and drive improvements within the service.
Further information is in the detailed findings below.