18 November 2016
During a routine inspection
We last inspected this service on the 21 July 2015. At the time the service was rated Requires improvement overall with an inadequate rating in the domain of well led and three breaches of regulation. At this inspection there was a new provider and a new management team in place and a number of positive changes were identified.
The deputy manager had been in post since February 2016 and the manager since April 2016. The manager was waiting for their registration with CQC to be processed with a date arranged for their fit person’s interview.
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 service is registered for 63 people. On the day of our inspection there were 39 people using the service. There are three floors including lower ground, ground and first floor which was unoccupied during our inspection. There were eleven people residing on the Turner unit, (lower ground) which is predominately for people living with dementia and 28 people residing on the ground floor.
The deputy manager was present during our inspection and the manager who was at a conference arrived later during the day along with her senior management team. All were fairly new to their posts and were working to improve standards of care in accordance with their detailed action plan.
The most notable change was around the recent appointments of staff which had led to a reduction in the use of agency staff. However, agency staff were still being used predominantly at night. New appointments had been made for a second activities co-ordinator, a chef and a maintenance person. We found staffing levels were sufficient on the day of inspection but improvements had been identified by the manager in call bell response times and continuity of care at night. The deputy manager had said they were looking to appoint staff working from 06:00am to 08:00am to assist night staff in getting people up that wanted to at that time as they felt this was a busy time of day. Staff said there were enough staff available . However, people using the service told us they did not always feel confident about the staffing levels and whether or not they were adequately maintained.
Risks to people’s safety were well managed and staff had sufficient training around managing risk and supporting people with their manual handling needs. Assessments were regularly carried out to ensure risks to people’s health and safety were known and sufficient steps could be taken to reduce risk.
Staff had an understanding of safeguarding people from the risk of abuse and who to report to should they have concerns about a person. Reporting procedures were clear and staff knew they could refer internally and to outside agencies.
We identified shortfall in the management of people’s medicines. We found through our audit that stock levels did not always match recorded number of tablets so could not be assured people always got their medicines as intended.
Staff recruitment and induction were satisfactory and staff felt well supported within the service.
The service took the necessary steps to ensure people without capacity were adequately protected and the service acted lawfully. Staff had sufficient understanding of legislation relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. People were supported to make decisions and any restriction on people with carried out lawfully.
People were supported to eat and drink sufficient to their needs. Staff actively monitored any one at risk of unintentional weight loss so this could be prevented as far as possible. People’s health care needs were met.
Staff were kind and caring and had time to spend with people. People told us they felt valued and staff were respectful and helped them maintain their independence. People were consulted about their care needs and wider issues about the running of the service.
The service was responsive to people’s individual needs and staff were familiar with people. The care plans were more individualised and improved but this was still working progress with some care plans yet to provide enough information and guidance for staff to ensure continuity of care.
Activities for people to alleviate social isolation and boredom were provided most days and very much enjoyed by those participating. However we met a number of people who felt isolated in the service and did not feel activities provided were suitable for them.
The service acted upon feedback, compliments and complaints to try and improve the overall experience people had.
The service had worked hard to improve the service and we found the manager was responsive and knowledgeable. The team of staff provided high standards of care and the atmosphere was calm and cohesive.
Service audits were not yet effective in identifying shortfalls within the service as we identified a number of concerns which the service had not already identified.. However the service was continuously improving the service which gave us confidence for the future.
People’s experiences could be improved at this service with better engagement of the voluntary sector and community groups.
We found one breach of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
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