Donec Mews

Updated 11 March 2021

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.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 27 January 2021 and was announced.

Updated 11 March 2021

This inspection took place on the 11 and 13 September 2018 and was unannounced.

During our previous inspection on 7 and 8 July 2017, we identified the provider had breached regulations 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We found that that not all people had evidence of decisions being made in people’s best interest if they lacked capacity. We also found that the provider’s quality assurance process had not picked up on a potential health and safety issue which put people at risk.

We asked the provider to take action to address these issues and at this inspection, we checked whether the provider had made improvements. At this inspection we found the provider had made and sustained the required improvements.

Donec Mews is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Donec Mews accommodates 16 people across three separate houses. The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a registered manager. 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 was guidance in place to protect people from risks to their safety and welfare, this included the risks of avoidable harm and abuse. Staffing levels were sufficient to support people safely and where there were any short falls these were covered by regular agency staff who knew the people they were supporting well. The provider had an effective recruitment process to make sure the staff they employed were suitable to work in a care setting.

Risks to people were assessed and action was taken to minimise any avoidable harm. Staff were trained to support people who experienced behaviour that may challenge others, in line with recognised best practice. Medicines were managed safely and administered as prescribed and staff had regular competency checks.

Staff raised concerns with regard to safety incidents, concerns and near misses, and reported them internally and externally, where required. The registered manager analysed incidents and accidents to identify trends and implement measures to prevent a further occurrence.

Staff understood the importance of food safety and prepared and handled food in accordance with required standards. High standards of cleanliness and hygiene were maintained within the home.

People were supported by staff who had the required skills and training to meet their needs. Where required, staff completed additional training to meet individual's’ complex needs. People were supported to have a balanced diet that promoted healthy eating.

The registered manager ensured people were referred promptly to appropriate healthcare professionals whenever their needs changed.

The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People or their families were involved in making every day decisions and choices about how they wanted to live their lives and were supported by staff in the least restrictive way possible.

People experienced good continuity and consistency of care from staff who were kind and compassionate. The registered manager had created an inclusive, family atmosphere at the home. People were relaxed and comfortable in the presence of staff who invested time to develop meaningful relationships with them.

People's independence was promoted by staff who encouraged them to do as much for themselves as possible. Staff treated people with dignity and respect and were sensitive to their needs regarding equality, diversity and their human rights.

Staff rotas were organised so that there were enough staff to meet people’s needs. Staff had time to listen to people, answer their questions, provide information, and involve people in decisions.

The service was responsive and involved people and their families where appropriate in developing their support plans. These were detailed and personalised to ensure their individual preferences were known. People were supported to complete stimulating activities of their choice, which had a positive impact on their well-being.

Arrangements were in place to obtain the views of people and their relatives and a complaints procedure was available for people and their relatives to use if they had the need.

The service was well managed and well-led by the registered manager who provided clear and direct leadership, which inspired staff to provide good quality care. The safety and quality of the support people received was effectively monitored and any identified shortfalls were acted upon to drive continuous improvement of the service.