Archived: Lady Anne Treves Memorial Home

Updated 5 April 2018

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 January 2018 and was unannounced. The inspection team consisted of two inspectors and an Expert by Experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we reviewed information we held about the service including any notifications, (a notification is information about important events which the service is required to send to us by law) and any complaints that we had received. The provider had submitted a Provider Information Return (PIR) before the inspection. A PIR asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. This enabled us to ensure that we were addressing any potential areas of concern at the inspection.

We spoke to ten people who use the service and three relatives. We spoke with eight members of staff and the registered manager. We observed the staff handover and spent time observing staff interacting with people. We looked at a range of documents including policies and procedures, care records for seven people and other documents such as safeguarding, incident and accident records, medication records and quality assurance information. We reviewed staff information including recruitment, supervision and training information as well as team meeting minutes and we looked at the provider’s information systems.

This was the first inspection since the home was registered with CQC on 21December 2016.

Updated 5 April 2018

Lady Anne Treves Memorial Home is a care home. People in care homes receive accommodation and 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. Lady Anne Treves Memorial Home provides accommodation, care and support for up to 21 people. Accommodation is arranged over three floors with stairs and a passenger lift linking each floor. The provider, Pilgrim’s Friend Society, is a Christian charitable organisation. The ethos of the organisation is to provide support for older Protestant Christians of any denomination. One of the provider’s stated aims is to provide people with every opportunity to pursue their Christian life.

This inspection was undertaken on 22 January 2018 and was unannounced. On the day of the inspection there were 18 people living at the home. The home had a registered manager who was present throughout the inspection on 22 January 2018. 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.

This was the first inspection since the home was registered with CQC on 21December 2016.

People and their relatives told us they felt safe at the home and that there were enough suitable staff on duty. One person said, “I use my bell quite a lot, the staff are pretty sharp answering it.” Another person told us, “I definitely feel safe here, the staff are wonderful.” People were receiving the medicines they needed safely and staff understood their responsibilities with regard to keeping people safe. Risks were identified and managed effectively and any incidents and accidents were monitored to inform practice and make improvements to the service.

Staff had received the training and support they needed to be effective in their roles. One staff member said, “The manager and the seniors are very approachable for anything.” People said they had confidence in the staff and one relative told us, “All the staff are good, and some have a real gift.” People had enough to eat and drink and they told us that they enjoyed the food on offer. One person said, “It’s just the same as I would have at home.” People were offered choices and their preferences were respected. Risks associated with nutritional needs were identified and managed and people received the support they needed to eat and drink.

People were supported to access health care services when they needed to. One person said, “If I needed the doctor the staff would arrange it.” Staff described positive working relationship with health care professionals. A visiting health care professional told us that staff made appropriate referrals and were knowledgeable about people’s needs. People‘s needs had been assessed using accredited tools in line with current good practice. Staff understood their responsibilities with regard to the Mental Capacity Act and people said that staff always asked them before providing care or support. Staff were using technology effectively to ensure that people’s needs were met in a timely way. Refurbishment work was being undertaken in the main lounge and dining area on the day of the inspection. Staff had taken steps to ensure that people were not caused distress during the building work.

People and relatives spoke highly of the caring nature of the staff. Throughout the inspection we observed staff treating people kindly. One person said, “We are very blessed that we have some very thoughtful people looking after us.” Staff knew people well and treated them with respect. One relative told us, “You only have to look at my relation’s face when the staff talk to her to know that she likes them.” People were included in decisions about their care and support as much as possible and where appropriate their family or representatives were also included. Staff supported people to remain independent and promoted their dignity. People’s privacy was respected and their personal information was kept securely.

Staff understood how to provide care in a personalised way and people’s choices and preferences were considered. Where people had difficulties with communicating their needs staff had used technology to support them. People told us that the Christian focus of the home was important for them and they enjoyed being supported to follow their religion, for example, with daily devotion services. One person said, “I wanted to come here because of the religious aspect.” Another person told us, “I like the services in the morning.” Staff had time to spend with people, supporting them to follow their interests and to maintain contact with people who were important to them. People were supported to plan for care at the end of their life. A relative told us that staff had been supportive to them as well as showing compassion for their relation.

People knew how to complain and felt confident that any issues would be addressed. There was a complaints system in place to record any concerns and the actions that were taken. The registered manager used complaints information to drive improvements at the service.

There was a clear management structure at the home and staff understood their roles and responsibilities. Staff had a firm understanding of the ethos of the home to provide care and support in line with the Christian values of the provider. Staff understood the provider’s equality policy and supported people with their diverse needs. Staff described being well supported and spoke highly of management at the home. Governance arrangements were embedded within practice and regular audits identified any shortfalls in standards of care. Action plans showed how learning from incidents and accidents was also used to drive improvements at the home. People, their relatives and staff were included in planning developments at the home.

Staff had made links with the local community and volunteers and ministers from local churches visited the home regularly. Staff described positive working relationships with a number of health and care professionals. One visiting professional told us that they had experienced good communication with staff who they described as knowledgeable about the people they were caring for. Staff were using technology to provide up to date information to health care professionals.

The registered manager had informed the CQC of significant events in a timely way. They were committed to keeping up to date with best practice and updates in health and social care and told us about plans to develop a more dementia friendly environment to benefit people living at the home.