Archived: 43 Naburn Walk

Updated 9 June 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 17 April 2018 and was announced. The provider was given 48 hours’ notice because we needed to be sure that someone would be in.

The inspection was undertaken by an adult social care inspector. At the time of the visit, there was one person using the service and we spoke with them. The operations manager told us that a second person had been assessed to live at the service. Arrangements had started to introduce the person into the service. We spoke with support staff, the operations manager and one of the nurses, the activity coordinator and occupational therapist. We observed how staff interacted and gave support to the person throughout this visit.

Before the inspection, we reviewed the information we held about the service. This included statutory notifications about incidents and events affecting people using the service. The acting manager had completed the Provider Information Return (PIR) and sent it to us. The PIR is a form that asks them to give some key information about the service, what the service does well and improvements they plan to make. We also spoke with the local council commissioning officer who also undertakes periodic visits to the home.

We looked at documentation relating to the person who used the service, staff and the management of the service. We looked at the person’s written records, including the plans of their care. We looked at the systems used to manage people’s medication, including the storage and records kept. We also looked at the quality assurance systems to check if they were robust and identified areas for improvement. We telephoned and spoke with a relative. They gave us their views about the staff and the care of their family member.

Updated 9 June 2018

This was the first inspection of the service following their registration with the Care Quality Commission on 6 February 2017. The inspection was completed on 17 April 2018 and was announced. We gave the provider 48 hours’ notice of the inspection because the service is small and we needed to be sure that operations manager was available and people who used the service would be in.

43 Naburn Walk is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides 24 hour nursing care and support for up to three people with physical disabilities and/or mental health problems. It is situated in a residential area on the outskirts of Leeds.

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 physical disabilities and/or mental health problems and nursing needs using the service can live as ordinary a life as any citizen.

The service is required to have 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 and associated Regulations about how the service is run. There was no registered manager at the time of this inspection. The operations manager told us that they were going to submit an application to be the registered manager and were in the process of completing the application. This application was received by the Commission on 3 May 2018.

People were happy with the care they received and the staff that supported them. There were enough staff available to offer support to people. Staff received an induction and training that helped them offer support to people. The provider ensured staffs’ suitability to work within the service. However, we found staff did not receive appropriate supervisions and appraisals in line with the provider’s policy and procedures. We have made a recommendation that the service provides formal supervision of staff at the required frequency determined by the registered provider.

Staff knew about their responsibilities to safeguard people. They were able to identify different types of abuse and knew where to report their concerns. They also demonstrated their knowledge of the provider’s whistleblowing policy.

The operations manager did not have full oversight and scrutiny of the service. Quality assurance records were primarily designed for a service within the organisation which was adjacent to 43 Naburn Walk. We found the operations manager knew what was going well and the areas that needed improvement. However, they had not given sufficient consideration to developing separate action plans for 43 Naburn Walk. The provider had sought feedback from people, staff and others involved with the service but we were unable to establish the views of the person at 43 Naburn Walk as the analysis was incorporated into the provider’s other adjacent service.

People were supported in a dignified way. The choices they made were considered by staff that supported them. There was an on-going safeguarding concern at the home and the provider had taken the necessary measures to ensure people were protected from potential harm.

People were encouraged to make decisions about meals, and were supported to go shopping and be involved in menu planning. We saw people were involved and consulted about all aspects of their care and support, where they were able, including suggestions for activities and outings.

People’s care plans contained sufficient and relevant information to provide consistent, person centred care and support. People's confidentiality was respected and their records were stored securely.

When risks to individuals had been identified action had been taken to minimise this and risk assessments were in place. Medicines were managed in a safe way. When people were unable to consent to their care, mental capacity assessments had been completed and decisions made in people’s best interest. The provider had considered when people were being restricted and authorisations for this had been appropriately submitted for approval.

People told us they were aware of the complaints procedure and said staff would assist them if they needed to use it.

There were regular health and safety checks of the environment to make sure everything was in good working order. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. There were regular fire drills at the service so that people knew how to leave the building safely. People's Personal Evacuation Emergency Plans (PEEPs) had been reviewed and updated to explain what individual support people needed to leave the building safely.

We found one breach of the Health and Social Care Act (Regulated Activities) Regulations 2014, namely Good Governance. You can see what action we asked the provider to take at the back of the full version of this report.