Background to this inspection
Updated
23 July 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
This focused inspection was carried out to check if the provider had complied with a warning notice concerning medicines management and two other breaches of regulation regarding suitability of staffing provision and safe care delivery which resulted from our previous inspection in November and December 2020.
Inspection team
This inspection was completed by one inspector and a pharmacist specialist.
Service and service type
This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care service.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
We visited the service on 10 June 2021.
What we did before the inspection
We reviewed information we held about the service. This included details about incidents the provider must notify us about, such as allegations of abuse, and accident and incidents. The provider was asked to complete a provider information return prior to this inspection and did so in May 2021. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection-
We spoke with four people using the service. We also spoke with four care workers, the manager, operations manager, and deputy manager.
We reviewed a range of records. This included five people’s medicines risk assessments, care planning documents, medicines administration records and medicines risk assessments. We looked at recruitment and background check information for one member of staff who had been recruited since our previous inspection. We also looked at records relating to the management of the service such as monitoring and audits and a variety of policies and procedures.
After the inspection
We continued to seek clarification from the manager to validate evidence found. We looked at care logs, electronic call monitoring logs, medicines management and quality assurance records.
Updated
23 July 2021
About the service
Mora Burnett House is an extra care housing scheme that provides support to people in their own flats in a purpose-built block. The provider is registered to support people with personal care and there were 29 predominantly older people using the service at the time of our visit.
People’s experience of using this service and what we found
Medicines were managed safely. Since the previous focused inspection there had been changes made to improve the way that medicines were managed. We were assured that people were receiving their medicines as prescribed. Systems to manage risk and monitor the quality and safety of the service had improved and were now suitably robust. Systems to ensure enough numbers of staff were effectively deployed to meet people’s needs had improved.
People told us they trusted staff and believed that staff were caring and treated them well. The provider had a policy and procedure for safeguarding adults from abuse although no concerns about people coming to harm had been raised since our previous inspection. The manager and staff understood the principles about what behaviours constituted abuse, the types of abuse, and the signs to look for. People were protected from the risk of infection and the service had good measures in place to manage during the COVID-19 pandemic.
People and their relatives, where relevant were involved in making decisions about their care. When people had short calls, or their visit times had changed from their agreed times, there was a record of this. The recording of why these visits did not meet the expected amount of time allocated had improved since our previous inspection with some further development needed. However, people told us that staff were usually arriving when they expected them to.
The provider completed checks and audits on accidents and incidents, staff training, safeguarding and spot checks to drive improvements. The service had an on-call system to make sure staff had support outside office working hours. The manager and the provider remained committed to working in partnership with other relevant agencies to achieve positive outcomes for people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 6 March 2021).
Why we inspected
This inspection was carried out to assess if the warning notice we had issued about medicines management had been complied with. There had also two others been breaches of regulations involving staffing, and systems to monitor the quality and safety of the service. We can report that the warning notice and other breaches of regulation had been addressed.
This inspection considered the key questions of safe and well-led and provide a rating for those key questions.
The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
After the inspection
We continued to seek clarification from the provider to validate evidence found.