3 March 2021
During a routine inspection
The service supports people with mental health needs, some of whom have brain injury related to substance use.
People’s experience of using this service and what we found
People were positive, in general, regarding staff at the service and we saw kind interactions between staff and people. Relatives and a health and social care professional told us in their view, staff were kind and caring.
We had some concerns regarding the way the service was managed as roles and responsibilities between the service manager and the registered manager were not always clear. This potentially impacted on the quality of the service as there were some management tasks which had not been undertaken and other areas in which the recorded evidence was not always available.
Quality audits were undertaken by the service manager in a number of key areas and the registered manager had identified some key areas that needed improvement prior to this inspection, and had started to make progress in these areas. This inspection has highlighted additional areas that need improvement.
We found some gaps in risk assessments which meant staff were not always provided with guidance in how to safely support people.
Staff had not completed training in all the key areas including safeguarding adults.
The service could not show how they involved staff and people who lived at the service in making decisions as team meetings and residents’ meetings were not regularly taking place.
Medicines management was mostly safe, but there was no guidance for one person who required an ‘as needed’, medicine. Staff competency in the giving of medicines was not checked each year in line with best practice.
Staff were not fully understanding of legislation regarding people’s capacity and their freedom. This meant we could not be sure people were always supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Subsequent to the inspection, staff have training booked in this area, and the service have applied for a formal mental capacity assessment for an additional person.
Care records contained personal information and staff seemed to know the needs of people who had lived there for some time. Health and social care professionals and family members spoke well of the care given to people living there.
The service had a number of systems in place to manage COVID-19. We signposted the service to some minor improvements which were implemented by the time of writing this report.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
This service was registered with us on 1 May 2018 and this is the first inspection.
At this inspection we found two breaches of the regulations related to the governance of the service and staffing issues.
You can see what action we have asked the provider to take at the end of this full report.
Follow up
we will continue to monitor information we receive about the service until we return to visit as per our inspection programme. If we receive any concerning information, we may inspect sooner.