199a – 203a Salthouse Road Lane is located in the east of the city of Hull and is registered to provide care and accommodation for up to a maximum of eight people with a learning disability. Accommodation is provided in three purpose built bungalows.We undertook this unannounced inspection on 16 March 2017. At the time of our inspection there were 7 people living at the service.
At the last inspection on 5 February 2016, the overall rating for the service was ‘Requires Improvement’. This related to making improvements to medicines management, stopping the practice of wedging doors open and the safe storage of disposable gloves and aprons. Further action also needed to be taken to promote good infection control practices when washing clothing and other items. Some minor incidents between people had not been assessed and scored using the specific risk management tool provided by the local safeguarding team. Risk assessments were completed; but further detail was needed to be included for staff about recognising the signs of changing behaviours. When accidents or incidents had occurred in the service, records of actions taken to review and investigate these were not always in place.
At this inspection we found automatic closures had been fitted to doors so they were no longer wedged open. Disposable gloves were stored away from clients. Records were being maintained of all incidents and the action that had been taken following these and any referrals made to the local safeguarding team and the Care Quality Commission. Risk assessments had been updated and included information to guide staff on how to recognise potential triggers and changes in behaviour. Processes had been introduced to ensure accidents and incidents were analysed within the service by the manager, and further reviews of these were completed by the quality assurance manager and at senior management level.
There was no registered manager in post. The previous registered manager had recently left the service to take up another post within the organisation and a new manager had been appointed to the post in the last month. The service is required to have a registered manager, and as such, the registered provider was not meeting the conditions of their registration. 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. When a service does not have a registered manager in place the rating in well led cannot be rated any more than ‘requires improvement’. A manager had been appointed but had not been through the registration process to become the registered manager. They had been at the service for two weeks at the time of our inspection.
We found improvements were required to ensure people’s specialist dietary records were completed in more detail to reflect what people had eaten and the texture and presentation of the food.
We found further action was required to ensure that the date was recorded when topical creams were opened. Individual ‘pro re nata’ (PRN when necessary) protocols for pain relief needed to be reviewed and include the dosage of the medicine that had been prescribed. These issues were addressed by the manager during the inspection.
Relatives and professionals praised the skills of the core staff team and shared their reservations about the reliance and use of agency staff and lack of continuity of managers in the service.
The majority of people who used the service had complex needs and were unable to tell us about their experiences. We relied on our observations of care and our discussions with staff and relatives involved.
The environment was found to be clean and tidy throughout. Areas of the service were beginning to look tired. This had been identified by the registered provider’s internal auditing system and plans were in place for a refurbishment of the service in April 2017, which included the replacement of the kitchens.
We found staff were recruited safely and there was sufficient staff to support people. Staff received training in how to safeguard people from the risk of harm and abuse and they knew what to do if they had concerns.
Staff had access to induction, training, supervision and appraisal which provided them with the relevant skills and confidence to provide care to people. This included training considered essential by the registered provider and also specific training to meet any individual needs of the people they supported.
Staff had received training in legislation such as the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and the Mental Health Act 1983. They were aware of the need to gain consent when delivering care and support and what to do if people lacked the capacity to agree to it. When people were assessed as not having capacity to make their own decisions, best interest meetings were held with relevant individuals and professionals.
We saw arrangements were in place that made sure people’s health needs were met. For example, people had access to the full range of NHS services. This included GP’s, community learning disability nurses, chiropodists, dentists, speech and language therapists, physiotherapists and occupational therapists. People received their medicines safely, as prescribed and medicines were held securely.
Staff supported people to make their own decisions and choices where possible about the care they received. When people were unable to make their own decisions staff followed the correct procedures and involved relatives and other professionals when important decisions about care had to be made.
People’s nutritional and dietary needs were assessed and people were supported to eat and drink to maintain their health. Menus were varied and staff confirmed choices and alternatives were available for each meal: we observed drinks and snacks were served between meals. People’s weight was monitored and referrals made to dieticians when required.
We found staff had a caring approach and found ways to promote people’s independence, privacy and dignity. People who used the service received care in a person centred way with care plans describing their preferences for care and staff followed this guidance.
People who used the service had assessments of their needs undertaken which identified any potential risks to their safety. Staff had read risk assessments and were aware of their responsibilities and the steps to minimise risk.
People who used the service were seen to engage in a number of activities both within the service and the local community. They were encouraged to pursue hobbies, social interests and to go on holiday. Staff supported people to stay in touch with their families and friends.
There was a complaints process and information provided to people who used the service and staff in how to raise concerns directly with senior managers. Relatives knew how to make complaints and told us they had no concerns about raising any issues with the staff team or the manager.