We carried out a review of the data available to us about Annefield House Limited on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Annefield House Limited, you can give feedback on this service.
Annefield House Limited is registered to provide residential care and support for 17 people with mental health needs. At the time of our inspection there were 16 people using the service. The service is located within a residential area of Derby and provides accommodation over three floors.
People's experience of using this service and what we found
Some areas of the home required improvements to the environment. There were worn carpets on the stairs leading to people’s bedrooms and some furniture required replacing. We have made a recommendation that these issues form part of their refurbishment programme.
People felt safe using the service and staff had a good understanding of how to identify and report any concerns. People living at the service had varying degrees of capacity. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests the policies and systems in the service supported this practice.
Risks were fully assessed using recognised tools and management plans provided clear guidance to staff on how to minimise the risk.
People were supported by enough staff who were well trained, kind and caring and knew people well.
People received their medicines as prescribed by trained and competent staff.
Staff worked well as a team and worked well with other professionals. Professionals were positive about their experience of working with the home.
People were supported by staff who routinely promoted privacy and dignity. Staff had a good understanding of people, their likes and dislikes.
There were varied activities in place tailored to people's needs. People were encouraged to be involved in the choice and delivery of activities as much as possible. People were encouraged to access the community independently. Some people needed support and encouragement from staff to undertake daily living skills such as cleaning their bedrooms and assisting with their personal washing.
People and staff were positive about the management. There was an open culture focussed on continual learning and improvement.
There were robust systems in place for auditing and reviewing the quality of care. The registered manager did a daily walk around the home to check on repairs, cleanliness and any refurbishment required. After the inspection the registered manager sent up a refurbishment plan with dates for completion. This included areas identified in this report.
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 good (published 13 April 2017).
Why we inspected
This was a planned inspection based on the previous rating.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Annefield House on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.
Annefield House Limited is registered to provide residential care and support for 17 people with mental health needs. At the time of our inspection there were 16 people using the service. The service is located within a residential area of Derby, which provides accommodation over two floors.
There was a registered manager in post. 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.
People who used the service were positive about the support they received and praised the quality of the staff and management. People told us they felt safe at the service. We saw staff interacting with people in a relaxed and friendly manner.
Staff we spoke with understood their responsibility in protecting people from the risk of harm. Recruitment procedures still needed further improvements so that they were thorough to ensure suitable staff were employed to work with people who used the service. Staff told us they had received training and an induction that had helped them to understand and support people.
Risk assessments and care plans had been developed where possible with the involvement of people and their representatives. Staff had the relevant information on how to minimise identified risks to ensure people were supported in a safe way. People received their medicines as prescribed and safe systems were in place to manage people’s medicines.
The provider understood their responsibility to comply with the requirements of the Mental Capacity Act (MCA) 2005. Some people were subject to restrictions on their freedom and the provider had identified where their support needed to be reviewed. This provided assurance the principles of the MCA 2005 were followed.
Staff understood the needs of the people they were supporting. People told us staff provided support with kindness and compassion. People were treated with dignity and respect by staff and encouraged to express their views. The delivery of care was tailored to meet people’s individual needs and preferences. People were supported to maintain a diet that met their dietary needs. People were supported to use healthcare services.
People were supported to maintain relationships which were important to them. People were able to access local community facilities and supported by staff to pursue their individual hobbies and interests.
The provider’s complaints policy and procedure were accessible to people who used the service and their representatives. People told us they felt if they raised any concerns these would be taken seriously and would be addressed by the registered manager.
People found the staff and management approachable. Staff felt supported by the management team. The registered manager was viewed as being approachable and involved in the day to day management of the service
A quality assurance system was in place which included audits and feedback from people who used the service. When shortfalls were identified action was taken to improve the level of service. The registered manager understood their responsibilities to inform the CQC when specific incidents occurred within the service
The inspection took place on 26 November 2014 and was unannounced.
Annefield House Limited is situated close to Derby City Centre. It provides a residential care service to 17 adults with mental health needs. At the time of this inspection there were 16 people living at the service and one person was in hospital.
The previous registered manager left the service in June 2013; however their registration was not cancelled until April 2014. At the time of this inspection the acting manager had submitted a registered manager’s application to us. 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.
At the last inspection on 17 December 2013, we asked the provider to take action to make improvements. We asked them to review the number of staff on duty to ensure people’s needs were being met. Improvements were also required with the recruitment procedures as the provider had not taken effective steps to ensure people were protected from abuse. The maintenance and the repairs of the home were not sufficient to protect people against unsafe or unsuitable premises.
The provider sent us an action plan outlining the improvements they would make.
At this inspection we found that action had been taken and improvements had been made.
The provider’s recruitment procedures had improved. The provider had recruited more staff and they were waiting for the relevant pre-employment checks to be received before they could start work.
People who lived at the service told us they felt safe and were happy living at the service.
The provider had taken steps in recruiting additional staff, so that there will be enough staff available at the service to safely support people with their care and interests.
Medicines were safely administered and most people received medicines when they needed them.
The acting manager and staff demonstrated an awareness of the basic principles of the Mental Capacity Act (MCA) 2005. However, the necessary documentation was not in place where it was identified that people may not have capacity. This did not ensure people were being supportive protecting their rights.
Staff told us that they had received training that was relevant in supporting the people using the service.
People told us they enjoyed living at Annefield House Limited and that the staff were caring and understanding.
People were able to take part in interests and hobbies that generally suited them.
The provider did not have a system in place to manage complaints. However, people we spoke with felt able to speak to staff should they have any concerns. Audits to monitor the quality of the service were being developed.
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People we spoke with told us they were happy with the care and support they received. Comments from people included, 'The care and service are very good" and 'I am happy with the service, because I feel safe and cared for."
People told us they enjoyed the meals and they always had a choice.
People were generally protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.
People who use the service, staff and visitors were not protected against the risks of unsafe or suitable premises.
The provider did not have effective recruitment procedures in place to ensure that people are cared for by suitably qualified, skilled and experienced staff.
Due to the possibility of unexpected changing circumstances, the provider did not have arrangements to ensure there were always enough staff available to meet people's needs.
In this report the name of a registered manager, Miss Lisa McIntyre, appears. She was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this report.
We received evidence from the registered manager that demonstrated that the compliance action left at our last inspection visit on 15 January 2013 had been addressed.
We have received evidence from the registered manager that demonstrated risk assessments had been changed to contain information regarding how identified risks were to be managed.
All of the people we spoke with told us that staff respected their privacy and dignity. We saw positive interactions between staff and people that lived at the service.
We saw that people's needs were assessed, and care plans were in place. This meant they received support in a way they prefer.
We found that risk assessments were in place, however these were not comprehensive. The assessment's identified area's of risk but did not contain clear action plans to demonstrate how these areas of risk were to be managed to ensure people were supported in a safe way.
People said they felt safe living at the service, and were able to report any concerns they may have to staff or the manager.
People we spoke with told us they liked the staff and got on well with them. Comments included 'the staff are friendly,' 'the staff understand my needs' and 'we are fortunate here, as the staff are good, they work well together.'
We found that there were systems in place to monitor the quality of the service, and make improvements where required.
They told us they make their own decisions and lead active and independent lives. One person said, 'everything runs smoothly here and I feel the staff respect my privacy. You are free to go where you want. I think that staff are respectful, they talk to us about our needs and wishes.'