Archived: Windsor Drive

Updated 4 May 2016

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.

The inspection was carried out by one inspector. We visited the service on 8 and 11 March 2016. The inspection was unannounced. This meant that the provider and staff did not know that we would be visiting.

We spoke with nine of the 10 people who lived at the home to obtain their views of the service. We also talked with one person’s relative.

We spoke with the registered manager, two nurses and two support workers. We examined three support plans and records relating to staff, including recruitment and training files. In addition, we checked records relating to the management of the service such as audits.

We consulted with a local authority safeguarding officer and contracts officer. In addition, we spoke with a senior social worker and a social worker. We used their comments to inform our judgements of this inspection.

We requested a provider information return (PIR) prior to the inspection. A PIR is a form which asks the provider to give some key information about their service; how it is addressing the five questions and what improvements they plan to make. We checked information which we had received about the service prior to our inspection.

Updated 4 May 2016

The inspection took place on 8 and 11 March 2016 and was unannounced. This meant that the provider and staff did not know that we would be visiting.

We last inspected the service in December 2013 where we found the service was meeting all the regulations we inspected.

Windsor Drive is registered to provide accommodation and personal care for up to 12 adults who require care and support. The service consists of three individual bungalows; the Manor; the Oaks and the Lodge. The Manor and Lodge are four bedroom bungalows, the Oaks consists of two bedrooms and two semi-independent flats. The service is situated in Howdon. There were 10 people using the service at the time of our inspection.

Prior to February 2016, the service had been registered to provide nursing care. However, people had been assessed as not requiring nursing care and the provider had applied to remove the regulated activity relating to nursing care, and now only accommodation and personal care were provided. The Health and Social Care Act 2008 (Regulated Activities) 2014 lists 14 regulated activities. If providers carry out any of these regulated activities they have to register with CQC.

The manager told us that the removal of nursing care was the first step in the service becoming an independent supported living service. Nursing staff were still employed and on duty until the end of March 2016.

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 told us they felt safe. There were safeguarding policies and procedures in place. Staff were knowledgeable about what action they would take if abuse was suspected. There was one safeguarding issue at the time of our first visit. This was closed by the end of our second visit.

The premises were clean and well maintained. There were no offensive odours in any of the areas we checked.

There was a safe system in place for the receipt, storage, administration and disposal of medicines. People told us that staff supported them with their medicines. Due to the change in service provision and nursing staff leaving at the end of March 2016, support workers were in the process of completing medicines training and were shadowing nursing staff to ensure that they were competent in all aspects of medicines management.

People told us there were enough staff to meet their needs. On the day of the inspection, we saw that people’s needs were met by the number of staff. There was a training programme in place. Staff were trained in safe working practices and to meet the specific needs of people who lived at the service.

Staff told us that they were a small supportive team. All staff told us that they felt well supported by the manager. We noticed that some supervision and staff appraisals had lapsed. The manager had put together a supervision and appraisal matrix to address this matter.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals.” The manager had submitted two DoLS applications to the local authority supervisory body for assessment in line with legal requirements. Other people had the capacity to decide where they wanted to go and there were no restrictions upon their movements.

The manager was strengthening the service’s paperwork with regards to the documentation of any decisions relating to mental capacity to ensure that it was clear how the MCA was followed.

People were supported to receive a suitable nutritious diet. They were complimentary about the service and staff. We observed that people were cared for by staff with kindness and patience. One person said, “It’s like my home, with staff.”

Support plans were in place which aimed to meet people’s health, emotional, social and physical needs. They gave staff information about how people’s care needs were to be met. The manager told us that new paperwork was going to be introduced to ensure that support plans were more person centred and outcome focused. The plans we examined did enable to us to gain an overview of people’s needs and preferences.

People told us that there was an emphasis on meeting their social needs. They were supported to access the local community, go on holiday and pursue their individual hobbies and interests.

There was a complaints procedure in place and people knew how to complain. One person raised a minor complaint with us and we fed this back to the manager to investigate and address.

We found shortfalls in the maintenance of records in several areas. These included supervision and appraisals, mental capacity, surveys and records of meetings for people who used the service. In addition, staff had not been completing the provider’s medicines audit which looked at all areas of medicines management and infection control audits had not been undertaken.

We found one breach of the Health and Social Care Act [Regulated Activities] Regulations 2014. This related to Good governance. You can see what action we have asked the provider to take at the end of this report.