22 October 2016
During a routine inspection
The service had a registered manager in place at the time of our inspection and a service leader. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. We were supported during the inspection by the service leader.
The registered provider completed some quality assurance checks to evaluate and improve the service. However, these were not always effective in their purpose and were not focused uniquely on Glendyke Road. Actions identified did not include timescales for implementation or review that ensured the measures implemented were effective in improving the service for the people who lived there in a timely manner.
The registered provider told us they completed ‘Quality Annual Satisfaction’ surveys with people living at their home, their relatives, care workers and other professionals involved in people’s care and support. However, this information was not provided when requested. The registered provider was unable to demonstrate how they actively sought and reviewed feedback that ensured they delivered high quality care or where they had implemented any actions as a result that had led to improvements in the care and support people received.
We saw that a medication audit had been completed but we did not see any additional audits or checks to demonstrate that the registered provider was assessing, monitoring, and improving the quality of service provision or that feedback from people was being used to evaluate and improve services.
Systems and processes that ensured staff had access to supporting guidance, policies and procedures were not effective. During our inspection, this information was not always available or up to date.
The above concerns meant that at the time of our inspection systems and processes implemented to assess, monitor and improve the quality and safety of the services provided had not been fully established and were not always effective in their purpose.
The above concerns were a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Safe recruitment practices were followed and staff were provided with regular supervision and support.
During our inspection, care workers told us there were not always enough full time permanent staff employed to ensure people were kept safe and their needs were met at all times. The registered provider did not use a staffing dependency tool to ensure sufficiently suitable and competent staff were on duty at all times. We have made a recommendation regarding this.
Risks associated with people's care, support and the home environment were effectively assessed and managed. Medicines were managed safely and people received their medicines as prescribed. People were supported to eat and drink enough. People had access to holistic healthcare from a variety of health professionals and people's health needs were monitored and responded to.
People were supported by staff who had the knowledge and skills to undertake their role and meet people’s individual needs.
People were supported to make informed decisions and where a person lacked capacity to make certain decisions the registered provider acted under the Mental Capacity Act 2005. This helped to ensure any decisions made were in the person’s best interest and that the least restrictive option was followed.
People were provided with information in a way that was accessible to them and staff had a very good understanding of how people communicated their agreement, preferences and wishes.
Staff were kind and compassionate and treated people with respect whose rights to privacy and dignity were promoted and upheld. People and their families were supported to raise concerns or complaints and were told us these would be responded to.
People and their families were involved as much or as little as they wanted to be in planning their care and support, staff knew their individual preferences and tailored support to meet their needs.
People were encouraged to make choices about their care and support and they were supported with a range of activities and interests including foreign holidays and excursions.
The service had a warm, friendly atmosphere and had an open culture for providing people with the best quality of health and life opportunities. There was a clear staffing structure and management and staff understood the requirements of their role.
We evidenced the registered provider was in breach of one of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.