Archived: Northbourne

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care records contained risk assessments and instructions on how these risks should be managed. For example, moving and handling and going out in the community.

Systems were in place to make sure that managers and staff learnt from events such as accidents, complaints, concerns and investigations. This reduced the risks to people and helped the service continually improve.

The CQC monitors the application of the Mental Capacity Act 2005 and operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS is a legal process used to ensure that no one has their freedom restricted without good cause or proper assessment. There was a policy in place related to people's mental capacity and deprivation of liberty safeguards. Records showed, and staff told us, they had received training on this. There was evidence to show that mental capacity assessments and deprivation of liberty checklists had been completed.

We looked around the premises and saw that people were provided with appropriate furniture and equipment to meet their needs and protect their safety.

Is the service effective?

The staff we spoke with were able to describe the individual needs of the people they cared for and how these needs were met.

The service worked well with other agencies and prompt referrals were made to health care professionals which helped ensure people's health care needs were addressed.

People's health and care needs were assessed and the care plans provided staff with information about how each person's care needs should be met.

People were provided with a choice of suitable and nutritious food and drinks to meet their needs. People told us they enjoyed the food served to them. Comments included, "I would say I don't like that and get something else" and "I like the food."

Is the service caring?

We looked at the care records for four people who used the service. We found that assessments had been carried out and their care and support was planned and delivered according to people's individual needs.

We observed the interactions between staff and the people they cared for. We saw staff interacted well with people, and supported them to carry out personal care tasks and access facilities in the community. On the day of our inspection two people were supported with their personal shopping and another person was taken for a walk around a nearby park. Two people told us they were going to a disco that evening which they enjoyed.

One person who lived at the home told us, "I'm going to the disco tonight. I have also been to the Opera at the Sage. I love it." When speaking about a care worker they said, "She's alright, I wouldn't have anything said against her." A relative told us "X has a good social life, he loves to be out and about."

We spoke with a reviewing officer from the Local Authority who was visiting the home at the time of our inspection. They told us, "The interaction between the staff and service users is very good. They don't talk down to them. I have no concerns whatsoever. This is a good home."

Is the service responsive?

There was a complaints procedure displayed in the home and each person was provided with a copy of this. A complaints book was maintained to record any complaints received in the home and the outcome of the investigation.

We saw prompt referrals were made to health care professionals when required and appropriate training was provided for the staff to help meet people's individual needs.

Is the service well-led?

The provider had systems in place to monitor the quality of the service people received. People were asked their opinion of the service and a relative told us they were kept very well informed about any concerns or events.

We saw records to show the manager was responsible for monitoring care records, incidents, risk assessments, complaints and health and safety.

The regional manager carried out audits in the home to ensure standards were being met and produced an action plan for any improvements which were required.

The staff told us the manager was very approachable and supportive. They said she listened to their opinions, new ideas or any concerns they may have.

The provider had taken steps to comply with the compliance action we set regarding a failure to carry out fire safety checks consistently and provide all staff with regular fire safety training.

Where people did not have the capacity to consent, the provider had acted in accordance with legal requirements. We found staff had carried out mental capacity assessments and made best-interest decisions where they had judged people to be unable to provide valid consent to their care and treatment.

People were protected from the risk of infection because appropriate guidance had been followed. The home was clean, hygienic and promoted people's health and well being.

People were not fully protected from the risk of fire. Checks of the home's fire equipment had not been carried out consistently.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. We found the majority of staff had updated their training and others were in the process of doing so. We also found arrangements had been made to provide staff with regular one-to-one supervision and an annual appraisal.

The provider's systems for identifying, assessing and managing risks to the health, safety and welfare of people who used the service and others, were not fully satisfactory.

Peoples' privacy, dignity and independence had been promoted. A relative said, 'The staff are always respectful... I couldn't ask for anything better.'

People experienced care and support that met their needs. A person who used the service said, 'The staff look after me good. They make sure I'm happy.'

Where people did not have the capacity to consent, the provider had not always acted in accordance with legal requirements.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. However, staff had not always received enough opportunities to receive appropriate professional development.

Some people's support plans and risk assessments had not been regularly reviewed. This increased the risk that people's support plans and risk assessments might not be an accurate reflection of their current needs.

There was an effective complaints system available which people had been told about.