Archived: Chapel Hill

This inspection took place on 17 and 21 January 2020 and was unannounced. Chapel Hill care home is a mental health project which provides accommodation and support for up to 21 people with the aim of preparing them to move on to independent living.

People's experience of using this service

People said they felt safe and that their needs were met. Medicines were administered safely. Risks were identified, assessed and appropriate risk management plans were in place to provide guidance for staff on how to minimise any risks. Accidents and incidents were logged and investigated in a timely manner.

People were protected against the risk of infection. Accidents and incidents were appropriately managed and learning from this was passed on to staff. There were enough staff deployed to meet people’s needs in a timely manner.

Before people joined the home, assessments to ensure people’s needs could be met. Staff were supported through induction, training and supervisions. People were supported to eat and drink sufficient amounts for their health and wellbeing. People were living in a home which was designed and decorated and personalised to meet their needs. People had access to a variety of healthcare professionals, when required to maintain good health.

People's rights were upheld with the effective use of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Their needs were accurately assessed, understood and communicated.

Staff were kind and caring and people’s privacy, dignity and independence were respected. There was a range of appropriate activities for people to partake in if they wished to. People were protected from the risk of social isolation. People had individual, person-centred weekly activity plans. Information was available to people in a format to meet their individual communication needs if required. The service had an effective system in place to manage complaints.

The home had effective systems in place to assess and monitor the quality of the service and feedback had been sought feedback from people to drive improvements. The provider worked in partnership with key organisations to ensure people's individual needs were planned.

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 of the service was requires improvement (published on 6 March 2019).

At our previous inspection in January 2019 we identified that improvements were needed as one to one-sessions with keyworkers were still not being documented. We also found that inhouse six-monthly reviews were not always carried out. This included completing and/or monitoring the 'Recovery Star' which enables people using the service to measure their own progress with the support of staff. The provider did not have effective processes in place to monitor the quality of the service.

At this inspection we saw that the provider had made improvements and Chapel Hill is now meeting CQC regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our previous inspection in July 2016 we identified that improvements were needed relating to safe care and treatment. One to one sessions with keyworkers were not always documented after meetings and Care Programme Approach (CPA) review meeting reports were not always available in people's care files.

At this inspection we saw that the provider had made some improvement; CPA review meeting reports were available in people’s support files. However, one to one sessions with keyworkers were still not being documented.

We also found that inhouse six-monthly reviews were not always carried out. This included completing and/or monitoring the ‘Recovery Star’ which was developed by Triangle in collaboration with the Mental Health Providers Forum and enables people using the service to measure their own progress with the support of staff. The provider did not have effective processes in place to monitor the quality of the service as they had not identified the issues we found at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

There was a registered manager in place. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection, we found that medicines were securely stored and managed safely. Risks were assessed and appropriate risk management plans were in place to provide guidance for staff on how to minimise any risks. Accidents and incidents were logged and investigated in a timely manner. Staff had received infection control training and people were protected from the risk of infection. There were appropriate safeguarding procedures in place to protect people from the risk of abuse. Staff understood the different types of abuse and knew who to contact to report their concerns. There were enough staff deployed to meet people's care and support needs and appropriate recruitment checks took place before staff started work.

Staff completed an induction when they started working for the service and they were supported through regular training and supervision to enable them to effectively carry out their roles. People's needs were assessed prior to joining the service to ensure their needs could be met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff told us they asked for people’s consent before offering support. People were supported to have enough to eat and drink. People had access to healthcare professionals when required to maintain good health to ensure people received the support they needed. The environment had been adapted to meet people's needs.

Staff were kind, caring and respected people’s privacy and dignity. People were involved in making decisions about their daily care and support needs. People were encouraged and supported to be independent if possible. People were provided with information about the service when they joined in the form of a 'service user guide' so they were aware of the services on offer.

People were involved in planning their care, and their support plans were reflective of their individual care needs. There was a range of appropriate activities for people to partake in if they wished to. Information was available to people in a range of formats to meet their communication needs if required. People were protected from the risk of social isolation. People had individual, person-centred weekly activity planners. Activities outside of the service included attending college, working voluntarily at charity shops and in a garage to fix cars and to places of worship. Activities within the service included arts, board games, cooking classes, swimming, walking, listening to music and watching television.

People's religious and cultural needs were recorded and they were supported to meet their individual needs if required. The service was not currently supporting people who were considered end of life. However, if they were this would be recorded in their care plans. People were aware of the home’s complaints procedures and knew how to make a complaint if necessary.

Regular staff and residents' meetings were held where feedback was sought from people. Staff and people using the service were complimentary about the registered manager and the home.

The provider carried out spot and competency checks to make sure people were being supported in line with their care plans. Regular feedback was sought from people about the service. The registered manager was knowledgeable about the requirements of a registered manager and their responsibilities. Notifications were submitted to the CQC as required. The ethos of the home was for everyone to feel valued for who they are and live the life they choose.

The provider worked in partnership with the local authority and other external agencies to ensure people's needs were planned and met.

Chapel Hill Care Home is a mental health project which provides accommodation and support for up to 21 people with the aim to prepare people to move on to independent living..

Chapel Hill Care Home had a registered manager in place. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At this inspection we found that improvement was required. Detailed records of one to one keyworker meetings were not maintained to support staff in recognising risks to people. Reports of Care Program Approach (CPA) review meetings were not always maintained on people’s care files. Failure to maintain these reports meant that staff may not be aware of any issues arising from these meetings.

People using the service said they felt safe and that staff treated them well. Safeguarding adults procedures were robust and staff understood how to safeguard the people they supported.

Medicine records showed that people were receiving their medicines as prescribed by health care professionals.

There were enough staff on duty to meet people's needs. The provider conducted appropriate recruitment checks before staff started work. The provider had carried out appropriate pre-employment checks to ensure staff were suitable and fit to support people using the service.

Staff training was up to date. Staff received supervision, appraisals and training appropriate to their needs and the needs of people who they supported to enable them to carry out their roles effectively. There were processes in place to ensure staff new to the service were inducted into the service appropriately.

The registered manager and staff demonstrated a clear understanding of the Mental Capacity Act 2005 (MCA).

People were protected from the risk of poor nutrition and had access to a range of healthcare professionals in order to maintain good health.

People were treated with kindness and compassion and people's privacy and dignity was respected. People were provided with information about the service when they joined in the form of a 'service user guide' which included the service's complaints policy.

People were involved in their care planning and the care and support they received was personalised and staff respected their wishes and met their needs. Support plans and risk assessments provided clear information for staff on how to support people using the service with their needs. Support plans were reflective of people's individual care needs and preferences and were reviewed on a regular basis. People were supported to be independent where possible such as attending to some aspects of their own personal care.

Staff were knowledgeable about people’s individual needs. Staff were committed to offering people a good service that improved the quality of their lives and allowed them to be part of the wider community. There were a variety of activities on offer that met people’s needs. People’s cultural needs and religious beliefs were recorded to ensure that staff took account of people’s needs and wishes.

People knew about the service’s complaints procedure and said they believed their complaints would be investigated and action taken if necessary.

People told us they thought the service was well run and that the registered manager was supportive. There were effective processes in place to monitor the quality of the service and the registered manager recognised the importance of regularly monitoring the quality of the service provided. People and their relatives were provided with opportunities to provide feedback about the service.