6 July 2017
During a routine inspection
The service has a registered manager. 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 and associated Regulations about how the service is run.
At our previous inspection on 14, 15 and 17 November 2016 we found a number of breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach in the Care Quality Commission (Registration) Regulations 2009. The provider was given an overall rating of ‘inadequate’ which placed them into special measures. We took enforcement action against the provider due to the concerns found.
We asked the provider to take action to make improvements in the areas of person-centred care; meeting nutritional and hydration needs; fit and proper persons employed; staffing and notifications of other incidents. After our visit we asked the provider to complete an action plan with a date when they would be compliant. The provider submitted the action plan by the required timescale and informed us improvements would be made by 31 January 2017.
During this inspection we found the provider had made significant improvements to reduce the risk of harm to people. However, further improvements were required in the service’s quality assurance systems to ensure any shortfalls would be promptly identified and addressed.
People were overwhelmingly positive about the caring attitude of staff. We heard comments such as, “They (staff) engage in a positive and affectionate way. You can tell they’re caring rather than just coming to do a job and leave.” Staff had a good understanding of people’s care and support needs; people and their relatives were involved in making decisions about their care and staff knew people’s individual communication skills, abilities and preferences.
People and their relatives said they felt safe from abuse; staff were aware of their responsibilities to keep people safe, medicine competency assessments still had not been completed for staff. Recruitment procedures were not thoroughly checked for accuracy. Staff job application forms contained missing information. We have recommended the service seek current guidance on the completion of medicine competency assessments in a timely manner.
Staff had received relevant training and supervision; people’s nutritional needs were met and people or those who represented them had signed to give consent to the care and support delivered.
Assessment of care needs were completed and updated to ensure care and support delivered reflected the care people said they wanted. Care plans were personalised and detailed people’s preferences for care. People and their relatives said the service was responsive to their needs.
People felt the service was well managed and provided them with safe, caring and effective care. The registered manager had undertaken relevant training and changed their work practice to ensure the service was managed effectively. However, further improvements were required with the thoroughness of audits and the completion of reports. We recommend the service seeks good practice on how to complete audits of recruitment records and ensure information submitted to the CQC is fully completed.
This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.