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Inspection report

Date of Inspection: 8 May 2014
Date of Publication: 6 June 2014
Inspection Report published 06 June 2014 PDF


Inspection carried out on 8 May 2014

During a routine inspection

We spoke with six people who use the service, four relatives, four care staff, the deputy manager and the registered manager during this inspection. We looked at five people's care records and three staff records. Other records we reviewed included staff training and quality and monitoring records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

Care records were updated to ensure that people received the care they needed to keep them safe. The service worked with other healthcare professionals when they were concerned about someone�s safety. The falls prevention team had worked with the service to reduce the frequency and impact of falls for one person.

Staff did not receive all the training they needed to carry out their roles safely. We found that fire training for some staff members was overdue and two members of staff had not received fire training since joining the service.

Relatives told us they trusted the staff and felt that the service was safe. One relative told us, �My (relative) is looked after and safe�.

We looked at rotas and were concerned that sometimes there were not enough staff on duty.

We found that the service was aware of its responsibilities under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (MCA DoLS) and had recently made multiple DoLS referrals to the local authority in relation to its practice of locking the external doors.

Is the service effective?

People�s health and care needs were assessed in consultation with the people who use the service or their relatives. People�s care plans reflected their healthcare needs and the service worked in conjunction with support from outside professionals to meet them.

People who use the service and their relatives told us they were happy with the care provided. One relative told us, �However under pressure the staff are, nothing is too much trouble�.

One person who uses the service told us, �The staff here are really and truly good. I get my pills on time and they come if I call them. I have no problems�.

We found that some care records were incomplete for one person whose care plan we looked at.

Is the service caring?

People were supported by staff who were kind, caring and respectful. We observed staff supporting people with genuine affection and concern.

People told us they were happy and felt well cared for. A relative told us, �The care here is 200%�.

People who use the service and relatives told us that the manager was very caring. One person said �(The manager) is very kind. I have been here four years and I am very happy�. One relative commented on the atmosphere and culture of the service. They told us, �You feel like you are coming into somebody�s house�.

Is the service responsive?

People's care records showed that where concerns about an individual�s wellbeing had been identified, staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance promptly from other health care professionals about a person's high blood sugar levels and frequent falls.

People�s preferences and choices had been recorded in their care plans and we observed that care and support was delivered in accordance with people�s wishes. We saw that where people had asked to be supported by a person of a particular gender this had been respected.

Is the service well led?

The service did not have an effective quality assurance system in place. We found that some audits were taking place but that strategies to deal with issues highlighted by the audits were not always put in place.

The service did not have effective systems to deal with the current low staffing levels.

We found that some important staff training was overdue and this could have placed people at risk.

Staff we spoke with were positive about the leadership of the service and said that they felt well supported.