15 March 2017
During a routine inspection
There was a registered manager in post at the service. A registered manager is a person who has registered with the Care Quality Commission 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. The registered manager was on leave at the time of the inspection and the service was being run by the deputy manager.
Following the last inspection in September 2015, the registered manager had not taken action to improve the way risks were managed. Plans to assess and manage the risks people faced did not always contain up to date information or provide guidance to staff on the support that people needed. The plans did not include information on how to safely evacuate people from the building in the event of a fire or other emergency.
The service did not always act in line with the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves.
The registered manager did not have effective systems to assess, monitor and improve the service being provided. The action plan submitted following the last inspection had not been followed and the improvements the registered manager had said they would make had not been completed.
Medicines were safely managed and people who use the service were positive about the care they received. Comments from people included, “I am generally happy here, I have everything I need” and “I am happy living here”.
There were systems in place to protect people from abuse and harm and staff knew how to use them. Staff understood the needs of the people they were supporting.
Staff received training suitable to their role and an induction when they started working for the service. They demonstrated a good understanding of their roles and responsibilities, as well as the values and philosophy of the service.
We found breaches 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.