Background to this inspection
Updated
17 July 2015
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place on 19 May 2015 and was unannounced. A single inspector carried out the inspection.
We reviewed the provider information return (PIR), submitted in 2014 and statutory notifications and other information received by CQC. A PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.
We spoke with five of the seven people who were using the service at the time of the inspection, one relative who was visiting their family member and three members of care staff including the registered manager. After the inspection we spoke with two of the provider's senior managers by telephone.
Four paper care files were examined and two on-line. Three staff files were checked, as well as their on-line training records. We viewed medicines administration records (MAR) for each person and we also looked at a range of the provider’s policies, procedures and management records.
During the day we observed the interactions between staff and people who used the service in the communal areas and the office.
Updated
17 July 2015
The inspection took place on 19 May 2015 and was unannounced. The service is registered as a care home for up to nine people with mental ill-health. There were seven people in residence at the time of inspection.
The service is located in a tall, narrow building over five floors including the basement. There is a courtyard area to the rear. All bedrooms have a wash handbasin and some have an en-suite bathroom. There is a communal lounge and a separate quiet room, a shared kitchen and a laundry room. The office is situated on the ground floor at the front of the building.
A registered manager was in place. 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 2008 and associated Regulations about how the service is run.
On our inspection visit we found people were supported in a calm and stable environment by staff members who knew them well. People told us that it felt homely. Staff were respectful of each individual and worked alongside them to maintain their independence. A person who used the service told us that they could make their own decisions, but they could rely on staff to advise them if they were making a bad choice. We have made a recommendation about reviewing restrictions in place within the building and gaining people’s consent to them if they need to continue.
People were encouraged to engage in activities outside the service and to attend occasional social events organised within the service. They had the opportunity to air their views in keyworker and residents’ meetings, as well as a users’ forum run by the provider.
There were up-to-date assessments and support plans in place for everyone who used the service and there were good links with local healthcare providers, including mental health services.
We have made recommendations about keeping the availability of locum staff under review and maintaining soft furnishings and floor coverings in a way that maximises fire safety.
We found staff did not always refer to the most recent of the provider's policies and procedures and checks and audits were not picking up on all relevant quality issues, particularly omissions. In some areas there was a mismatch between what senior managers believed was in place within the service and what was actually happening in daily practice. You can see what action we told the provider to take at the back of the full version of the report.