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Inspection report

Date of Inspection: 24 April 2014
Date of Publication: 28 May 2014
Inspection Report published 28 May 2014 PDF | 95.22 KB


Inspection carried out on 24 April 2014

During a routine inspection

At our inspection we asked five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service safe?

We observed that people were treated kindly and respectfully by staff. Staff were attentive to people’s needs and offered people choice. People we spoke with felt safe. Staff knew how to report suspected abuse and who to report to. Some staff were unsure about how to recognise the signs of abuse. There were times when there no staff in attendance in the lounge area. Some people were dependent on staff to meet their needs and ensure their safety because of physical of cognitive disability.

There was an annual programme of audits to monitor the quality of service provision. Staff were not involved with or aware of the audits undertaken.

There was limited evidence available to demonstrate that learning from incidents / investigations took place and appropriate changes were implemented. This increases the risk of harm to people and fails to ensure that lessons are learned from mistakes.

People were not always cared for in a clean and hygienic environment. There were not enough domestic staff on duty to clean all areas of the home on a daily basis. We found significant breaches to the expected standard for infection prevention and control.

Staffing numbers were not always sufficient to meet people’s needs or keep them safe. One person told us they had to wait for staff to attend to them at certain times of the day.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. This means that when people have their liberty deprived in order to keep them safe, this was only done following a best interest assessment carried out by the local authority DoLS team. At the time of our visit there were two people using the service who required a DoLS authorisation. However, the actions staff should take to manage the deprivation in the least restrictive way was not recorded in one person’s care plan.

People were not fully protected from the risks of receiving care that was inappropriate or unsafe. Staff had not carried out risk assessments for three people who had recently moved in.

Is the service effective?

People’s health and care needs were assessed before they moved in, but care plans for three people who had recently moved in had not been completed. Some care plans had not been reviewed regularly. Care plans were therefore not able to support staff consistently to meet people’s needs.

Staff had not received all the appropriate training they required to meet people’s needs or to keep them safe.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. Some staff members told us that they did not always have the time to spend with people because they were so busy.

People’s preferences, interests, aspirations and diverse needs had not always been recorded. Because of this care and support could not always be provided in accordance with people’s wishes.

Is the service responsive?

People had been supported to maintain relationships with their friends and relatives.

People knew how to make a complaint if they were unhappy. People told us that staff

would listen to them and take appropriate action.

An activities organiser had recently been appointed. We were told that the activities organiser would be responsible for arranging monthly residents meetings so that people could provide feedback about their experience of care, treatment and support.

Is the service well-led?

The service had a quality assurance system, records seen by us showed that not all of the shortfalls identified had been addressed. The system did not systematically ensure that staff were able to provide feedback to their managers, so their knowledge and experience was not being properly taken into account.