The inspection was carried out by one inspector, who answered the five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? 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.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
We found the service to be safe because people were treated with respect and dignity by the staff. People were involved in making decisions about any risks they may take.
When people were at risk, staff followed effective risk management policies and procedures to protect them. Staff supported people to take informed risks with minimal necessary restrictions to as far as possible protect their welfare.
Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
The manager was in the process of re-assessing the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) for people who use the service and was having discussions with local authorities about this. This meant that people were protected from discrimination and their human rights were protected.
The service followed safe recruitment practices. The service followed clear staff disciplinary procedures when it identified unsafe practice.
Is the service effective?
We found the service to be effective because there was an advocacy service available if people needed it, this meant when required people could access additional support.
Care plans reflected people's current individual needs, choices and preferences. People's health was regularly monitored to identify any changes that may require additional support or intervention. Referrals were made quickly to health services when people's needs changed.
People's identified needs were monitored and managed.
Is the service caring?
We found the service to be caring because people were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. Staff responded in a caring way to people's needs when they needed it.
People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. Appropriate professionals were involved in planning, management and decision making.
Staff knew the people they were caring for and supporting. Staff showed concern for people's well-being. People were as independent as they wanted to be. People told us, 'We have a choice of activities. I like drama, college and I play drums on Saturday' and 'They give me options, I have three choices.' Staff told us, 'People can choose their own holidays and day care activities' and 'People choose their daily activities and also choose their meals for the week.'
Is the service responsive?
We found the service responsive because, where appropriate, a person's capacity was considered under the Mental Capacity Act 2005. When a person did not have capacity, decisions were always made in their best interests. Advocacy support was provided when needed.
People had their individual needs regularly assessed and met. There were arrangements in place to speak to people about what was important to them.
People completed a range of activities in and outside the service regularly. People had access to activities that were important and relevant to them and were protected from social isolation.
Is the service well-led?
There was a registered manager in post on the day of our visit and all other conditions of registration were met.
There was a clear set of values that included involvement, compassion, dignity, respect, equality and independence which was understood by all staff. Staff were motivated, caring, well-trained, supported and open.
The service worked well with other agencies and services to make sure people received their care in a joined up way.
The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Robust quality assurance and governance systems were in place and used to drive continuous improvement.
Concerns and complaints were used as an opportunity for learning or improvement. The management team enabled and encouraged open communication with people, those that matter to them and staff. Staff knew and understood what was expected of them. People told us, 'I'd tell a member of staff if I wasn't happy' and 'I can tell staff if I don't want to do anything.'