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Inspection report

Date of Inspection: 18, 29 March and 8 December 2011
Date of Publication: 28 June 2011
Inspection Report published 28 June 2011 PDF | 214.66 KB

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There should be enough members of staff to keep people safe and meet their health and welfare needs (outcome 13)

Not met this standard

We checked that people who use this service

  • Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 18/03/2011, 29/03/2011, 08/12/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Although the staffing numbers are reflective of the current occupancy of the home and the needs of residents are being met, systems to ensure flexible staffing arrangements and cover for staff absence are not well established.

There is no registered manager in post and the appointee manager who has been in post since October 2010 has not applied to be registered. The deputy manager has taken on the management role although she currently lacks management experience.

Overall, we found that improvements were needed for this essential standard.

User experience

People who use this service made no specific comments about this outcome.

Other evidence

At the beginning of the site visit the staffing levels were checked against the duty rota. This identified that the home did not have the full compliment of staff as one staff member was off sick. This shortfall had not been replaced and so staff were very busy during the morning shift.

The duty rota displayed in the home recorded that for the occupancy of 12 people living in the home three staff work on the morning shift on direct care and this is reduced to two staff members for the afternoon and evening. A staff member working in the home confirmed that these numbers were usually maintained in the home. The night is covered by two staff with one able to sleep from 10pm till 6am, unless needed.

The provider works in the home as the chef and on any maintenance issues but is also available for care and support if required. During the site visit he was seen to be helping by supporting people to eat. A designated cleaner was also working in the home.

Staff were seen to be providing care in a kind and courteous way and people living in the home responded to their contact positively, demonstrating a good level of well being. A visiting health care professional was complimentary of the staff working in the home and their proactive approach to care.

Discussion with the provider and deputy manager confirmed that at least 5 people are washed and dressed by the night staff. Although this was said to be due to individual wishes this was not reflected in the individual plans of care and suitable staffing should allow for all personal choices to be responded to. People living in the home have a range of care and support needs some requiring two staff members to assist. The provider acknowledged during discussion that the staffing levels need to remain flexible in response to changing needs, levels of activity and dependency of people using the service, ensuring their safety is maintained along with their care needs.

The appointee manager has been in post since 4 October 2010 but has still not applied to be registered with the Care Quality Commission. The duty rota examined confirmed that she had been on annual leave for the proceeding two weeks and was now off sick. The provider indicated that he did not feel that the appointee manager was competent to fulfil the role of registered manager. He has now appointed a deputy manager with the intention for her to develop her skills and knowledge to manage the home.

The provider said that he was confident that the deputy manager would be suitable and effective in managing the home. He is currently supporting her to complete a diploma that incorporates the registered manager’s award which is to be completed by July 2011.

The deputy manager advised that a further senior staff member has been asked to become the deputy manager as her replacement with further training for them both already identified.