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Inspection Summary

Overall summary & rating


Updated 20 June 2017

The inspection took place on 10 May 2017 and was unannounced.

The service provides residential care for up to 17 older people. At the time of our inspection 16 people were using the service.

A registered manager was in post. 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.

We had previously carried out an inspection on 9 February 2016 during which we identified four breaches of regulation. These related to the poor management and recording of risk, insufficient numbers of staff and failure to assess people’s capacity to give consent. We also identified a breach relating to the overall governance of the service. We issued four requirement notices and the service supplied an action plan detailing how they would make the required improvements. At this inspection we found improvements in all areas that had previously concerned us.

People received safe care which met their individual needs.

Staff were trained in safeguarding people from abuse and the manager understood their responsibility to refer incidents appropriately to the local authority safeguarding team for investigation and to inform the Care Quality Commission.

Risks were assessed and documented in care plans and environmental risks were well managed.

There were enough staff to keep people safe and to enable them to live their lives in the way they chose.

Medicines were managed safely and people received their prescribed medicines when they needed them.

Infection control measures were in place and staff had an understanding of how to reduce the risk and spread of infection.

Staff received an induction and relevant training to help them carry out their roles. Staff were supported with regular meetings, supervision and appraisal of their performance.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Practice related to MCA and DoLS was in line with legal requirements.

People who used the service were happy with the food and were supported to eat a varied diet.

People were supported to access the healthcare support they needed promptly. There was evidence of good partnership working with the district nursing team.

Staff were caring and treated people respectfully, ensuring their dignity was maintained. Good, caring relationships were evident between the staff and those they were supporting and caring for.

People who used the service, and their relatives, were involved in planning and reviewing their care and had opportunities to feedback about the service.

People were supported to follow their own hobbies and interests.

A complaints procedure was in place and formal complaints were dealt with appropriately and in a timely way. Informal issues were well managed and resolved quickly to people’s satisfaction.

Audits were in place to monitor the safety and quality of the service and the manager took overall responsibility for ensuring that any identified actions were put in place. There was a commitment to continuous improvement of the service.

Inspection areas



Updated 20 June 2017

The service was safe.

Staff understood their responsibilities with regard to safeguarding people from abuse and had received appropriate training.

Risks to people were well managed and staff demonstrated skills in reducing risks to people.

There were enough skilled and experienced staff to meet people’s individual needs.

Medicines were managed safely.



Updated 20 June 2017

The service was effective.

Staff received a comprehensive induction and training was provided to help staff meet people’s individual needs.

Staff had received training in MCA and DoLS and demonstrated an understanding of the requirements.

People were positive about the food and were supported to eat a healthy diet.

People were promptly supported to access healthcare professionals when they needed to.



Updated 20 June 2017

The service was caring.

Feedback from people who used the service and relatives was positive about the kindness and patience of the staff.

People’s privacy and dignity was maintained and their anxiety alleviated.



Updated 20 June 2017

People’s care needs were assessed before they were admitted to the service and they, and their relatives, were involved in assessing, planning and reviewing care which responded to people’s individual needs.

People were supported to follow their own interests and hobbies.

A complaints procedure was in place and any issues raised were responded to appropriately.



Updated 20 June 2017

The service was well led.

Staff felt well supported by the manager.

There was a comprehensive system of audits in place to monitor the quality and safety of the service.

The manager had good oversight of the service and was focussed on continuous improvement.