Background to this inspection
Updated
22 May 2018
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 second comprehensive inspection took place on the 29 March and 6 April 2018. The first day of the inspection was unannounced and we spoke to a relative on the telephone on the second day.
The inspection was undertaken by one inspector.
Before the inspection, the provider completed a Provider Information Return (PIR). This 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. The provider completed and returned the PIR in October 2017 and we considered this when we made judgements in this report.
We also reviewed other information we held about the service, including statutory notifications that the provider had sent us; a statutory notification is information about important events, which the provider is required to send us by law. We contacted commissioners and asked them for their views about the service. Commissioners are people who work to find appropriate care and support services for people, which are paid for by the local authority. We also contacted Healthwatch; an independent consumer champion for people who use health and social care services.
During our inspection, we viewed the accommodation and facilities used by people and observed the interaction between people and the staff in the communal areas. We spoke with two people who used the service and the relative of one person on the telephone. We spoke with four members of staff including support workers, the registered manager and area manager. We looked at two people's care records and three records in relation to staff training and recruitment. We also looked at other records related to the running of the home and the quality of the service provided. This included medicines records, quality assurance audits, maintenance schedules, training information for staff, and arrangements for managing complaints.
Updated
22 May 2018
Royal Mencap Society – 12 Wales Street is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Royal Mencap Society – 12 Wales Street is registered to provide support to four adults with learning disabilities and physical health needs. At the time of our inspection, two people were receiving support from the service.
At our last inspection on the 24 February 2016, we rated the service “Good.” At this inspection we found that the service ‘Required Improvement’.
There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
The quality assurance processes in place to monitor the quality and safety of the service and drive improvement required strengthening. Audits had not resulted in sufficient action to mitigate risks to people’s health and safety. Health and safety checks had not been carried out as scheduled and staff did not consistently adhere to environmental fire safety measures. Records relating to medicines stock levels were incomplete and did not allow this aspect of medicines to be audited effectively.
The provider had recognised that the environment at 12 Wales Street was no longer suitable to meet people’s needs. People, their relatives and staff had been consulted and people were due to move to alternative accommodation in June 2018. The provider informed us that they would then apply to remove 12 Wales Street from their registration.
Staff understood their responsibilities to keep people safe from harm. Safeguarding procedures were in place and staff understood their duty to report potential risks to people’s safety. Staffing levels ensured that people's care and support needs were safely met. Safe recruitment practices were in place.
People received their medicines as prescribed and risk assessments were in place to manage risks within people’s lives. There were arrangements in place for the service to make sure that action was taken and lessons learned when things went wrong, to improve safety across the service.
Staff induction training and on-going training was provided to ensure that staff had the skills, knowledge and support they needed to perform their roles. Staff had regular one to one supervisions.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff demonstrated their understanding of the Mental Capacity Act, 2005 (MCA) and they gained people's consent before providing personal care.
People were encouraged to make decisions about how their care was provided and staff had a good understanding of people's needs and preferences. Staff treated people with kindness, dignity and respect and had spent time getting to know them and their specific needs and wishes.
Staff supported people to access healthcare professionals, and encouraged them to maintain a healthy lifestyle. The service worked with other organisations to ensure that people received coordinated and person-centred care and support.
The service had an open culture which encouraged communication and learning. People, relatives and staff were encouraged to provide feedback about the service and it was used to drive improvement. The provider had a process in place, which ensured people could raise any complaints or concerns.
At this inspection, we found the service to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.