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Archived: Royal Mencap Society - 12 Wales Street Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

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 activit

Inspection areas

Safe

Requires improvement

Updated 22 May 2018

The service has deteriorated to Requires Improvement

Improvements were required to ensure that health and safety checks were carried out as scheduled and arrangements were in place to mitigate environmental risks.

Procedures were in place to ensure that people received their medicines as prescribed. However, records of medicines stock levels required improvement.

People felt safe and comfortable in the home and staff were clear on their roles and responsibilities to safeguard them.

Individual risk assessments were in place and were reviewed and managed in a way which enabled people to receive safe support.

Effective

Good

Updated 22 May 2018

The service remains Good.

Caring

Good

Updated 22 May 2018

The service remains Good.

Responsive

Good

Updated 22 May 2018

The service remains Good.

Well-led

Requires improvement

Updated 22 May 2018

The service remains Requires Improvement

The quality assurance processes in place required strengthening to ensure sufficient oversight of the service.

A registered manager was in post; they encouraged a culture that was positive and supportive of people and staff.

People, their relatives and staff were encouraged to contribute to the running of the service and their feedback was valued.