Archived: Mencap - North West Surrey SL Service

The inspection was announced. We told the provider three days before our visit that we would be coming. This was to ensure that the people we needed to talk to would be available.

There was a registered manager in place who was present on the day of the inspection. 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.

People’s needs were met safely because there were enough staff at the service. Accidents and incidents were recorded and action was taken to minimise the risks of further incidents. Staff had knowledge of safeguarding adults procedures and what to do if they suspected any type of abuse. Staff had undergone recruitment checks before they started work.

People’s medicines were administered and stored safely. Risks had been assessed and managed appropriately to keep people safe. The risk assessments for people were detailed and informative and included measures that had been introduced to reduce the risk of harm.

In the event of an emergency there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

People’s human rights were protected because the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLS) were followed. There was evidence of mental capacity assessments specific to particular decisions that needed to be made.

People were supported by staff that were knowledgeable and supported in their role. Staff had received all the appropriate training specific to the needs of people and their competencies were regularly assessed.

People were supported to eat healthy and nutritious meals. People at risk of dehydration or malnutrition had effective systems in place to support them. People had access to a range of health care professionals, such as the GP, opticians and dentist.

Relatives told us that the staff were caring, respectful and treated their family members with dignity. People and relatives, where appropriate, were involved in planning their care. We saw that care plans had detail around people’s backgrounds and personal history and included people’s views on what they wanted. Staff knew and understood what was important to people and supported them to maintain their interests.

People were supported by staff that were given appropriate information to enable them to respond to people effectively. Where it had been identified that a person’s needs had changed, staff were providing the most up to date care. People were supported to take part in activities which they enjoyed.

Relatives told us that they knew how to make a complaint and there was procedure in place for people to access if they needed to. This was in a pictorial format for people to understand. We saw that complaints were investigated appropriately.

The service was managed well. Staff said that they felt supported, valued and listened to. Systems were in place to monitor the quality of the service that people received. This included audits, surveys and meetings with people and staff.

If you want to see the evidence supporting our summary please read our full report. This is a summary of what we found based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records. We spoke with one person using the service and two relatives. We spoke with three staff in addition to the Registered Manager.

Is the service safe?

People told us they felt safe. One person said "I have every confidence in staff.' Safeguarding procedures were robust and staff understood how to safeguard people they supported.

Staff knew about risk management plans and care records were detailed and person centred promoting people's rights and dignity. One person told us 'I like being at the service and I like my support workers.'

People were not put at unnecessary risk. Systems were in place to make sure managers and staff learnt from events such as accidents/incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The provider took people's care needs and preferences into account when making decisions about the numbers, qualifications, skills and experience required when allocating staff. This helped to ensure people's needs were always met.

Recruitment practice was safe and thorough. Comprehensive policies and procedures were in place to make sure people were protected.

Is the service effective?

People's care needs were assessed with them. Care plans reflected people's current needs, choice and preferences and were reviewed regularly with them.

Is the service caring?

Feedback from people was positive, for example one person told us 'I am very pleased with the service and it is very good.' When speaking with staff it was clear they genuinely cared for the people they supported.

Is the service responsive?

People were offered support to make a complaint if they were unhappy. People could be assured complaints were investigated and action taken as necessary.

The service worked with other agencies and services to make sure people received care in a coherent way.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where concerns were raised these were dealt with.

Is the service well-led?

The service had a quality assurance system, and records showed opportunities to improve things were addressed promptly. Staff told us they were clear about their roles and responsibilities. This helped ensure people received a good quality service at all times.

People who used the service told us that staff were polite and respectful towards them and that they had been involved in planning and reviewing their care and support. One person told us, 'They do keep asking if what they do is OK'.

Both people that we spoke with told us that they were happy with the care that was provided for them. One person told us, 'The staff are very good to me and watch while I do things I'm not sure about. But they treat me like a grown up'.

Guidance regarding safeguarding people from abuse was available to staff and we noted that they had received recent relevant training. One person we spoke with told us, 'They are nice and wouldn't let anything bad happen to us'.

We saw that staff recruitment processes were thorough and that the required checks had been carried out before staff were engaged by the service. This gave the service an opportunity to assess the suitability of applicants before appointing them.

Managers at the service used a number of methods to monitor and assess the effectiveness of the care and support their staff provided. These included Mencap Continuous Compliance Tool. (CCT) We saw that CCT monitored events that could affect the compliance of the service, including staff training, fire safety and electrical appliance testing. An effective complaints system was also in place.