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Inspection report

Date of Inspection: 25 April and 2 May 2014
Date of Publication: 1 June 2015
Inspection Report published 01 June 2015 PDF | 87.6 KB


Inspection carried out on 25 April and 2 May 2014

During a routine inspection

As part of this inspection we spoke with six people who used the service, seven care staff, two visitors, the activity co-ordinator and two members of the management team. We looked at five people's care records. Other records we reviewed included, staffing records, quality and monitoring records, health and safety records and satisfaction questionnaires completed by the people who used the service and their relatives.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

People told us that staff always respected them and that they felt safe. Signage around the whole service was well lit and clear, this included all emergency exits which enabled people to move around the service freely and safely.

The rotas seen provided information with regard to how many staff were on duty each shift. However we saw that some people were left for unacceptably long periods of time before receiving the support and care they required. This created unnecessary anxiety and stress to some people because there were not enough staff to respond to people in a timely manner.

We found the service to be unsafe with regard to the current systems in place for the prevention and risks of fire. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the prevention of fire for the people who live, work and visit the service and in relation to staffing .

Is the service effective?

People's health and care needs were assessed but these were not always completed in consultation with either the person themselves, relatives or their advocate. People had a plan of care in place that reflected their healthcare needs. However some of these care plans had not been reviewed or updated to reflect the person’s current and changing needs. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the assessing and monitoring of people’s care, and how they were going to involve people in the planning of their care.

We found that the service had not followed the appropriate procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards with regard to appropriate assessments being completed for people who were unable to give consent. We have asked the provider to tell us what they are going to do to meet the requirement in law and in relation to ensuring that people who do not have capacity are assessed appropriately to ensure they are safeguarded from harm or inappropriate care.

Is the service caring?

People were supported by staff who were kind, caring and respectful. Care workers

supported people with patience and genuine affection and assisted people who required additional support in a dignified manner and at their own pace.

People commented: "All the staff are very kind. I really like it here especially the daily activities.” People's preferences, interests and choices had been recorded along with the care and support offered in accordance with people's wishes.

Is it responsive?

People who used the service and their relatives involved in the service had completed a satisfaction survey and some of the issues raised had been addressed and an action plan completed.

People were involved in participating in a range of interesting and varied activities both within the service and were also offered regular visits from outside entertainers.

People told us that they knew how to complain if they needed to. One visitor stated that they had been provided with information on how to raise a concern when they first moved their relative into the service. There was information displayed around the service on how to make a complaint.

Is the service well led?

The service had a quality assurance system in place but records seen showed us that not all areas of the service were monitored or reviewed regularly. This included the records that relate to the monitoring of the environment, health and safety monitoring and the monitoring of individual care records.

We have asked the provider to tell us what they are going to do to meet the requirement in law in relation to quality assurance.