Last updated 20 April 2016
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 inspection took place on 24 and 25 February 2016 and was announced.

The provider was given 24 hours’ notice to provide an opportunity for the provider to help facilitate the inspection process.

The inspection was carried out by two inspectors, a pharmacy inspector and a specialist advisor. The specialist advisor had the experience working as a nurse within the community and within the field of palliative care.

Before the inspection, we asked the provider to complete 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 PIR was completed and returned to the Care Quality Commission. We found the information in the PIR was an accurate assessment of how the service operated.

We also reviewed the information that the provider had sent to us which included notifications of significant events that affect the health and safety of people who used the service.

We spoke with five people who used the service and four relatives who were visiting.

We spoke with the registered manager, the Chief Executive, managers with differing responsibility for areas within the service, which included staff training, risk management and quality monitoring. We spoke with a Reverend and with clinical staff, which included, nurses, health care assistants, a pharmacist, a dietician, the safeguarding lead, infection prevention lead nurse and patient experience lead and the tissue viability lead nurse.

We reviewed three people’s care plans to see how their support was planned and delivered. We looked at a selection of medication records to check medicines were managed safely. We spent time observing staff interacting with people and their relatives.

We also looked at the recruitment files of four members of staff, a range of policies and procedures, maintenance records of equipment and the building, quality assurance and clinical audits and the minutes of meetings.