St Anne's Community Services - Lees Hall Road

People’s experience of using this service:

There were enough staff to meet people's needs and keep them safe. Staff understood how to manage any risks to people and knew the processes to follow to manage any allegations of abuse.

Risks to people had been identified and a positive risk approach was used to ensure the potential for harm was minimised without restricting a person’s human rights. People had been involved with decisions in how to reduce the risk of harm to them, although some chose not to engage and partook in activities which posed some risk to their health.

People were supported by staff who received appropriate training and support to carry out their roles and responsibilities. We found staff to be knowledgeable about people, their medicines and how best to support them. Staff in turn told us they felt supported by the registered manager.

People received support to eat and drink if this was part of their care plan and were responsible for making most of their own meals with varying degree of support from support staff. Staff knew how to access relevant healthcare professionals, and this was evidenced in people’s care records. The service worked in partnership with other organisations and healthcare professionals to improve people's outcomes.

People's care and support had been planned in partnership with them where possible, either formally at review or informally through conversations. 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 knew people well and supported them in line with their current needs and wishes. Staff were knowledgeable about people's likes, dislikes and personal preferences.

People and relatives were aware of the complaints procedure although they had not needed to use this. Information was present on notice boards in the building to direct people to the complaints process.

The service was well-led by a registered manager with support from a deputy manager. Staff took on responsibility for aspects of service improvement such as health and safety to ensure continuous monitoring and improvement of the service.

The provider and registered manager used a variety of methods to assess and monitor the quality of the service. We saw detailed provider audits, measuring the service against best practice to ensure a good standard of care provision.

The service worked in partnership with other organisations such as the local authority and health professionals.

Rating at last inspection: Good (report published 06 October 2016)

Why we inspected: This was a planned inspection to check this service remained Good.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

St Anne’s community services Lees Hall Road is a service that is registered to provide personal care and rehabilitation support for up to seven people with a mental health condition. The service covers the Dewsbury area and at the time of our inspection provided support to three people.

The service had manger in place that was not registered with the CQC but was part way through the registration process and was awaiting their fit person’s interview. 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..

Systems were in place to ensure that the medicines had been ordered, stored, administered, disposed of and audited appropriately. Staff we spoke with knew how to administer medicines safely and the records we saw showed that medicines were being administered correctly. However there were some discrepancies with the stock counts of medicines we looked at.

The service had an up to date safeguarding policy in place and staff had a working knowledge of this. They were able to tell us about different types of abuse and were aware of the action they should take if they suspected abuse was taking place. Staff were also aware of whistle blowing procedures.

Accidents and incidents were appropriately recorded and analysed so that any trends could be identified.

People’s care plans we looked at were written in plain English and in a person centred way. People who used the service had ownership of their care plans and were involved in the process. These were regularly reviewed and updated by the care staff and the manager.

Individual care plans contained personalised risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The daily records we viewed also showed people’s health was monitored and referrals were made to other health care professionals where necessary for example: their GP and care managers.

We saw safe recruitment and selection procedures were in place and appropriate checks had been undertaken prior to staff starting work. The checks included obtaining references from previous employers and a Disclosure and Barring Service check to ensure that staff were safe to work with the people who used the service.

When we looked at the staff training records and spoke with the manager we could see staff were supported to maintain and develop their skills through training and development opportunities. The staff we spoke with confirmed they attended a range of learning opportunities. They told us they had regular team meetings and supervisions with the manager, where they had the opportunity to discuss their care practice and identify further mandatory and vocational training needs.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. Anyapplications must be made to the Court of Protection.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. We checked to see if the service had procedures in place and was working within the principles of the MCA. At the time of our inspection no applications had been made to the Court of Protection. From speaking to staff and looking at the training records we could see that training for staff was provided regarding MCA and Deprivation of liberty safeguards (DoLS)

We saw a complaints procedure was in place and this provided information on the action to take if someone wished to make a complaint and what they should expect to happen next. People also had access to advocacy services and safeguarding contact details if they needed it.

We found the service had been regularly reviewed through a range of internal and external audits. We saw action had been taken to improve the service or rectify any issues found. We found people who used the service and their representatives were regularly asked for their views via an annual quality survey to collect feedback about the service.

We spoke with support staff who told us that the manager was supportive and approachable. Throughout the day we saw people who used the service and staff were comfortable and relaxed with the manager and each other. The atmosphere was homely, relaxed and we could see that staff interacted with each other and the people who used the service in a person centred way and were encouraging, friendly, positive and mutual respect was noticeable.

We looked at two care records and saw each person had a care plan and risk assessment which covered their needs. We saw people had access to health services when required. There was evidence within the care records to show that regular evaluations of the care plans had taken place.

We spoke with two people who used the service who told us they chose what they ate and shopped for the food themselves. They said they prepared and cooked the food with support from the staff. Staff we spoke with confirmed this.

All of the areas we observed in the home looked clean and there were no unpleasant odours. We looked at the cleaning schedules, which detailed the standard of cleanliness required and the frequency of cleaning.

Staff confirmed there were enough staff on duty and that gaps in the rotas were covered by permanent staff working extra hours. The deputy manager told us they did not use agency staff. This ensured people who used the service received consistency of care from staff who knew them well.

During our inspection visit we reviewed how the quality of care was monitored. The area manager had the responsibility to ensure a range of quality audits and checks were undertaken each month.

We spoke to the staff and they told us they enjoyed working at the home. They told us they thought the person living in the home was treated with respect and dignity. They felt supported by the management and they felt safe working in the environment of the home.

People who used the service told us they felt safe and would know who to talk to if they had any concerns or were unhappy.

We saw that staff interacted positively with the person who used the service.