Our inspector set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is 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.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
People were treated with respect and dignity by the staff. People told us they felt safe.
Staff supported people to take informed risks with minimal necessary restrictions.
Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people will be safeguarded as required.
There were clear procedures for giving medicines in accordance with the Mental Capacity Act 2005.
Prescribed medicines (including Controlled Drugs) were stored and administered safely in line with current and relevant regulations and guidance.
People were safe because staffing levels were sufficient to meet their identified needs. The registered manager set the staff rotas, they took people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were always met.
Is the service effective?
There was an advocacy service available if people needed it, this meant that when required people could access additional support.
People's health and care needs were assessed with them. Specialist dietary, mobility and equipment needs had been identified in care plans where required.
Support plans reflected people's current individual needs, choices and preferences.
People's health was regularly monitored to identify any changes that required additional support or intervention.
Referrals were quickly made to health services when people's needs changed.
Is the service caring?
People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'They've been very good to me here, excellent', 'They look after me." People said that staff knew their needs 'very well' and 'they're very good'.
People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.
People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.
Is the service responsive?
People, and those that matter to them, were encouraged to make their views known about their care, treatment and support.
Staff made sure that people had the time they needed to make decisions, taking account of the urgency of the situation.
People completed a range of activities in and outside the service regularly.
People were enabled to maintain relationships with their friends and relatives.
People knew how to make a complaint if they were unhappy. One person told us 'I wouldn't fault them for anything' and another said 'I don't think I could make a complaint, everything's ok'. The manager informed us that there had been one complaint in the past year, when this was investigated it was found to be unfounded. People can therefore be assured that complaints were investigated and action was taken as necessary.
Is the service well-led?
The service worked well with other agencies and services to make sure people received their care in a joined up way.
Senior management were aware of the culture of the service and they kept this under review. This was to ensure that care was centred on people's needs and their rights were protected. Staff knew and understood what was expected of them.
CQC requirements for the submission of notifications and other legal obligations, were not met. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to notifications.
Resources and support were available to the manager and the team to develop and drive improvement.
The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.