Archived: Saint John of God Hospitaller Services - 1-2 Cuthbert Close

The service was last inspected in December 2014 and was fully compliant with the outcome areas that were inspected against.

Saint John of God Hospitaller Services situated at 1 and 2 Cuthberts Close is registered to provide care for a maximum of 12 people with learning disabilities. The accommodation compromises of two bungalows each with six single rooms. The service is located in the residential area of Queensbury, close to Bradford and Halifax.

There was a registered manager in place. A registered manager is a person who has registered with the CQC 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.

Medicines were not managed safely and appropriately and medicine audits were not robust enough to identify the concerns we raised.

There were safeguarding adult’s policies and procedures in place to protect people from possible harm and incidents and accidents were recorded and acted on appropriately.

Assessments were conducted to assess levels of risk to people’s physical and mental health. Care records contained guidance to provide staff with information that would protect people from harm.

There were safe recruitment practices in place and appropriate recruitment checks were conducted before staff started work. There were appropriate levels of staff on duty and deployed throughout the home to meet people’s needs.

There were arrangements in place to deal with foreseeable emergencies and there were systems in place to monitor the safety of the premises and equipment used within the home.

People were supported by staff that had appropriate skills and knowledge to meet their needs and staff received regular supervision, training and an annual appraisal of their performance.

Staff demonstrated good knowledge of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s right to make informed decisions independently was respected.

People were supported to eat and drink suitably healthy foods in sufficient quantities to meet their needs and ensure well-being. People had access to health and social care professionals when required.

Interactions between staff and people using the service were positive and staff had developed good relationships with people. People were supported to maintain relationships with relatives and friends. Care records documented people’s involvement in their care and where appropriate relatives were involved.

Staff were knowledgeable about people's needs with regards to their disability, race, religion, sexual orientation and gender and supported people appropriately to meet their identified needs and wishes.

People were supported to engage in a range of activities that met their needs and reflected their interests.

There were quality assurance and governance systems in place to monitor the quality of the service provided. Concerns raised from audits fed into action plans to rectify problems or issues.

Relatives told us they knew who to speak with if they had any concerns. There was a complaints policy and procedure in place and management was aware how to deal with complaints in line with the provider’s policy.

The provider took account of the views of people using the service and their relatives through annual residents and relative’s surveys.

We found one breach of the Health and Social Care Act (2008) Regulated Activities Regulations 2014. You can see what action we asked the provider to take at the back of this report.

We looked at the care records for two out of the twelve people who used the service. People's personal records including medical records were accurate and fit for purpose.

We saw that assessments regarding people's hydration and nutritional needs were translated into daily charts to record food and fluid intake.

Maintenance records and safety certificates were readily available for us to inspect.

Our last inspection of Medicines on 30th January 2014 had found that the provider was not meeting this standard because there were not adequate systems and practices in place to manage medicines safely.

During this visit we found the provider had addressed all the regulatory breaches regarding medicines.

Medicines were handled appropriately by staff who had been adequately trained and who had access to regular updates.

We saw that all oral medicines not dispensed in a monitored dosage system were correctly accounted for.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Is the service caring?

We observed staff respecting the people that used the service. We saw staff placing a hand on someone's shoulder and another staff waiting for a response from someone before they supported in any care or treatment. Staff told us there is a positive atmosphere in the home and all staff are caring.

Is the service responsive?

We saw people were involved in regular activities. The home had its own adapted minibus which helps to keep people involved in their local community. The home sent out a questionnaire survey on a six monthly basis. We looked at the last results and found areas of improvement had been acted on. We also looked at the quality and compliance audit completed by the service improvement manager. This audit created an action plan of jobs to be completed and we saw evidence of the completion these concerns.

Is the service safe?

We saw that people's care plans were linked with risk assessments to minimise and eliminate risk where possible. Staff told us they knew what safeguarding meant and gave us examples of abuse and how to report it. We saw sufficient levels of staff to keep people safe.

We looked through records for water temperatures and fridge freezer temperatures and found numerous gaps in the record keep. For example one weekly water temperature sheet only had one recording since 5/2/14.

Is the service effective?

We saw that people's care plans showed their needs had been assessed and were person centred. The care plans we looked at included people's preferences, likes and dislikes. Where appropriate we saw regular communication with other healthcare professionals.

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. Records seen by us showed that identified short falls were addressed promptly. As a result the quality of the service was continuingly improving. Staff told us they were clear of their roles and responsibilities and knew of the quality assurance processes in place.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, staff supporting them and from looking at records.

Peoples' needs were assessed and care and treatment was planned and delivered in line with their individual care plan Two peoples relative's told us they found the care and treatment their relative had received 'Excellent' and one told us they would give the home a score of 'Nine and a half out of ten'. They told us they had no concerns about the service.

We found appropriate checks were carried out before staff started work.

However we found people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. Also people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

service, such as reviewing care records. We observed the people who lived at the home. We also observed staff engagement with people who used the service.