Archived: Saint John of God Hospitaller Services - 3/4 Cuthberts Close

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

3 & 4 Cuthbert Close provides accommodation and personal care to a maximum of eight people who are living with learning disabilities. All the accommodation is in single rooms and the service is located in the residential area of Queensbury, close to Bradford city centre.

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.

People were protected from harm by staff who knew how to keep people safe and what action to take if they suspected abuse was happening.

Potential risks to people had been identified and assessed appropriately. When accidents or incidents occurred, risk assessments were updated as needed.

There were sufficient numbers of staff to support people and safe recruitment practices were followed.

Medicines were administered in a safe way. Storage and recording of medicines was audited regularly.

Staff had received all mandatory training and there were opportunities for them to receive service specific training. All staff training was up-to-date.

Regular supervision meetings were organised and the deputy manager had planned supervisions with staff as well as annual appraisals. Team meetings were held and staff had regular communication with each other at handover meetings which took place between each shift.

Consent to care and treatment was sought in line with the requirements of the Mental Capacity Act 2005.

The registered manager and deputy manager were seeking authorisation for people under the Deprivation of Liberty Safeguards legislation.

People were supported to have sufficient amounts to eat and drink and to maintain a healthy diet.

People had access to healthcare professionals. People’s rooms were decorated in line with their personal preferences.

Staff knew people well and positive, caring relationships had been developed. People were encouraged to express their views and these were communicated to staff in a variety of ways.

People were involved in decisions about their care as much as they were able. People’s privacy and dignity was respected and promoted. Staff understood how to care for people in a sensitive way.

Care plans provided comprehensive information about people in a person-centred way. People’s personal histories had been recorded and their preferences, likes and dislikes were documented.

Relatives acknowledged and we observed there was a variety of activities and outings on offer which people could choose to do.

Complaints were dealt with in line with the provider’s policy, but there had been no formal complaints logged in the previous year.

People could express their views and discuss any issues or concerns with their keyworker, who co-ordinated all aspects of their care. The provider organised surveys for relatives to feedback their views about the service.

The culture of the service was homely and family-orientated. Regular audits measured the quality of the care and service provided.

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 who used the service, their relatives, staff supporting them and from looking at records.

Is the service safe?

We spoke with staff who gave us examples of different types of abuse and how they would report it. A safeguarding policy was present in the service for staff to read. We saw risk assessments linked with the Individual Living Plans (ILP's) which identified and rated the level of risk for each aspect of care. The service had an annual health and safety audit of the location.

We spoke with staff and they told us they were aware what safeguarding was and could list different types of abuse. Staff told us they would report safeguarding issues to their manager and felt confident it would be dealt with.

The service was safe clean and hygienic. Equipment was well maintained and serviced regularly. This meant people were not put at unnecessary risk.

Is the service effective?

The ILP's we looked at showed us people's needs had been assessed and peoples 'preferences had been taken into account. We saw in daily notes and staff told us they had regular contact with outside professionals such as psychiatrists, doctors, dentists and physiotherapists. We saw people had end of life plans in place and this had been discussed with the person using the service and their family.

Is the service caring?

People were supported by kind attentive staff. We saw that staff showed patience and gave encouragement when supporting people. One person told us, "Staff are good here."

We looked at the ILP's for people using the service. We found peoples' preferences, interests and aspirations had been taken into account. We observed staff following guidance in the ILP's when supporting one person when they were showing signs of distress.

Is the service responsive?

In people's ILP's we saw that, where possible, people were present during review meetings. The attendance lists also included family members. A copy of an invite to a review meeting for one person's parents was present in their file. We found all ILP's had been reviewed and updated following a recent audit by the service improvement manager,

Is the service well-led?

The service has two quality audit tools it used. Records showed where shortfalls were identified, or there was room for improvement, an improvement plan was actioned with a time frame and a single person responsible. As a result the quality of the service had continuously improved.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the quality assurance processes and said this information was given to them through team meetings and supervisions.

We looked into the safeguarding policy and staff told us the procedure to follow if they had any concerns. Staff also informed us they had regular training.

On the day of inspection all records requested were provided to us in a timely fashion and we assessed the storage and destruction of confidential waste as appropriate and fit for the needs of the service.

Overall we found improvements were required to help make sure medicines are handled safely.

We found 3/4 Cuthbert Close had new systems in place which enabled the management to regularly assess and monitor the quality of the service people received and had systems in place that enabled the managers to identify the possibility abuse and prevent it from happening.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. Such as we reviewed peoples care records and we observed people's experience of living at Cuthbert Close.