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The Minims (12 & 31) Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 9 January 2019

This inspection took place on the 13 and 17 December 2018 and was unannounced. At the last inspection in March 2018 the service was rated as overall requires improvement. The provider was in breach of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not ensure proper and safe management of medicines. In addition, the provider had not ensured equipment was tested to ensure peoples safety and not all staff understood what action was required in the event of a fire to keep people safe. The provider had failed to complete their own action plan for the required improvements needed to be made at the service. Systems to monitor and identify areas of concern were not effective.

We received an improvement action plan following the last inspection, which the provider had updated so we could monitor the progress. The action plan told us how they would make the required improvements. At this inspection, we found the provider had made the required improvements. However, we found other areas that needed further improvement.

12 and 31 The Minims is a residential care home for 12 people who have a learning disability and some who have a mental health diagnosis. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home comprises of two separate bungalows within the same street, numbers 12 and 31. Each bungalow can accommodate six people. There were five people living at number 12 and six people living at number 31 at the time of this inspection.

People had their own personalised bedroom and en-suite facilities. There were shared communal areas such as the lounge, dining area, kitchen and laundry facilities. The registered manager’s office is located at number 31.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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. The service has a new manager starting on the 24 December who will be registering with CQQ before the end of January 2019.

Staffing levels did not always ensure people needs were met at a time they wanted.

Suitable systems to monitor the cleanliness of the home were not in place.

Safe medication practices were followed by staff when administering people`s medicines. There was guidance for medication given when required (PRN).

Staff were familiar with people’s personal evacuation plans in the event of an emergency.

The provider ensured Deprivation of Liberty Safeguards (DoLS) applications were renewed when required. Staff understood the Mental Capacity Act (MCA) and the importance of promoting people’s choice.

Staff supported people to access the community and follow their interests. A key worker role had been introduced to promote personal development for people who lived at The Minims.

People were supported to have a voice and complaints were dealt with appropriately.

Audits were effective and contained action plans where areas of concern were identified.

Fire alarm tests were routinely completed as required to ensure people were safe.

Safe and effective recruitment practices were followed to help ensure that all staff were suitably qualified and experienced.

People felt safe, happy and well looked

Inspection areas


Requires improvement

Updated 9 January 2019

The service was not consistently safe.

Sufficient numbers of staff were not always available to meet people’s individual needs at all times.

Medicines were managed safely by staff and guidance for ‘as required’ (PRN) medicine was in place.

Fire alarm tests were completed and staff were aware of the personal evacuation plans for people who lived at The Minims.

People were kept safe by staff trained to recognise and respond effectively to the risks of abuse.

Safe and effective recruitment practices were followed to help ensure that all staff were fit, able and qualified to do their jobs.



Updated 9 January 2019

The service was effective.

People had their capacity assessed and best interest decisions completed.

People’s wishes and consent were obtained by staff before care and support was provided.

People were supported by staff who were trained to meet their needs.

People were provided with a healthy balanced diet, which met their nutritional needs.



Updated 9 January 2019

The service was caring.

People were cared for in a kind and compassionate way by staff that knew them well and were familiar with their needs.

People were involved in the planning, delivery and reviews of the care and support provided.

Care was provided in a way that promoted people’s dignity and respected their privacy.

People's confidentiality of personal information had been maintained.



Updated 9 January 2019

The service was responsive.

There was a key worker system in place to support people with developing their interests.

People received personalised care that met their needs and took account of their preferences and personal circumstances.

People were supported to raise concerns which were dealt with promptly.

People were supported to maintain social interests.


Requires improvement

Updated 9 January 2019

The service was not consistently well led.

Systems in place to quality assure the services provided, manage risks and drive improvement had improved and were effective.

However, there were no appropriate systems in place to monitor the cleanliness of the home.

The provider had an improvement plan that was regularly reviewed.

Staff understood their roles and responsibilities and felt supported by the management team.