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Inspection report

Date of Inspection: 8 August 2014
Date of Publication: 12 September 2014
Inspection Report published 12 September 2014 PDF


Inspection carried out on 8 August 2014

During an inspection looking at part of the service

We inspected this service on the 8 August 2014 to follow up areas of concern identified at a previous inspection on the 1 May 2014. The service had sent us their action plan, telling us what action they where taking to become compliant in the areas were we had concerns.

During our inspection on 8 August 2014 we found that the service had made the improvements we had asked them to.

During this inspection we were met by the manager who was not yet registered with the Care Quality Commission as they were relatively new in post. The manager told us that they had started the process to become registered with us. We also met the Area Manager.

During our inspection we spoke with 5 people who used the service, two people�s relatives and observed the care on both the ground and first floor. We looked at six people�s care plans and other associated care records. We also looked at staffing records, quality audits and health and safety records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

The entrance of the building was secure and staff checked our identity. People were free to move about but a key code system gave people additional security. We saw that a number of people had door sensors which would alert staff as to when people were mobile and at an increased risk of falls.

People received adequate supervision from staff and records showed us that people were regularly checked to ensure they were safe.

Staff had received training in safeguarding vulnerable adults from abuse, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were provided with the information that they needed to recognise and report concerns so that people were protected from abuse as far as possible.

The environment was well maintained and free from offensive odours. We noted a carpet that needed replacing during our previous inspection of 1 May 2014, it had been replaced.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that the records had been reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met.

We saw that staffing levels were being maintained in accordance with people�s assessed needs which meant staff were able to meet people�s needs. The service had taken action to address our concerns that the service was failing to meet people�s social needs at our previous inspection. An activities person had been appointed, had set up a schedule of activities, begun to talk to people independently about their preferences, and had produced a newsletter.

Is the service caring?

The staff interactions we observed were kind and we found staff responded appropriately to people�s requests and needs. We spoke with some relatives, one told us, �The staff are so good and helpful.� Another said, �They (the service) care about me as well as (their relative).�

Is the service responsive?

We saw call bells were answered promptly and people�s needs were responded to quickly. We observed lunch and saw that most people received the support they needed in a timely way and staff did not outpace people when supporting them with their meals. The staff team appeared relaxed and frequently interacted with people, even when just passing through communal lounges they would stop and acknowledge people in an appropriate manner.

Is the service well led?

The manager who was new at our previous inspection on 1 May 2014, has now become �bedded in� and had made themselves known to all the people who used the service and their relatives by arranging relative and resident meetings and spending time with people. One person�s relative told us, �The manager is like a breath of fresh air, so open and friendly.�

The manager no longer covered shifts unless it could not be avoided or by choice so that they could �keep their hand in�, which they did occasionally.

We saw the service's records which related to infection control and the maintenance of equipment, such as lifting equipment. We found that all the records we looked at relevant to the management of the service were accurate and up to date.

We saw that complaints were dealt with effectively and recorded in line with the provider�s complaints policy. However, there was one complaint that was still being dealt with and had also been referred to us, the Care Quality Commission. We will continue to monitor this complaint to its conclusion.

The manager ensured that staff were appropriately supported throughout their shift and that they received regular supervision of their practice and annual appraisals.

There were regular audits of the quality of the service and the care provided to people. This meant there were systems in place to identify where the service was meeting regulation and where it needed to improve. We saw that audits took place across the day and night shift which enabled the manager to see the service provided over a 24 hour period.