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Inspection report

Date of Inspection: 8, 15 May 2014
Date of Publication: 13 June 2014
Inspection Report published 13 June 2014 PDF


Inspection carried out on 8, 15 May 2014

During a routine inspection

This inspection was conducted over a two day period. One inspector carried out this inspection on the first day and two inspectors inspected the home on the second day. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with the five people who use the service, a relative, the deputy manager, the registered provider, a business consultant employed by the provider and three care staff.

We also reviewed records relating to the management of the home which included, six care plans, daily care records, accident /incident records, complaints records, audits, safeguarding files, staff records and notification records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

All of the people and their relatives spoken with told us that they felt that the care provided was safe. A person that lived at the home told us, �The staff are alright, they are caring for me.� A relative told us, �I have no major concerns about the care at the moment.�

Systems were not in place to make sure that managers and the staff team learnt from events such as accidents and incidents, complaints and concerns. This was because managers were not always aware of incidents that had occurred in the home. Therefore the appropriate actions were not always taken.

Safeguarding procedures were in place, but staff did not always report and act on incidents that were classified as safeguarding.

There were sufficient staff to meet the needs of people that currently lived at the home.

Records were not maintained to show that people�s needs were appropriately considered.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted recently. Staff currently managing the home has not been trained to understand when an application should be made, and how to submit one.

Is the service effective?

All of the people and their relatives spoken with told us that they were receiving the care that they needed.

Care plans that we saw lacked detail and contained conflicting information about people�s care.

Improved systems were in place to ensure staff had the supervision, training and personal development plans that they needed.

Is the service caring?

All of the people and their relatives spoken with told us that they felt that the service was caring. A person that lived at the home told us, �I don�t find anybody unpleasant.� Another person told us, I like it here and the people are all pleasant.�

During the two days that we inspected the home we saw good interactions with people that lived at the home and staff.

Is the service responsive?

All the people and their relatives that we spoke with told us that they had no complaints about the care provided. A relative told us, I made a complaint a long time ago and they dealt with it. I think they would address complaints.�

We saw that the provider had introduced new activities and community involvement for people, so that their social needs were met.

Records looked at did not contain a pre-admission assessment and an audit trail was not available to show if an assessment had been undertaken prior to admission or that care needs were being reviewed.

Procedures were in place to ensure that people�s lifestyle and preferences were recorded, but these were not completed on the records that we saw.

Is the service well led?

Whilst people and relatives spoken with had no concerns about the service they received. We found that effective systems were not in place to monitor the quality of the service. This has led to shortfalls in a number of the regulations that we assessed.

The registered manager was absent from the home for an indefinite period of time. The deputy manager was designated to be in charge of the home and we have been kept informed of the changes by the provider.