During an assessment under our new approach
Date of the assessment: 10th October to 12th November.
Appleton Court is an extra care housing facility which provides care at home services for people who require support with personal care. The service can provide care to adults of all ages, who may be living with dementia, mental health disorders, physical disabilities and for people who may have learning disabilities or autistic spectrum disorder.
Not everyone using the service received a regulated activity. The Care Quality Commission (CQC) only inspects the service being received by people provided with 'personal care’. Where they do, we also consider any wider social care provided. At the time of our inspection 23 people were being supported with personal care.
We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider was meeting the Right support, right care, right culture guidance.
People were supported by a passionate team, who worked hard to ensure people lived as independently as possible. Staff worked with people to understand their goals, setting achievable targets and monitoring these to best promote autonomy and learning.
There was enough staff to ensure care calls were covered when planned, with additional provision in place to support people 24 hours of the day and in emergencies. The staffing requirement was monitored by the registered manager who was on site daily to support the service.
Staff felt supported in their roles and training was provided in all expected areas to ensure staff were confident in providing care to people with various needs.
The registered manager led the service with a positive and open culture. People and staff were given the opportunity to feedback about care and were confident in the registered manager ability to address any concerns if any should arise.
The provider had processes in place to help review and monitor the service, however we found not all areas of the peoples care records were audited for safety and quality. Shortfalls were identified in the standard of records which internal auditing tools had not addressed. Care plans were in place to help instruct staff on how to provide care for people; however, these lacked detail in certain areas and were not regularly reviewed and updated when peoples need changed. Some care plans did not hold all the required information regarding people’s health concerns, and not all had the correct risk assessments or information to ensure peoples safety. The Registered manager explained that some information was held in separate folders to the care plan, however due to this, we could not be assured that staff had access to all necessary information to help promote people’s safe care.
People had not been affected by the shortfalls identified; however, people were potentially at risk of poor care due to the discrepancies found in the records. We found a breach of regulation in relation to the service’s governance and record keeping, we have asked the provider for an action plan in response to these concerns found at this assessment.