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Mencap in Kirklees - 1 Victoria Road Good


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Mencap in Kirklees - 1 Victoria Road on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Mencap in Kirklees - 1 Victoria Road, you can give feedback on this service.

Inspection carried out on 29 March 2019

During a routine inspection

About the service: Mencap in Kirklees, 1 Victoria Road is registered to provide accommodation for up to six people with learning disabilities.

People’s experience of using this service: People felt safe while being supported by the staff team. Risk assessment’s provided guidance to staff and gave opportunity for people to remain as independent as possible. Staff could accurately describe risks people presented and how to reduce the risks.

Staff knew how to safeguard vulnerable people from abuse. They were able to describe signs of abuse and knew what action they would take to report such concerns. Staff told us they were fully confident the registered manager would act on any concerns they had.

People were safely supported to receive their medicines as prescribed. Staff received regular training and competency checks to ensure they were competent to administer medicines. Staff felt competent to administer medicines.

Staff were recruited safely and had the appropriate pre-employment checks were in place.

Staff were given an induction and training suitable to their job role. Staff told us, and we saw they were given time to get to know people as part of their induction. Staff got to know the people they were supporting on a personal level.

People were supported to have choice around their meals and food and drink preferences. The information was clearly captured in their care plan and staff could describe people’s favourite food and drinks. Any concerns with people’s nutritional intake were reported to appropriate health professionals.

The service worked in line with the Mental Capacity Act 2005 and staff had a clear understanding of how to support people with fluctuating capacity and giving support with decision making.

People told us the staff were caring and we observed staff treating people with dignity and respect.

Staff genuinely cared for people and knew people well.

The service promoted communication for people and explored how communication could be more effective.

Staff had an approach of encouragement to promote independence.

People and relatives were involved in care planning and personal preference and choice was captured throughout the care plans. Care plans were very person-centred and regularly reviewed to ensure they remained reflective of people’s current needs. Staff could accurately describe the content of people’s care plans and were able to read them and digest the information prior to supporting the person.

People could easily raise any concerns. Staff felt the registered manager was approachable and hands on in their role so would not hesitate to contact them if required.

Rating at last inspection: At the last inspection the service was rated as Good (4 August 2016).

Why we inspected: This was a planned inspection to check that this service remained Good.

Follow up: We did not identify any concerns at this inspection. Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for services rated Good.

For more details, please see the full report which is on the CQC website at

Inspection carried out on 16 June 2016

During a routine inspection

The inspection took place on 16 June 2016 and was unannounced. We returned for a second day on 24 June 2016 and this was announced. The last inspection was in May 2014 and highlighted the need for the provider to improve food safety, care plans and staff training and supervision. All the requirements from the last inspection had been addressed.

Mencap, 1 Victoria Road is registered to provide accommodation for up to six people with learning disabilities. There were six people living at the home at the time of our inspection.

At the time of our inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

There was a homely, welcoming atmosphere and people enjoyed good quality interactions from kind and caring staff. Care was personalised and people were supported to engage in plenty of individual, meaningful activity.

Staff had a good understanding of how to keep people safe, and support their understanding of safety. Procedures for safeguarding people were followed promptly and the provider worked closely with other agencies where concerns arose.

Staffing levels were supportive of people’s needs. Staff worked closely as a team and felt supported by managers and the organisation.

Staff had regular opportunities to update their professional skills and knowledge. Staff demonstrated an understanding of the impact of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

Care records were detailed and person-centred for all aspects of people’s individualised care and support. People were involved in their care planning and consulted about their wishes and preferences.

People were supported to complain if they were unhappy about any aspect of their care. Compliments were made to the service by visiting professionals.

There were well organised systems for auditing the quality of the provision. Staff knew their roles and responsibilities and there was an open and transparent culture in the home.

Inspection carried out on 8 May 2014

During a routine inspection

We carried out two visits to this home because on the first visit all the people who used the service had been attending community activities. We returned at the weekend to speak with people and observe care being delivered.

The focus of the inspection was to answer five key questions, is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what people using the service, and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report. This is a summary of what we found.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Environmental and equipment safety checks were being carried out on a regular basis.

People appeared relaxed with the staff in their interactions with them. One person said they �felt safe living here.�

There were systems, processes, policies and procedures in place to support safe care delivery. There were up to date risk management plans in relation to falls and behaviours which were clearly documented in people�s support plans.

The manager and staff recorded incidents, accidents, complaints and concerns. We saw examples where staff had learned from these events.

We saw food stored in the fridge that had been opened, but not dated or labelled. Open food can cause harm to people as food may be kept beyond a safe time period. We have asked the provider to address this practice immediately.

Staff personnel records did not did not contain all the information required by the Health and Social Care Act 2008. This meant the provider could not demonstrate that staff had received the appropriate training, professional development, supervision and appraisal needed to enable them to deliver care and treatment to people safely and to an appropriate standard.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to supporting workers.

Is the service effective?

It was clear from what we saw and from speaking with staff they understood people�s care and support needs and they knew them well.

People�s care records had been assessed and regularly reviewed. There was evidence of people and their relatives being involved in assessments of their needs and care planning.

We found the care plans required more detail when cross-referencing between risk assessment and personal support plans. There was evidence staff had signed care plan reviews without reading the care plan in detail. The provider told us all care plans would be audited and amended immediately.

Is the service caring?

Our observations of the service showed care staff spoke with and interacted with people who used the service in a patient and pleasant manner. People told us: �staff are good here.�

Staff supported people in a sensitive way using differing methods of communication to ensure people understood what was going to happen.

We saw staff encouraged people when providing support and allowed people to do things at their own pace and were not rushed. One person told us: �I cook for myself, I do my own shopping but if I need help they help me.�

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey, and staff acted on concerns raised.

Is the service responsive?

People�s needs were assessed and reviewed on a regular basis. People told us staff provided help when it was needed. Records confirmed people�s interests, preferences, aspirations, health and personal care needs had been recorded. We saw that care and support had been provided that met people�s wishes. People had access to activities, which were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff told us the provider was a good company to work for. We saw evidence people were asked for feedback on the service they received. People�s relatives and professionals were asked to complete a customer satisfaction survey. People told us they attended resident meetings on a regular basis where they could raise concerns and knew they would be acted on.

The staff we spoke with said the manager was very supportive and approachable. They told us if they had any concerns or witnessed poor practice they would report their concerns to the manager. They were confident managers would act on their concerns.

We were concerned to note that the registered manager had failed to implement staff supervision and development and senior staff within the organisation had not addressed this prior to our inspection.

Inspection carried out on 8 November 2013

During an inspection looking at part of the service

We spoke with two, including the manager and one person who used the service.

We found people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Inspection carried out on 23 July 2013

During a routine inspection

At the time of our inspection there were 5 people living in the home; we talked with four of those people, one member of staff and the manager.

People told us they had plenty to do, like working at the day centre, visiting their relatives and going to organised social events such as, �keep fit�.

People told us they felt safe and liked living in the home. They said they were able to make choices about their care with help from the staff.

People experienced care, treatment and support that met their needs and protected their rights. However, not all care plans were accurate and up to date. This meant that although the staff might know the needs of the people in their care, potentially people might not have received continuity of care, or care that met their needs.

Inspection carried out on 27 June 2012

During a routine inspection

We carried out this review as part of our routine schedule of planned reviews. However, we also received anonymous concerns in relation to the care people receive and on the management of the service. This included, people not having person centred care, choice, respect, management of medicines and repairs to the property. All of these issues were included for review as part of this visit.

During our visit we attempted to speak with all six people who used the service however, as we were not familiar with everyone�s way of communicating, we were not able to gain everyone�s views. However, as we observed their care we saw that staff were very supportive and familiar with people�s ways of communicating.

One person told us how they liked to take care of themselves and how staff were involved in helping them to make decisions about their daily routines, such as when they shopped for their food, and supported them to go out into the community and live as an independent life as possible.

People told us they felt safe and liked living in the home. They said they were happy with the care they received, and they could make choices and decisions about their care.

People told us that they take it in turns to choose what to have for tea and if they did not want the meal, which other people had chosen, then they could choose something else.

No-one raised any concerns with us during our visit. The people we spoke with said if they were not happy they would tell the staff.