Archived: Sara Lodge

Updated 24 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 11 May 2016 and it was unannounced.

Prior to our inspection, we reviewed information we held about the service, including notifications sent to us at the Care Quality Commission. We looked at the information sent to us by the provider in the Provider Information Return. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

The inspection was carried out by one adult social care inspector and one expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

We spoke with the registered manager, assistant manager and one member of the care staff. People could not let us know what they thought about the home because they could not always communicate with us verbally. Because of this we spent time observing interactions between people and the staff who were supporting them. We contacted two health and social care professionals to gain their views on the care provided by the service. We were unable to get feedback from any relatives.

We looked at two people’s care records, medicine administration records and four staff files including their recruitment and training records.

We looked at accidents / incidents and complaints records, staff team meeting minutes, handover records and communication book, quality audits and monitoring checks.

Updated 24 June 2016

We inspected this service on 11 May 2016. We last inspected the home on 25 March 2014 and the service was meeting all the requirements inspected. The inspection was unannounced.

Sara Lodge is registered to provide residential care for up to six people with a learning disability, autistic spectrum disorder or a mental health condition. At the time of the inspection there were two people receiving support as part of the residential care home. The provider also operated a supported living service from the same address. The same staff team and policies covered both services. As the supported living service was inspected within the same month, we have utilised information from both inspections for each report. You can read the report related to the supported living service by selecting the 'all reports' link for Dillan Care Pathway on our website at www.cqc.org.uk .

The service had a registered manager who has been registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission 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.

There was a joyful and lively atmosphere at the home on the day of the inspection. We saw people were treated with dignity and respect by staff and staff told us how important it was to gain people’s consent before offering any care. Staff were able to demonstrate their understanding of the needs and preferences of the people they cared for, and we could see that people were assisted to be as independent as possible. The two people at the home were facilitated to attend a wide range of activities in the community, and we saw that the staff carried out activities with people at the service.

We checked medicines administration charts and found that clear and accurate records were being kept of medicines administered by staff. Care plans were personalised and detailed life histories, individual needs and likes and dislikes were recorded. Risk assessments were up to date and detailed.

There were safeguarding policies and procedures in place, and staff were able to tell us the different types of abuse and the action they would take if they had any concerns.

Staff told us they were supported well and we saw evidence of regular staff supervision and key training had been undertaken.

Staff recruitment processes included checks to confirm people were eligible to work in the UK, Disclosure and Barring Service (DBS) security checks and references. We noted that not all references had been verified prior to September 2015, but the provider had improved their processes and paperwork so recruitment processes were now more rigorous.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and whether any conditions on authorisations to deprive a person of their liberty were being met. The registered manager had made referrals to the local authority with regards to deprivation of liberty safeguards (DoLS) for both of the people living at the service. One had run out in March 2016, but the provider could show us following the inspection they had applied to extend the DoLS for this person.

The service had good systems and process in place to assess, monitor and improve the quality and safety of service provided. There was evidence of regular monitoring checks of the quality and safety of the service.

The service was located in two adjoining terraced houses and there was access to a back garden. The building was not fully wheelchair accessible throughout as there were stairs to the first floor bedrooms, but there were wheelchair accessible downstairs bedrooms with ensuite showers.