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Inspection report

Date of Inspection: 15 April 2014
Date of Publication: 16 May 2014
Inspection Report published 16 May 2014 PDF | 82.54 KB


Inspection carried out on 15 April 2014

During a routine inspection

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

- Is the service safe?

CQC monitors the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw that a proper policy relating to DoLS was in place and we spoke with the registered manager who demonstrated their knowledge of the procedures to follow. We saw evidence that all staff had been trained in DoLS, in the Mental Capacity Act 2005 and in the safeguarding of vulnerable adults. We found that best interest meetings were held when necessary following people's mental capacity assessments. Risk assessments with clear action plans were in place to ensure people remained safe. There were effective systems in place to reduce the risk and spread of infection.

- Is the service effective?

People and their relatives stated they were satisfied with the quality of care that had been delivered. We saw that the delivery of care was in line with people's care plans and assessed needs. We found that the staff had received training to meet the needs of people living at the home. Staff received additional training when needed and when they requested it. We found that people who used the service were supported by suitably qualified, skilled and experienced staff. Relatives commented, "We are very pleased with the service that is provided", and, "My son is always happy when he knows he is going there for respite".

- Is the service caring?

We found that people who lived in 36a Birling Avenue were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff provided encouragement, reassurance and practical help. We saw staff helped people with their care and support, at mealtimes and during activities with patience and kindness. People who used the service told us, "It is like a holiday, I like it a lot"; A member of staff said, "This is where people can have a break, feel safe and enjoy themselves ". We found that the service responded promptly and appropriately when people were unwell.

- Is the service responsive?

People's needs had been assessed before they moved into the home and their support plans were reviewed regularly to reflect any change in their needs. We saw that people's records included people's history, wishes and preferences and individual communication needs. Preferences such as choice of rooms were accommodated when practicable. People and/or their representatives were involved with reviews of care plans and were kept informed of any changes. People had access to daily activities that included outings to bingo, bowling, golf driving ranges, cinema, drama and social clubs. People and their relatives' comments and suggestions were listened to and followed through with adjustments made when practicable.

- Is the service well-led?

We found that comprehensive policies and procedures that addressed every aspect of the service were in place. The registered manager operated a system of quality assurance and completed audits to identify how to improve the service. Staff told us the manager and deputy manager operated an open door policy. They described how they were able and encouraged to express their views and concerns they may have and said they were listened to. Complaints, incidents and accidents were appropriately recorded and audited. People and their relatives or representatives were consulted about how the service was run and annual survey questionnaires were sent and analysed. The surveys were audited to identify how the service could improve.