Background to this inspection
Updated
11 May 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 over three days, 15, 17 and 23 March, and was unannounced on the first day when we visited Donnybrook Court, and on subsequent days the service knew we were returning. On the second day we visited Duncan Court, and on the third day we returned to Donnybrook Court. The inspection was carried out by two inspectors on the first and second day, and a single inspector on the final day.
Prior to the inspection we looked at information the Care Quality Commission (CQC) held about the service. This included notifications of significant events sent to CQC since the service registered in February 2015.
In carrying out this inspection, we spoke to 13 people who used the service, three support workers two team leaders and the two site managers. We reviewed eight people’s care records, including care plans, risk assessments and records of care received. We reviewed six staff files, including records of recruitment and supervision of staff, and other documents relating to the management of the service.
Updated
11 May 2016
This inspection took place on the 15, 17 and 23 March 2016. On the first day the inspection was unannounced, and on subsequent days the service was aware that we were returning. This is the first inspection of this service since it registered in February 2015.
Donnybrook Court is an extra care service which provides care and support to 75 older people and people with physical disabilities. There are two sites, Donnybrook Court and Duncan Court, both of which consist of 40 self-contained flats, with shared facilities such as a lounge, dining room and launderette. At the time of our inspection 40 people were living at Donnybrook Court and 35 at Duncan Court.
The service had a registered manager, who is the Area Manager for Creative Support. 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. At the time of our inspection, there were service managers in place for each building, and one of these site managers intended to become registered manager for the whole service. However, both buildings were managed as separate services, and managers have informed us they intend to review the service’s registration.
People who used the service benefitted from a varied and interesting activities programme. The service had innovative activities on both sites, although we saw that this programme was more developed at Donnybrook Court than at Duncan Court.
People had detailed care plans with summaries for staff to follow. We saw evidence that these plans incorporated people’s wishes and preferences and had detailed information on how to ensure people’s dignity and independence was maintained. However, care plans at Donnybrook Court were frequently inconsistent and were not regularly reviewed, and people were not receiving the hours they were allocated from the local authority. Measures were in place to ensure that people had consented to their care, and that when people may not have the capacity to do so, the service had worked in line with the Mental Capacity Act (MCA) 2005 in order to assess people’s capacity and to work in line with people’s best interests.
Risks to people were assessed and management plans were put in place in order to manage these. Not everyone had a personal evacuation plan, but the service had identified this and had measures in place to address this. It was not always clear that people were receiving support from two staff when a risk management plan required this, and in one instance the risk management plan may not have been adequate to address the risks to a particular person.
People’s safety was promoted through an adequate safeguarding policy, and we saw that when abuse of vulnerable adults was suspected, staff were aware of their duty to report this, and that safeguarding concerns were appropriately raised with the local authority.
The provider followed safe recruitment measures to ensure that staff were suitable for their roles, this included checking references and identification and carrying out appropriate pre-employment checks.
Medicines were administered by staff who had the skills and competencies to do this, however care plans were not always clear on who had this responsibility, and we found gaps in the recording of people’s medicines which were not addressed by a suitable audit system.
The service had a detailed induction for staff and all staff received regular assessments on their skills and understanding in areas such as safeguarding adults, promoting dignity and administering medicines. Managers at the service provided leadership through regular supervisions and team meetings. Staff had regular training in order develop the appropriate skills to carry out their roles and systems were in place to ensure that training remained up to date.
We found breaches of the regulations relating to safe care and treatment and person-centred care. You can see what action we told the provider to take at the back of the full version of the report.