3 July 2017
During a routine inspection
This inspection took place on 3 and 7 July 2017. Cheviot Gardens is an extra care service that provides support to up to 66 people in their own flats on the premises. At the time of the inspection the service was delivering personal care to 34 people.
The service had a registered manager. 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.
This service was registered by the CQC on 23 June 2016 and this was the first inspection for the service.
At this inspection, we found the provider had not always notified us of incidents or accidents affecting service users. This was a breach of Regulation 18 of the Registration Regulations 2009 - Notifications of other incidents. You can see what action we told the provider to take at the back of the full version of the report.
People were protected against the risk of harm and abuse. Staff received on-going training in safeguarding and demonstrated sound knowledge in how to report suspected abuse, and identify changes in people’s presentation that could indicate they were victims of abuse. People were protected against identified risks through comprehensive risk assessments that gave staff guidance to mitigate those risks.
The service ensured people received their medicines in line with good practice. Medicine administration recording [MARs] sheets were completed correctly and audited regularly to ensure any errors were identified swiftly and action to minimise the impact on people. Staff received comprehensive medicine management training.
People’s care was delivered in line with the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff sought people’s consent to care and treatment and respected their decisions. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. ;The policies and systems in the service reinforced this practice.
The service employed sufficient numbers of suitable staff to meet people’s needs safely. Rotas reflected the needs of people and where people’s needs increased staffing levels were adjusted. Records confirmed all new employees had to receive satisfactory references and a Disclosure and Barring Service’s (DBS) check prior to commencing work. Staff confirmed they underwent a comprehensive induction whereby they shadowed more experienced staff.
People were supported by staff who received on-going training and who reflected on their working practices. Staff records confirmed mandatory training had been completed and staff stated they were confident they could request additional training and this would be provided in a timely manner. Records showed all staff received regular supervisions with senior staff where their work performance was discussed and support given.
People’s care and support was planned and delivered with their involvement. Care plans were person centred and detailed people’s preferences, medical and health needs and support required to meet their goals. Staff confirmed when changes were made to care plans, this was shared with them to ensure they delivered care that was relevant to their needs. Care plans were updated regularly to reflect people’s changing needs.
People’s consent was sought prior to care being delivered. Staff understood the importance of seeking people’s consent and where consent was not given staff respected people’s decisions. Where possible, people were encouraged to maintain their independence. Staff spoke to people with respect and treated them with dignity.
People were encouraged to have access to sufficient amounts of food and drink that met their dietary requirements. Where people chose to have their meals in the dining room provided by the service, people were offered an array of choices. The service supported people to access professional healthcare services to ensure their health was maintained, where required.
People were encouraged to share their views of the service through questionnaires and weekly service meetings. People confirmed their views were taken on board and action taken where appropriate. The registered manager carried out audits of the service to drive improvements. People were aware of how to raise a concern or complaint. The service provided people with details of who to contact, what to expect when raising a complaint.
The registered manager encouraged partnership working. Records held by the service showed where healthcare professionals had given guidance which was then implemented in the support people received.