22 March 2018
During a routine inspection
This inspection was prompted by an incident we were notified of in March 2018. This incident did not directly have an impact on people using the service but it did raise some questions about potential risk which we wanted to follow up. Colville Terrace is a 10 bed supported living service that provides care and support for men and women with mental health needs. At the time of the inspection, nine people were using the service.
The property comprises self-contained studio flats with cooking and bathroom facilities. Communal areas include a lounge, a computer room, a laundry area and a courtyard located at the rear of the home. The building is owned by a separate landlord.
The service had a registered manager in post who was available during both days of our visit. 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 had been no safeguarding concerns and safeguarding processes were in place so staff knew how to report abuse if this was suspected and/or witnessed in the service. Staff were not always confident about how to report whistleblowing concerns. Staff had completed training in how to report unsafe practice. Risks were not always assessed and reviewed when people’s needs had changed. Safety checks were not consistently carried out during the night to ensure people’s safety.
Recruitment processes were followed and pre-employment checks were undertaken on staff before they began work. There was enough staff on duty to provide care to people who used the service. Staff were not provided with effective support and supervision to develop their knowledge, skills and practice. A programme of training was completed by staff that was reflective of the needs of people they supported.
People prepared their own meals. Staff encouraged people to eat a well-balanced diet and medical practitioners supported people to maintain good health. Medicines were not always managed safely. Staff had completed medicines awareness training.
People told us that staff were caring and listened to their views. Staff treated people with dignity and respect and understood their preferences, and how best to care for them. The provider worked with other agencies that provided specialist support and advice.
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 supported this practice.
Care plans were not always reviewed to fully capture information about people’s individual needs and how they had met their goals. People took part in activities that reflected their interests and hobbies. People and their representatives were provided with information about how to make a complaint if they were unsatisfied with the service.
The service was not well led. There was a lack of consistent leadership in the service that impacted on the service operating effectively. A comprehensive audit had been carried out by the provider to improve the standards of care, however this did not detect all the shortfalls we identified. Records were not always kept safe and secure in accordance with the Data Protection Act 1998 (DPA). People spoke positively about their experiences of using the service and their feedback was sought to improve how the service delivered their care and support.
We found three breaches of regulations relating to the management of risks to people's health and welfare, staffing and good governance. You can see what action we asked the provider to take at the back of the full version of this report.