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Inspection report

Date of Inspection: 17 July 2014
Date of Publication: 19 August 2014
Inspection Report published 19 August 2014 PDF | 84.56 KB


Inspection carried out on 17 July 2014

During a routine inspection

The inspection was carried out by one inspector, who answered the five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found the service to be safe because people’s rights and dignity were respected and they were involved in making decisions about any risks they may take. When people were at risk, staff followed effective risk management policies and procedures to protect them. Staff supported people to take informed risks with minimal necessary restrictions to as far as possible protect their welfare.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The service understood the requirements of the Mental Capacity Act 2005, its main Codes of Practice and Deprivation of Liberty Safeguards, and put them into practice to protect people. This meant that people were protected from discrimination and their human rights were protected.

People received their medicines as prescribed. Prescribed medicines (including controlled drugs) were stored and administered safely in line with current and relevant regulations and guidance. People could administer their own medicines safely. One person told us, “They come over every night and help me with my tablets. They’re always there and on time”.

People were safe because the service considered skill mix and experience when arranging staffing and staffing levels were sufficient to meet their identified needs.

Is the service effective?

We found the service to be effective because there was an advocacy service available if people needed it, this meant when required people could access additional support.

Care plans reflected people’s current individual needs, choices and preferences. People were involved in the assessment of their needs. People’s health was regularly monitored to identify any changes that may require additional support or intervention. People we spoke with said “They’re excellent”, “Lovely girls”, “Very helpful”. People said that staff knew their needs “very well” and “They organise everything for you”. Staff said, “I think we know people really well”, “We’re a small team and we see the same people every day”.

Staff supported people to take informed risks with minimal necessary restrictions. The environment enabled staff to meet people’s diverse care, cultural and support needs. People’s identified needs were monitored and managed.

Is the service caring?

We found the service to be caring because people were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. Staff responded in a caring way to people’s needs when they needed it.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. Appropriate professionals were involved in planning, management and decision making.

Staff knew the people they were caring for and supporting. People were as independent as they wanted to be.

Is the service responsive?

We found the service responsive because, staff actively sought, listened to and acted on people’s views and decisions. Staff responded to changing needs in line with people’s choices and wishes.

People had their individual needs regularly assessed and met. There were arrangements in place to speak to people about what was important to them. People we spoke with said, “

People completed a range of activities in and outside the service regularly. People had access to activities that were important and relevant to them and were protected from social isolation.

Is the service well-led?

We found the service to be well-led because there was an emphasis on fairness, support and transparency and an open culture.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Robust quality assurance and governance systems were in place and used to drive continuous improvement. The management team recognised innovation.

Concerns and complaints were used as an opportunity for learning or improvement.