23 July 2018
During a routine inspection
There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The registered manager was available for an hour on the first day of the inspection due to planned leave. For the remainder of the inspection we were supported by the service senior management team.
The provider was not following their own policy in relation to staff training. people’s confidential information was not always securely sent via emails to staff. We have made a recommendation around this.
People told us that they felt safe. Recruitment process were robust and staff understood what they needed to do to protect people from the risk of abuse . People told us that they received their medicines when needed. Medicines audits were effective in identifying shortfalls with medicines management.
There were sufficient levels of staff to support people. Risk assessments were in place for people and staff were aware of how to reduce risks. Staff were following good infection control processes. Accidents and incidents were recorded and analysed to reduce further risks.
The principles of the Mental Capacity Act were being followed and staff ensured that they gained consent from people before delivering care.
Staff had the training and supervision necessary to carry out their role. People felt that staff were effective and understood what care they needed to deliver. Staff worked closely with health care professionals to ensure that people were supported with the health care needs. This included being supported with their food and hydration needs.
A full assessment of people’s needs took place before people started using the service. Care plans were detailed and people were fully involved in the planning including for those people on end of life care. Staff understood the needs of people and were effective in communicating changes in people’s care.
People and relatives felt that staff were caring and respectful. People felt that staff assisted with their independence and included them in any decision making.
People understood how to make a complaint. Complaints were investigated and actions taken to resolve complaints.
Other audits and quality assurance were robust and used to make improvements to the care provided. People and staff thought the leadership of the service was good. Staff felt supported and valued. Staff understood the ethos of the service.
The service worked closely with other agencies outside of the organisation. The registered manager ensured that notifications were sent to the CQC where necessary.
This was the first inspection at the service. During the inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.