Archived: Royal Mencap Society - Teversall Bungalow

Updated 18 April 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was conducted by two inspectors.

Service and service type

Royal Mencap Society - Teversall Bungalow is a care home who provide care for up to six people. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during the inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We reviewed previous inspection reports, information received from other agencies and statutory notifications. A notification is information about important events which the provider is required to send us by law.

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections

During the inspection-

We spoke with two people and one relative about their experience of the care provided. We spoke with three care staff, the assistant manager and the registered manager. We looked at the relevant parts of the care records of two people who used the service. We also looked at four staff recruitment files and other records relating to the management of the home. This included audits, policies and incident records.

After the inspection.

We continued to seek clarification from the provider to validate evidence found after the inspection. We looked at training data and quality assurance records.

Updated 18 April 2020

About the service

Royal Mencap Society-Teversall Bungalow is a residential care home providing personal and nursing care to five people with learning disabilities. The service can support up to six people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People’s experience of using this service and what we found

Risk assessments were completed to mitigate specific risks associated with individuals, but some lacked detail of how staff would manage these risks.

Systems were in place to protect people from avoidable harm. People felt safe living at the home. People received their medicines as prescribed. The service followed policy and procedures related to infection control legislation. Lessons were learned when things went wrong.

The provider demonstrated an understanding of the need to consider people's mental capacity and followed the principles of the mental capacity act. However, the MCA assessments we looked at were not clear, or person centred. Initial assessment of care was undertaken, monitored and managed to ensure people received effective care. Staff were supported to acquire the knowledge and skills required to support people’s needs. People received a balanced diet and made choices of what they wanted to eat and drink. The service worked well with other healthcare professionals and provided consistent care and support.

Staff were kind and considerate. They always treated people with respect and dignity. People were encouraged to achieve their hopes and dreams. People were encouraged to share their views and expressed choices to ensure they had a happy, content life. Staff respected people’s wishes and choices.

People’s care, choices and preferences were adhered to. Staff and management worked with passion and dedication and the people who used the service always came first. People were supported to participate in activities that were relevant and important to them. Peoples communication needs were met in line with the Accessible Information Standard. The service was open and transparent when dealing with complaints. People who wished to make advanced plans for their end of life care were supported to do so.

The provider was meeting their responsibility to report incidents to CQC. Themes and trends were clearly identified when monitoring accident and incidents. People and relatives spoke positively about the management of the service. The registered manager took a proactive approach to address issues and concerns. People were encouraged to be involved with promoting the service. The registered manager and staff worked well with external healthcare professionals to ensure people received good care and support.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for this service was requires improvement (published 24 October 2018). and there was a breache of regulation 17. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We have made a recommendation about the detail and recording of decisions for Mental Capacity Assessments.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.