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Inspection Summary

Overall summary & rating


Updated 9 December 2017

The inspection took place on 22 September 2017. The inspection was unannounced but we telephoned the service before we left to ensure people were in. The service was last inspected on 25 July 2016 and was rated requires improvement with two breaches for regulation 12: Safe care and treatment and regulation 11, Consent. We had concerns about the safe administration of medication and poor documentation for people who lacked capacity to make their own decisions. At this inspection we found the necessary improvements had been made.

The service was registered in April 2013 and this was only the second inspection. It was registered for five people who had a learning disability. At the time of our inspection there were four people using the service. There was a registered manager, who was also one of the five directors. The directors had known each other for many years and set up the service together. All took an active role in managing and developing the service and this was their only care home.

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 was a highly individualised service where the needs of people using it were paramount. The staff knew people really well and people had continuity of care and support. People had previously lived at home with parents and this was their first home since reaching adult hood. Each person had their own room and an individual activity programme around their needs. Staff recognised people’s anxieties and behaviours and supported people accordingly.

There were systems in place to reduce risks people faced from day to day tasks and from people’s associated learning difficulty. Risks were well managed but without stifling people’s opportunity or lessoning people’s independence. The environment was well maintained and risks from potential hazards such as fire were well controlled.

Medicines were administered to people as and when required and there were safe systems to do this. Staff were well trained and audits were in place designed to ensure people received their medicines as intended.

Staff received training necessary for their role and continued professional development. Staff understood different types of abuse and said they would raise any concerns if they suspected a person to be at risk from harm or actual abuse. There were clear policies for staff to follow. Robust staff recruitment processes helped ensure that only suitable staff were employed and did not have a criminal past which might make them unsuitable.

Staff were supported in their role and although the directors were always available staff had both informal and formal support.

People were supported to stay healthy and had adequate diet and fluids for their needs. Staff monitored people’s health and there was a plan in place to ensure people received regular health care as needed. People had support around their needs in association with their mental health and associated behaviours.

Staff understood mental capacity and supported people to make day to day decisions and where people were unable to make more complex decisions staff acted in their best interest and followed due processes. This meant staff acted lawfully in terms of supporting people who lacked capacity. Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process.

Staff had sufficient

Inspection areas



Updated 9 December 2017

The service was good.

Risks to people care, welfare and safety were identified and steps taken to reduce the risk. Staff had the necessary skills to protect people as far as reasonably possible for known risk.

There were sufficient staff to ensure people�s needs were met.

Staff had knowledge of what constituted abuse and what actions they should take if they suspected a person to be at risk of harm or abuse.

There were safe systems in place to ensure people received their medicines as intended. Staff had the necessary training and competencies.

There were robust staff recruitment processes in place to help ensure only suitable staff were employed.



Updated 9 December 2017

The service was effective.

Staff were supported to ensure they had the right knowledge and skills to undertake their role. Staff had opportunities for professional development. Staff received regular support and training.

Staff supported people lawfully where they lacked capacity to make decisions. People were given day to day choices.

People were supported to stay healthy and to have access to health care as needed .People had regular meals and supported with their hydration and nutrition.



Updated 9 December 2017

The service was caring.

Staff met people�s individual needs and gave them sufficient opportunity to develop their skills.

Staff were kind and compassionate and valued people they were supporting.

People determined what they wanted to do and their views and opinions were taken into account with regards to how the service was provided



Updated 9 December 2017

The service was responsive.

The service was based around people�s individual needs and people had personalised care around their wishes.

There were sufficient opportunities for people to engage in activities and hobbies they enjoyed.

There was an established complaints procedures and people and extended families and professionals were able to voice their concerns if they had any.



Updated 9 December 2017

The service was well led.

The directors had invested a lot of time to ensure the service was safe, and provided people with the care they needed and the opportunities to have a full live as possible.

They worked with people�s families to ensure the service was inclusive.

There were audits in place and quality assurance systems to establish what the service did well and where they needed to improve.