28 July 2016
During an inspection looking at part of the service
The service had not had a registered manager for 15 months prior to our inspection. 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. A new manager had been recruited and was due to start working at the service shortly after our inspection. We will monitor the situation to ensure that an application to register is made.
We carried out an announced comprehensive inspection of this service on 31 March & 1 April 2016. Breaches of legal requirements were found in respect of recruitment procedures and good governance. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.
We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk
Improvements had been made to the recruitment procedures. Staff were required to undergo an interview and assessment process prior to being offered work. Appropriate checks of their conduct in previous employment, identification and criminal record were carried out. These checks are important to assist providers in making safer recruitment decisions.
Improvements had also been made to the systems used to assess and monitor the quality of the service provided. People were regularly asked for their opinion and changes made to their care package where necessary. Audits were carried out on staff performance and record keeping and any issues identified were acted upon. Improvements had been made to record keeping although there were still occasions where staff had not fully completed records relating to the care they had provided to people.