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Inspection report

Date of Inspection: 23, 25 April 2014
Date of Publication: 18 June 2014
Inspection Report published 18 June 2014 PDF | 125.87 KB


Inspection carried out on 23, 25 April 2014

During a routine inspection

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

We saw that people�s assessments, care plans and risk assessments were not accurate and did not reflect the current needs of people who lived at the home.

People had been cared for in an environment that was safe. We saw that regular electrical and gas safety checks took place. There had been a recent fire check and legionella risk assessment undertaken. There was evidence of a passenger lift service and repair contract.

We observed a medication round and saw there were procedures in place that ensured people were protected against the risks associated with medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There were no policies and procedures in place and staff had not received training to understand when an application should be made. Staff we spoke with were unable to demonstrate knowledge of DoLs.

Staff were able to tell us about their understanding of, and what actions they would take if they believed people in the home were at risk of abuse.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from our observations and from speaking with staff that they understood people�s care and support needs and knew people well. One person told us. "I need more help at the moment but I couldn�t have better care than I get here.�

We saw that staff had not received induction or mandatory training and there was no supervision taking place.

There was not enough appropriate equipment to promote the independence and comfort of people with specific care needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. People told us they were able to do things when they wanted to. Our observations confirmed this. One person told us, �I like all the girls, I think they�re wonderful.�

Is the service responsive?

Most people�s needs had been assessed before they moved into the home. However for people who had moved into the home more recently these were not detailed and did not indicate who had been spoken to in relation to people�s care needs. There was no information about people�s individual choices and preferences.

A �This is me� booklet had recently been completed and this reflected people�s individual likes and dislikes.

People had access to a wide range of activities and these were important to people. One person told us, �Activities really get us together.� We saw that people had access to a range of healthcare professionals.

Is the service well-led?

There was no evidence that feedback surveys had been undertaken. People we spoke with told us they could raise their concerns with staff and the appointee manager. They told us they were listened to and action was taken appropriately.

We saw evidence that when concerns had been raised about staff who had previously worked at the home, the provider had taken appropriate actions in a timely manner. We saw that staff were referred to the appropriate bodies when they had a concern.

There was no evidence of any regular assessment and monitoring the quality of service that people received. Not all relevant policies and procedures were in place.

The service had failed to notify the Care Quality Commission (CQC) of any incidents or deaths of people who used the service.

At the time of the inspection the named registered manager and nominated individual was not in post. The provider and appointee manager were currently responsible for the running of the home.