Archived: Custom House

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 a focused inspection on 8 January 2016 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 these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Custom House’ on our website at www.cqc.org.uk’

Custom House is the only residential establishment run by Blyth Star Enterprises. Blyth Star also operates an outreach service from the same building, which is not regulated by the Commission, because this is outside the scope of the regulations; because this arm of the service does not deliver personal care to people who use it. It also runs a number of work placements and day facilities.

Custom House provides accommodation for up to seven people with mental health issues, who require assistance with personal care and support. People living at the service have their own apartments, which include bathing facilities and a small kitchen area. They also have access to communal facilities. At the time of this inspection there were five people living at the service.

The home had a registered manager who had been registered since November 2013. 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.

The provider had engaged with the local NHS pharmacy advisor, who had undertaken a comprehensive review of how medicines were managed at the home and made recommendations to improve the administration process. The provider had implemented these recommendations and made significant changes to how medicines were handled at the home. New medicine administration records (MARs) had been introduced which gave full details of the medicines people were receiving. Specific care plans related to the administration of “as required” medicines had been developed and plans and risk assessments were in place to support people who managed their own medicines. Medicines were stored safely in locked cabinets or boxes in fridges. The provider had appointed a specific member of staff to order, monitor and check the appropriate management of medicines at the home.

New risk assessment processes had been developed which covered any risks associated with people’s individual care, along with wider environmental risk issues. The manager also showed us additional person centred quality monitoring systems that had been developed. These were based around each individual person living at the home. They covered reviews of care, care records and associated items of risks, such as monitoring electrical appliances in people’s rooms and other environmental factors. These checks were carried out on a rolling three monthly programme and were in addition to the more general checks and audits undertaken at the home. Actions and quality reports were also now reviewed by the provider’s board or quality assurance group.

At our focused inspection on 8 January 2016, we found that the provider had met the requirements of the warning notice, followed their action plan and met legal requirements.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found '

Is the service caring?

People's needs were assessed and care delivered in relation to their identified needs. People we spoke with told us they felt well supported by staff. One person told us, 'The staff are very helpful to me. Everything is more or less okay. This is a much better way of life.' Another person told us, 'I absolutely love it. The staff are nice, friendly and patient.'

Is the service responsive?

People's care plans were reviewed as their needs changed. People who used the service had regular access to one to one time with staff and were accompanied by staff on social and therapeutic trips. People were encouraged and supported to access health care and other appointments. One person told us, 'The staff are always there when you need them, helping us through a lot of things; good and bad times.'

Is the service safe?

The home was a recent development and most systems in the home were new. Appropriate fire and other safety systems were in place and checked. There were enough staff available 24 hours a day to respond to people's needs and additional support was available through an on call system. Risk assessments had been undertaken were necessary. One person told us, 'The staff are really very professional, they stay calm in all situations and that makes us feel safe.'

We found that medicines were not always safely administered and monitored. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager told us that all the people using the service had capacity to make their own decision and there were no current applications in relation to DoLS.

Is the service effective?

We saw that people's general care needs were addressed and that they had appointments with doctors and other health and social care professionals. We noted that where people's care needs changed then action was taken and care plans updated to acknowledge this change. One staff member told us, 'I love the whole thing. It's the thought that I can help someone; even a tiny little bit.'

Is the service well led?

The home had a range of quality assurance systems in place to monitor the quality and consistency of care. The service undertook monthly 'red days' which were combined meetings involving both staff and people who used the service. People told us these were effective and responsive.

People we spoke with told us that the service manager was always available if they wanted to raise any issues or talk about things. One person told us, 'The staff are approachable and always listen.'

Staff told us that there was good support from senior managers within the organisation and that there was always someone on call.

We saw records were not always maintained in a way that meant they were easy to follow or access and the most up to date information may not be readily available. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.