We reviewed the evidence we had obtained during our inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.
Is the service safe?
We found that sufficient staff were on duty during both days of our inspection to meet people's needs. Where there had been periods where staff numbers were short during April we saw that substantial progress had been made from the beginning of May to increase staff on duty.
Staff were safety conscious and observant. We noted one staff member leaving the activities room giving their scissors to a colleague for safe-keeping until they returned. Where one person was attempting to walk unaided staff quickly spotted this and went to their assistance promptly.
The manager was aware of their responsibilities under the Mental Capacity Act 2005 and had taken appropriate action in relation to one person in accordance with the Deprivation of Liberty Safeguards.
Is the service effective?
It was clear from our observations and speaking with staff that they knew people well and understood what people's individual support needs were. The computerised care records system generated person centred, detailed care plans, which helped guide staff to look after people safely and effectively.
We found that there were substantial gaps in staff's training records, appraisals and supervisions which we discussed with the manager. They had been managing the service for four months and were aware that these areas needed considerable and prompt attention.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staff training records, appraisals and supervisions.
Is the service caring?
We were impressed by the attention to detail in the way people were dressed and groomed. When supporting people we noticed that staff were patient and encouraging. We spent time in the dining area when activities were being undertaken and in an area which contained three adjacent lounges. Staff were always on hand to do activities with people in the dining room. We noted that staff were frequently popping in to the lounges to make sure people were okay. Everybody was spoken with or given individual attention periodically from staff.
Is the service responsive?
A high proportion of people were engaged in activities inside the home on both days of our inspection. People clearly enjoyed the activities they were participating in.
We saw where a complaint had been made that the manager took prompt action to investigate the concerns raised. A written response was made which was timely and appropriate to the situation.
Is the service well-led?
People were not protected against the risks of inappropriate or unsafe care because a quality assurance system was not in place to identify, assess and manage risks to people's health, safety or welfare. Substantial improvements were required.
We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing, identifying and managing risks to people.