7 February 2018
During a routine inspection
At our last inspection we rated the service as good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
The service had a registered manager. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff understood the procedure they needed to follow if they suspected abuse might be taking place.
Risks to people were identified and plans were put in place to help manage the risk and minimise them occurring. Medicines were managed safely with an effective system in place. Staff competencies, around administering medication, were regularly checked. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety was maintained.
People and relatives told us there were suitable numbers of staff on duty to ensure people’s needs were met.
Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with people.
The registered manager had systems in place for reporting, recording, and monitoring significant events, incidents and accidents. The registered manager told us that lessons were learnt when they reviewed complaints and any accidents and incidents to determine any themes or trends.
People were supported by a regular team of staff who were knowledgeable about people’s likes, dislikes and preferences. A training plan was in place and staff were suitably trained and received all the support they needed to perform their roles.
People were supported with eating and drinking and feedback about the quality of meals was positive. Some people were also supported with meal preparation. Special diets were catered for, and alternative choices were offered to people if they did not like any of the menu choices. Nutritional assessments were carried out and action was taken if people were at risk of malnutrition.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
The premises were clean and tidy. However, some areas were in need of redecoration and replacement flooring.
We observed numerous examples when staff were kind, caring and courteous. Privacy and dignity of people was promoted and maintained by staff. Explanations and reassurance was provided to people throughout the day.
Care plans detailed people’s needs and preferences. Care plans were reviewed on a regular basis to ensure they contained up to date information.
The service had a clear process for handling complaints.
The registered manager was aware of the Accessible Information Standard that was introduced in 2016. The Accessible Information Standard is a law which aims to make sure people with a disability or sensory loss are given information they can understand, and the communication support they need. The registered manager told us they provided and accessed information for people that was understandable to them. They told us their service user’s guide and other information was available in different formats and fonts.
Staff told us they enjoyed working at the service and felt supported by the registered manager and senior staff. Quality assurance processes were in place to monitor and improve the quality of the service. However, we did note a three month gap where the health and safety audit had not been undertaken and the medicine audit did not pick up that the room in which medicines were stored was on occasions too high. We pointed this out to the registered manager who was to take action to address this.