7 May 2014
During a routine inspection
During our inspection on 7 May 2014 we set out to answer five questions. These were whether the service is 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. The summary is based on our observations during the inspection, discussions with people who used the service and the staff that supported them. We also spent time looking at records. If you wish to see the evidence supporting our summary please read the full report.
Is the service safe?
We found that care was planned and delivered in a way that was intended to ensure people's safety and welfare.
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Where applications had needed to be submitted, proper policies and procedures were followed. Relevant staff had been trained to understand when an application should be made, and how to submit one.
However, we found that there were shortfalls in relation to safeguarding people from the risk of abuse and the service is required to make improvements. For example, to ensure that they react promptly to any concerns raised.
Is the service effective?
People told us that they were happy with the care that they received and that their needs had been met. Care plans were written in a way which reflected people's choice and preferences.
We saw that the risk assessments and support plans had been reviewed monthly and where needed, updated to reflect the person's current needs. We looked at the care notes for people whose plans we had viewed and saw that care was delivered in accordance with the plans.
Is the service caring?
People told us that care and support was delivered in a way in which they preferred. We asked people whether the staff caring. One person described staff to us as, 'Lovely.' They went on to say, 'Everyone is nice.' They also told us, 'I get everything I need.' Another person we spoke with said of the care they received, 'It's grand.'
We observed staff interaction with people who used the service and staff appeared to know people well. Most of the staff we observed were attentive and kind. Staff we spoke with had a good understanding of the people that they were supporting.
Is the service responsive?
We found that the service responded to issues identified through their own monitoring systems. This enabled them to monitor trends in areas such as incidents, falls and complaints. Any trends identified were responded to and actions for minimising any reoccurrence were put in place.
We saw that where concerns had been highlighted during the monitoring process that the service had responded to these issues in an appropriate timescale to resolve them.
Is the service well led?
We noted that the manager was new to the service and was currently applying for their registration. They were being supported by the regional manager and a manager from within the organisation as a mentor. The staff, people who used the service and relatives we spoke with told us that they felt the manager listened to people, gave guidance and set a good example.
People told us that they knew how to make a complaint and we noted that the management had responded appropriately to complaints made by people who used the service.
The service carried out regular audits on care plans, medication and environment. We saw that where an audit identified an issue, an action plan was developed and there was a record of actions being completed.
Surveys were sent out annually to people who used the service, their relatives and staff. The manager had taken steps to address any issues identified. This included introducing holding a staff meeting to discuss the outcome of the surveys.