We carried out this inspection so that we could answer our five questions; 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. The summary is based on our observations during the inspection, discussions we had with four people who lived at the home, two members of staff who supported people, four relatives and the registered manager. We looked at five people's care records.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
We found that systems were in place to support learning from events like accidents, incidents and complaints. People we spoke with told us they were happy with the support staff gave them. One person said, "If I am unhappy I will speak to staff".
Records showed that risk assessments were in place to identify potential risks and the action needed to reduce the risk. For example, where people needed two members of staff to support them this was identified. This meant that people confident that risks would be identified and action taken to reduce any potential risks.
We found that people's medication administration records (MAR) chart showed gaps where staff had not signed to show whether people had in fact been given their medication and if not why not. We also found that the medication process was not being checked regularly. This meant that people were at risk of unsafe administration of medicines.
People told us they felt safe living within the home. We found there was a stair gate on the main stairs used by people living in the home, but this had been risk assessed and there was a lift in the home for people to use who were unable to use the stairs, to ensure people's movement was not restricted.
An application under the Deprivation of Liberty Safeguards had been submitted by the service to the local authority. Training records showed that staff had not received training in the Deprivation of Liberty Safeguards (DoLS) or the Mental Capacity Act (MCA). Staff confirmed this, however staff we spoke with had a good understanding of the DoLS, but they had limited understanding of the MCA. The manager confirmed further training would be provided.
We have asked the provider to tell us what improvements they will make in relation to ensuring the service is safe to meet people's needs.
Is the service effective?
We found that staff were able to explain people support needs. Records showed that people's needs were specific to them and identified in a care plan.
We found that audits were not being carried out consistently. The audits that were being done were not always effective in identifying areas of poor quality. This meant that where people were at potential risk this was not always being identified.
People were able to access health care professionals where needed. Records showed that where health care professionals visited people this was recorded.
We have asked the provider to tell us what improvements they will make in relation to ensuring the service is effective in meeting people's needs.
Is the service caring?
People we spoke with told us that staff were, "Caring" and "Kind". One relative said, "Staff know what they are doing". Staff we spoke with were able to explain people's needs. We observed staff on the day of the inspection communicating with people in a way that promoted their independence.
Staff we spoke with had a good understanding of how to promote people's dignity and privacy. People told us they were able to go to their rooms when they wanted. On the day of our inspection we observed people in their rooms watching television or just lying on their beds. This meant that people independence, dignity and privacy was being promoted.
Where people were assessed as being safe, they were able to go out of the home as often as they wanted to go shopping or just visit friends and relatives.
The provider had adequate systems in place to meet the requirements of the law in ensuring the service was caring.
Is the service responsive?
We found that the provider had a system in place to gather the views of people about the service they received, and take action as required. Some people and relatives we spoke with told us they had not received a survey questionnaire from the provider. We raised this with the provider, who confirmed they would take action to ensure everyone got a questionnaire.
We found that a complaints, compliment and comments process was in place. People told us even though they did not remember being given a copy of the complaints process they knew who to speak to if they had a complaint. One relative said, "I would speak to the manager". This meant that people were able to raise concerns they had about the service.
The provider had adequate systems in place to meet the requirements of the law in ensuring the service was responsive to people's needs.
Is the service well-led?
The service was managed by a registered manager who was supportive throughout the inspection. We found that where the manager needed to act in people's best interest this was being done. This meant that people could be confident in how the service supported them.
We found that the environment in the home was not always risk free. A number of windows were not restricted to ensure people were safe. Wardrobes were not all secured to the wall, however audits were not identifying these concerns. The manager confirmed action would be taken to rectify the shortfalls in their auditing processes.
We have asked the provider to tell us what improvements they will make in relation to ensuring the service is well-led to meet people's needs.