This focused inspection took place on the 10 and 13 November 2017 and was unannounced. At our last unannounced comprehensive inspection of this service on 8 November 2016 we found one breach of legal requirements in relation to Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) 2014. People were not adequately protected against the risks associated with the premises. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 10 and 13 November 2017 to check that they had followed their plan and to confirm that they now met legal requirements. We found that the provider had followed their plan and this legal requirement had been met. The provider had taken action to ensure the premises were safely managed.
At the time of our last inspection this breach was included under the key question of effective. At this inspection we have also inspected the key question of safe to check how risks to people are managed. All focussed inspections consider the question of well-led.
This report only covers our findings in relation to the three key questions of safe, effective and well-led. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The You Trust - 34-36 Shaftesbury Road on our website at www.cqc.org.uk.
The You Trust – 34-36 Shaftesbury Avenue is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. 34-36 Shaftesbury Avenue accommodates up to 13 people living with mental health needs. The service does not provide nursing care. At the time of the inspection there were eight people living there.
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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Risks associated with people’s medicines had not always been assessed with plans in place to mitigate risks. Records of medicine administration were not always fully completed. Policies and procedures in relation to the safe management of people’s medicines had not always been followed. This meant people were at risk from the unsafe management of medicines.
Quality assurance systems were not always effectively used to identify and make improvements to the quality and safety of the service people received. Audits had not always been completed and actions identified were not always acted on to ensure concerns were addressed.
Incidents were investigated and had been used to make improvements. Providers are required to have procedures in place to ensure the duty of candour is followed. The registered manager was not aware of this requirement and they told us the provider did not have a policy in place about this. This is important to promote an open and transparent culture when things go wrong.
The provider was working to improve key relationships with external health and social care professionals to promote effective joined up care for people.
Staff were aware of their responsibilities to safeguard people and protect them from abuse and the registered manager acted on concerns. People were supported to manage risks to their mental health and well-being by staff who knew and understood their needs.
Procedures were in place and followed by staff to prevent the risk of harm to people from emergencies such as fire. Checks were completed to monitor the safety of the premises and equipment for people. Concerns identified were acted on promptly and monitored for completion by the registered manager.
People told us there were sufficient staff to meet their needs. Staff were recruited safely and the provider used their own temporary staff to cover absences and provide a continuity of care for people.
Learning from incidents had been used to make improvements to the care people received.
People’s needs were assessed and recovery plans were in place to support people with their identified goals. People told us they were supported to achieve their goals such as moving on into independent living.
Staff completed training in equality and diversity. Staff showed an awareness of how to support people with their diverse needs including how people may experience discrimination and a commitment to address this.
Staff completed an induction and had access to a range of training to ensure they remained competent to meet the needs of the people they supported. Staff had received supervisions; however an appraisal system was not in place to enable staff to evaluate their performance with their line manager. The registered manager told us this was in development at the time of our inspection.
People were supported to attend healthcare and community services to support their needs.
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.
Staff were confident the registered manager would listen and act on concerns. Staff spoke positively about the leadership in the home and regular meetings were held to share information and plan effective care and support for people. The provider had a set of values which were used to promote a positive culture in the home.
People told us they were kept informed by staff and involved in the running of the home. People said they were able to make decisions and these were respected by staff.
We found two breaches of the Regulations. You can see what action we told the provider to take at the back of the full version of the report.