17 February 2016
During a routine inspection
9 Victoria Square provides support and accommodation for up to six people who live with a learning disability. On the day of our inspection there were five people living at the home.
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. The registered manager was unavailable on the day of the inspection. The registered manager for the service is also the registered manager for another of the provider’s services which is five minutes’ walk away. The manager referred to throughout the report is a registered manager from another service belonging to the provider. They are managing the service at present.
CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. The manager reported that applications had been submitted to the local authority in relation to the people who lived at 9 Victoria Square where necessary, and these were pending. There were times when decisions had been made regarding people’s capacity without recording this.
Risks associated with people’s care had been identified, but these had not always been updated as people’s needs and risks changed. Incidents and accidents were being logged.
Staffing levels were variable with between one and three staff on each shift. The current manager had been arranging training, as staff had not renewed their training before it expired and new staff had not always accessed the training that was needed to meet people’s needs; for example epilepsy awareness. Procedures in relation to recruitment of staff were followed ensuring people were kept safe.
People had developed good relationships with staff who were kind and caring in their approach. People were treated with dignity and respect.
Paperwork associated with people’s care was not always up to date. It was difficult to see where staff had included people in the development of the care plans. People were provided with activities but these were not always matched to meet individual preferences and consisted of routine such as going to the bank.
There were clear procedures in place for safeguarding people at risk and staff were aware of their responsibilities and the procedures to follow in keeping people safe.
People were provided with a choice of healthy food and drink ensuring their nutritional needs were met. People’s physical and emotional health was monitored and appropriate referrals to health professionals had been made.
A system of audit was in place however until recently it was not clear from records how these had been used to identify where improvements could be made. The manager was working with staff on this.
The provider Sanctuary Supported Living carried out a full audit of the home in January 2016. The provider had recognised in their audit that there had been a failure in systems and processes available to assess and monitor the quality of the service which would mitigate the risks relating to the health, safety and welfare of people. Their action plan and the management now in place sought to remedy this and we saw from the action plan and looking at records that a lot of work had been completed already. There was more to be done followed by the embedding of good practice and systems.
We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.