Archived: Fen Road

Updated 21 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 4 and 5 May 2016 and was unannounced. The inspection was carried out by one inspector.

Before we carried out this inspection we reviewed the information we held about this service including notifications. A notification is information about events that the registered persons are required, by law, to tell us about. We also contacted healthcare professionals and people’s relatives for feedback about the service being provided.

Not everyone who used the service was able to tell us about their care this was because they had complex communication skills. We observed how the staff supported people in the communal areas. Observations are a way of helping us understand the experience of people living in the home.

During our inspection we spoke with the manager, the clinical lead, two care assistants and one nurse. We looked at the care records for two people. We also looked at records that related to health and safety and quality monitoring. We looked at medication administration records.

Updated 21 June 2016

Fen Road is registered to provide accommodation and nursing care for up to 10 people. There were eight people with a learning disability using the service at the time of the inspection. People were accommodated in two bungalows in single occupancy rooms.

This unannounced inspection took place on 4 and 5 May 2016.

At the last comprehensive inspection on 30 October and 2 November 2015 this provider was placed into special measures by CQC. A breach of ten legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• providing care that was appropriate, safe and met people’s needs,

• treating people with dignity and respect,

• ensuring that the requirements of the Mental Capacity Act 2005 were met,

• safe management of people’s medicines,

• maintaining the premises,

• assessment and monitoring of the service,

• ensuring staff were competent to meet peoples assessed needs,

• having a robust recruitment procedure in place that was being followed.

During this inspection we found that there was sufficient improvement to take the provider out of special measures. We found that the provider had followed their plan which told us that the action required to make the required improvement would be completed by 10 April 2016.

There was a registered manager at the time of the inspection. However they were no longer working in the home. A new manager had recently been appointed. 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 Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was acting in accordance with the requirements of the MCA including the DoLS. The provider was able to demonstrate how they supported people to make decisions about their care. Where people were unable to do so, there were records showing that decisions were being taken in their best interests. DoLS applications had been submitted to the appropriate authority. This meant that people did not have restrictions placed on them without the correct procedures being followed.

Staff were aware of the procedures to follow if they were concerned that anyone had suffered any harm. Risk assessments had been completed and staff were aware of how to reduce risks to people’s health and safety. Procedures were being followed so that any accidents or incidents were dealt with appropriately and action was being taken to prevent a reoccurrence.

Sufficient numbers of staff were in place to ensure that people were safe and received the care that they required. There were a number of staff vacancies but agency staff were being used so that there were enough staff on duty. Staff had completed training to ensure that they were able to meet people’s needs. Staff were supported and were receiving regular supervisions. There was a robust recruitment procedure to ensure that only the right staff were employed to work with people using the service.

Since our last inspection improvements had been made to ensure that medicines were stored, recorded and administered safely. Regular audits were being undertaken to check that this was the case.

The buildings and facilities had been maintained to an appropriate standard and equipment and furniture had replaced where needed.

People were receiving a balanced diet and people who had special dietary needs were receiving an appropriate diet. People received the support that they needed at mealtimes.

People had access to healthcare professionals when needed. When this had not been requested in a timely manner a full investigation had been conducted and action had been taken to prevent this from happening again.

People received personal care in private and their dignity was promoted. People were supported by staff in a kind and caring manner.

Care plan’s had improved and they contained all of the information that staff required to meet people’s needs in the way that they preferred. People and their relatives had been involved in updating and reviewing the information in the care plans.

The manager had carried out regular audits to assess what improvements needed to be made. The provider had carried out visits to the home to ensure that the action plans for improvements were being met.