27 July 2017
During a routine inspection
A manager had been appointed one month before this inspection and was in the process of applying to register with the CQC as the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
Although everyone had an up to date care plan, not all of the relevant information about each person was included in their records. Some people had a mental health condition which was not recorded, and which staff did not understand. There was no information for staff, or risk assessments in place to keep people safe and to make sure their mental health needs were met.
Recruitment practices were not robust and there were some gaps in pre-employment checks, such as full employment history. Staff knew how to recognise the signs of abuse and that they should report any concerns they may have to the manager. There were enough suitable staff on duty to meet people’s needs and keep them safe. People’s medicines were managed safely.
The provider’s quality monitoring system was not always effective. Although the provider and manager were completing quality monitoring audits, they were not always identifying areas for improvement. The manager had been in post for one month at the time of the inspection, and had already noted areas for improvement at the service, and had a robust action plan in place, to make sure those improvements were made.
Although staff were caring most of the time, people’s privacy and dignity was not always protected. People had developed positive relationships with staff and there was a friendly and relaxed atmosphere in the home. People were supported to remain independent and do the things that were important to them, such as going to the shops.
The providers quality monitoring processes were not always effective. The manager had identified this and understood what action they needed to take to make sure this area of practiced improved. The provider asked for feedback about the service from people and staff. Any feedback received was acted on where possible. There was a complaints procedure in place and the registered manager and staff knew what they should do if anyone made a complaint.
The manager had a good understanding of the Mental Capacity Act (2015) and understood that some people living in the home did not have the capacity to make some decisions about their care. Some of the staff needed further support to make sure they understood their responsibilities under the Act. All of the relevant DoLs had been applied for, and where these had been authorised, the conditions of the DoLs were properly recorded and acted on.
People were well supported to eat and drink enough. Food was homemade and nutritious and people were supported with healthy eating and to maintain a healthy weight. Everyone was supported to maintain good health and appropriate referrals were made to health care professionals when required.