We visited Briarscroft and carried out an inspection there. We looked at information to help us gather evidence about the quality of the provider's care and support to people that lived there. On the day of our inspection, the registered manager told us that 60 people lived there. We spoke with the registered manager and care staff on duty. We also spoke with the chef and activities person. We spoke with 10 people that lived there and observed other people that lived there and later spoke with 13 relatives. Our conversations with people helped us to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? and, Is the service well led?
Below is a summary of what we found. The summary is based on our findings during the inspection, speaking with people and their relatives about the service, staff members supporting people that lived there and from looking at records.
The detailed evidence supporting our summary can be read in our full report.
Is the service safe?
All of the people spoken with told us that they felt safe living at the home. One person told us, 'I feel safe here.' All of the relatives spoken with confirmed to us that they felt that their family member was safe there. One relative told us, 'The staff are very good. I think they care well for my family member and keep them safe.'
There was a system in place to record accidents and incidents. Staff spoken with showed that they were aware of the reporting system. We saw that 45 accidents and incidents were recorded for March 2014. We saw that the provider had taken appropriate action and that a high proportion of these related to one person whose needs had been reassessed.
There was a system in place to handle concerns and complaints. The registered manager told us that three complaints had been received by the provider from people that lived there or their relatives since our last inspection in November 2013.
The registered manager told us that several new staff had commenced employment at the home since our last inspection. We saw that staff files looked at contained the required pre-employment checks. This meant that the provider ensured that people employed were suitable to work with vulnerable adults.
As part of our inspection we asked the registered manager about how they implemented the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DOLS). They told us that they would make the appropriate referrals for people if needed. We saw that a recent audit had identified that some updates were needed in a few people's care plans that included the provider's general mental capacity assessment which meant updates were planned for and the registered manager was aware of their responsibilities under the Mental Capacity Act.
We looked to see if the service was safe, clean and hygienic. We saw that all communal areas were visibly clean, and were free from any strong odours. Of the 13 relatives spoken with, two told us that they felt their family member's bedroom was not always visibly clean. All of the other relatives spoken with told us that they felt that the level of cleanliness throughout the home was good.
We also looked at the main kitchen and saw that this was visibly clean. This meant that there was a reduced risk of cross infection.
We looked at the management of medicines and found that actions needed to improve systems were not always implemented or sustained.
Is the service effective?
We saw that the provider's information guide was displayed in the home and gave people information about the service.
The registered manager told us and gave us an example of when an advocacy would be used for people.
We saw that information was displayed about activities that were planned for. We also saw that a newsletter was available that provided details of what was planned. Some people told us that they enjoyed the activities that took place. One person told us, 'I enjoy watching a film.' This meant that activities were planned for and took place.
Is the service caring?
People we spoke with told us that they thought staff were kind and caring. One person told us, "The staff are good.' One relative told us, 'I am happy with my family member's care at the home and the activities that they provide there.' Another relative told us, 'My family member is always well-presented. I am happy with the care they receive.'
Is the service responsive?
Most relatives spoken with told us they had no concerns or complaints. One relative told us, 'I find the manager approachable. If I had any concerns I would speak with them.'
Is the service well led?
We saw documented evidence that showed that the provider worked with other health care professionals and made referrals for advice and guidance when needed.
People that lived there and their relatives were asked for feedback about the service. Resident and relative meetings took place so that feedback could be gathered. However, a few relatives told us that they did not know if actions were implemented.
The service had a quality assurance system. Records looked at showed that audits took place. However, we looked at a recent medication audit and saw that actions needed to improve were identified but were not effective. We have set a compliance action.