Archived: 20 Westwood Avenue

There was a registered manager in post. 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.

At our last inspection on 20 October 2015, we found breaches of legal requirements in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the assessment of risks to the health and safety of people using the service was not being done appropriately. Complete and contemporaneous records were not maintained in respect of the care and treatment provided to people using the service and quality assurance systems were not effective in to monitor the quality of the service being provided to people who used the service. The service was rated as requires improvement.

Following the inspection the provider sent us an action plan setting out the actions they would take to meet the regulation. During this inspection we found action had been taken to meet the regulations. Records showed the registered manager had taken appropriate action to review and update people’s care plans and risk assessments to accurately reflect people’s needs. Care plans were individualised and person- centred. The service undertook a range of checks to monitor the quality of the service and took action to improve the service. A satisfaction survey had been carried out in April 2016 and the results from the survey were positive.

Relatives informed us that they were satisfied with the care and services provided. Relatives also told us that they were confident that people were safe in the home.

Systems and processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse.

Systems were in place to make sure people received their medicines safely. Arrangements were in place for the recording of medicines received into the home and for their storage, administration and disposal.

We found the premises were clean and tidy. There was a record of essential maintenance carried out at the home. However we noted and discussed with the registered manager the décor of the home as it contained basic furnishing and there was a need for improvement. The registered manager told us she would address these matters. Shortly after the inspection, we were told by the registered manager that a decorator had been called and work had already commenced in the home.

Staff had been carefully recruited and provided with induction and training to enable them to support people effectively. They had the necessary support, supervision and appraisals from management.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Capacity to make specific decisions was recorded in people's care plans.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had made necessary applications for DoLS as it was recognised that there were areas of people’s care in which people’s liberty was being deprived. Records showed that the relevant authorisations had been granted and were in place.

There were suitable arrangements for the provision of food to ensure that people's dietary needs were met.

Staff were informed of changes occurring within the home through daily handovers and staff meetings. Staff told us that they received up to date information and had an opportunity to share good practice and any concerns they had at these meetings.

There was a management structure in place with a team of care workers, registered manager and the provider. Staff spoke positively about working at the home. They told us management were approachable and the service had an open and transparent culture. They said that they did not hesitate about bringing any concerns to the registered manager.

Relatives spoke positively about management in the home and staff. They said that the registered manager was approachable and willing to listen.

At the time of our inspection, the home was providing care for three people.

We used a number of different methods to help us understand the experiences of people who used the service, because people who used the service had complex needs which meant they were only able to communicate using key words, body language, gestures, facial expressions and objects of reference.

We observed the care provided and the interaction between staff and people who used the service. We also spoke with three care staff, the Registered Manager and the Provider. We also spoke with two relatives.

Below is a summary of what we found. The summary describes what people using the service and staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who used the service had support plans and risk assessments which helped to ensure their safety and welfare.

We found the home had safeguarding, whistle blowing and Deprivation of Liberty Safeguards (DoLS) policies and guidance in place. Training records showed staff had received training in safeguarding and DoLS. When speaking to them, they were able to provide examples of what constituted abuse and how they could identify abuse. They were aware of action to take and how to report allegations or incidents of abuse to the relevant authorities.

The Care Quality Commission (CQC) monitors the operation of the DoLS which applies to care homes. While no applications have been submitted, appropriate policies and procedures were in place.

Is the service effective?

We found the home had taken steps to ensure that people were included and involved as much as possible in their care and support. We found they used various methods of communication to engage and involve people who used the service as much as possible such as pictures, facial expressions, sign language, key objects and words.

We looked at three care plans and saw that people's needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out.

We found the home ensured people were cared for, or supported by, suitably qualified, skilled and experienced staff. We saw there were recruitment and selection procedures in place and found that the appropriate checks had been undertaken before staff began work. Staff were trained in areas of relevance to their job roles and demonstrated knowledge of people's individual needs and requirements.

Is the service caring?

We found good feedback had been received about the home. One relative told us 'they are very good indeed. I can't fault the care provided.'

We saw people treated with respect and dignity. Staff communicated well with people and explained what they were doing and why. We observed staff supporting people to make choices and staff asked people what they wanted to do.

Is the service responsive?

We found that regular reviews of each person's support and care needs took place. Care plans were regularly reviewed by the manager and we also found regular reviews were being held between people who used the service and their family where all aspects of their care were discussed and any changes actioned if required.

People's health and medical needs were assessed and we viewed records demonstrating that they were supported and had access to health and medical services when necessary.

Is the service well-led?

There were regular consultations between people who used the service and their relatives which gave them the opportunity to discuss any issues or concerns they had and if they had any complaints they wished to make.

We also found that regular monthly staff meetings took place which ensured staff had the opportunity to communicate their views about the service and to discuss the care and support needs of people who used the service.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. Checks were also conducted on all electrical equipment and maintenance checks and service records were up to date.

There were processes in place to protect people using services from harm. The staff were trained to recognise the signs of abuse and to report concerns in accordance with the home's procedures.

The staff were supported to provide care and treatment to people who use the service and were being trained, supervised and appraised appropriately.

There were systems in place to monitor the quality and safety of the service.

We asked people how they were supported with making choices. One person told us that staff made decisions on their behalf regarding things such as holidays and food choices. Staff confirmed that they would generally make decisions for people regarding food choices and holidays.

We looked at three care plans and found they included sufficient detail for staff to provide adequate care to people. We observed how care was delivered and found it was being carried out in relation to people's assessed needs by sufficient numbers of staff.

We observed the cleanliness of the home and found that there were systems in place to prevent the risk of infection. We also noted the provider was in the process of appointing an infection control lead to ensure continued prevention of infection.

We audited a sample of one person's medication and found that medication records were up to date and also medication was stored and administered correctly.