Archived: Kavita Chumroo - 44 Kimberley Road

We found the following examples of good practice.

Staff supported people to receive visitors safely. Before they could enter the service, relatives and healthcare professionals undertook temperature and COVID 19 checks. This reduced the risk of the virus being brought into the service. People and staff were tested regularly for COVID 19 and all had received both doses of their anti-virus vaccines.

To protect people from the risk and spread of infection staff wore personal protection equipment (PPE). Items of PPE used by staff included mask and gloves. Staff at the service confirmed that there were sufficient stocks of PPE available to deliver care and support in line with published guidance. An enhanced cleaning programme had been introduced at the service to ensure surface areas remained clean.

People were supported to protect themselves from COVID 19. Staff provided people with guidance around hand hygiene when at home and with gloves and masks when in the community.

The registered manager and staff continued to work collaboratively with other organisations to meet people’s needs. For example, the service continued to liaise with healthcare professionals such as community psychiatric nurses. This meant people’s changing needs continued to be met in a safe way.

At our last inspection on 24 July 2015 the service was rated as 'Good’. At this inspection we found the service remained Good.

The service had a registered manager in post at the time of the inspection. 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.

People living in the service continued to feel safe and the provider had procedures in place to keep people safe. These included training staff to detect and report abuse, assessing and mitigating known risks to people and ensuring there were enough suitable staff to deliver care. People’s medicines were administered and stored safely and medicines records were maintained appropriately. The care home was a safe environment.

Staff delivering care and support to people were trained and supervised. They sought people’s consent before providing care and people were treated in accordance with the Mental Capacity Act 2005. Healthcare services were accessed whenever people required them and people received the support they required to eat and drink healthily.

People continued to live in a caring environment. Staff were friendly and kind towards people. Visitors were welcomed into the home and people were encouraged to develop and maintain relationships with family and friends. People’s independence was encouraged through skills teaching and their dignity and privacy were respected.

The service remained responsive to people’s needs. People’s needs continued to be assessed and reviewed. Care plans were up to date and guided staff as to how people’s needs should be met. People were supported to engage in a range of activities and received the support they required to remain actively involved in the life of their local church. The provider sought and received the views of people, relatives and healthcare professionals and acted in response to the information shared. People understood the provider’s complaints process but no complaints had been made.

Good governance continued to be evident at the service. The registered manager undertook a range of audits to confirm the quality of service being delivered to people. There was an open culture within the service and staff were encouraged to share their views. The provider worked collaboratively with other agencies to meet people’s needs and to improve the quality of the service.

Below is a summary of what we found.

The summary is based on our observations during the inspection, speaking with one person using the service, speaking with two members of staff, and from looking at care records. We requested information from the provider which we reviewed. Following the inspection visit we spoke with two community based care coordinators from the NHS mental health trust involved with people currently using the service.

Is the service safe?

People were protected from the risk of abuse. Recruitment procedures were robust and only suitably vetted staff were employed. The service had effective safeguarding procedures, and staff were knowledgeable in recognising signs of abuse and aware of the reporting procedures to the local safeguarding team. Risks posed by individuals to themselves and to others using the service were identified and managed appropriately.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.

Is the service effective ?

Individual care plans were in place outlining the care and support needs of people who used the service. The plans identified the physical health, mental health, social, and cultural needs of people who used the service. People were supported to maintain good health, had access to healthcare services and receive ongoing healthcare support. The service acted promptly in consulting with other professionals where needed. The service worked in cooperation with other agencies and services to make sure people received effective care and support.

Staff received the training required to ensure they had the skills and knowledge to support people who used the service.

A care co-ordinator from the local NHS mental health trust told us "staff were hands on", and people received the care and support they required and progressed as a result. They said staff were proactive and kept them up to date on a person's progress, they worked closely with them so that they were made aware if there any setbacks or concerns.

Is the service caring ?

We found that caring and positive relationships were developed by staff with people using the service. People told us they were listened to and felt that they mattered. People found they enjoyed life in this home, and told of using a variety of mental health services where they had mixed experiences. One person told us, 'this is good, I am well cared for, in fact the best place I have been, people looking after me are compassionate and patient, they help introduce activities and things that are motivating for me."

Is the service responsive to people's needs?

People received personalised care that was responsive to their needs and preferences. People said that they received the individual care and support they needed. A community professional told us, 'staff work with the person using the service to identify and choose the best way in which their needs can be met, this helps support the person to achieve their goals.'

Staff knew people as individuals and could give us examples of how they had supported and encouraged people to develop confidence and self-esteem. People had access to activities that were important and relevant to them. People were satisfied with opportunities to get involved at the service.

Is the service well-led?

The service had a permanent manager in place who oversaw the running of two other homes. The service promoted a positive culture that was person-centred, inclusive and empowering. People spoke positively about the approach of staff and the manager. Staff were supported to discuss and question practice and there were safe and effective systems to raise concerns and whistle-blow.

There were processes in place to monitor the quality of the service. Any areas for improvement were identified and addressed

The service ensured that there were sufficient numbers of suitable staff to meet people's needs. The management team had systems in place to keep this under review and assign further staff where needed.

We did not speak to people using the service at this inspection but spoke with them in May 2013 when we last visited the service. We gathered evidence of people's experiences by speaking with staff and reviewing other records related to the running of the service.

The registered manager showed us the changes that had been made since our inspection in November 2010. We saw the service had reviewed and updated its systems to gain and review consent from people who use the service and to act on them, develop good working relationships with health and social care professionals to ensure that people who use the service are appropriately supported and protected and to appropriately record and store records so they can be accessed when required.

We saw the service had adopted various ways to ensure that people who use the service were supported fully and people's needs were being met. Monthly residents meetings were held and provided opportunities for people who use the service to meet collectively and discuss any issues or changes they wished to make to the service.

We asked people using the service what improvements had been made to their home since our last inspection. People told us the garden had been cleared and it was now a space they liked to use. One person told us 'we have created a vegetable patch at the bottom of the garden. We are growing lots of different vegetables'.

People's views and experiences were taken into account in the way the service was provided and delivered and there were effective systems in place to regularly assess and monitor the quality of service that people receive. We saw people using the service had been fully involved in developing their care plans and had been able to state their preferences and choices about how they lived their lives.

We found that the care plans did not reflect all areas of need and the action staff should take to meet these. For example, they did not reflect how people's cultural and religious needs should be met or the support people needed to complete daily living tasks as part of their recovery and rehabilitation. We found that there was very little information recorded about people's individual preferences. Risk assessments had been completed for some identified risks to people's safety and welfare but not for all.

Parts of the home were not adequately maintained. For example, the garden was not well maintained and there was a broken light fixture on the landing. We also found that the portable appliance testing certificate for the home was out of date.

There were sufficient numbers of staff on duty to meet people's needs but the duty rosters seen did not accurately reflect the staff who were working on particular shifts.

The home had a complaints system in place and details about how to make a complaint were displayed in a communal area that everyone had access to.