Archived: 94 Windmill Street

Updated 2 November 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 the 29 September and 1 October 2015 and was unannounced. The inspection team consisted of an inspector.

We would normally ask the provider to complete a Provider Information Return (PIR). This is a form that asks for some key information about the service, what the service does well and improvements they plan to make. However, this inspection was planned in response to concerns we had received and there was not time to expect the provider to complete this information and return it to us. We gathered this key information during the inspection process.

Before the inspection, we examined previous inspection reports and notifications sent to us by the registered manager about incidents and events that had occurred at the service. A notification is information about important events which the provider is required to tell us about by law.

We spoke with the manager, assistant manager, and three members of staff. We spoke with two people and one relatives. We received information from two relatives and two health and social care professionals via email after the inspection visit. We looked at personal care records for three people, medicine records; activity records and two staff recruitment records. We observed staff interactions with people whilst carrying out their duties.

This was the first inspection of the service, since registering with the Commission in March 2014.

Updated 2 November 2015

We carried out this inspection on the 29 September and 1 October 2015, and it was unannounced. We inspected this service due to concerns we had received. It was alleged that there was poor maintenance of the windows, no hand washing facilities, rooms were not clean and the quality of the food was poor.

94 Windmill Street is a privately owned care home. The service provided personal care, accommodation and support for up to 12 adults. There were seven people living at the service at the time of the inspection, together with a person who received respite care at the weekend. People had a variety of complex needs including mental and physical health needs and behaviours that may challenge.

Due to people’s varied needs, some of the people living in the service had a limited ability to verbally communicate with us or engage directly in the inspection process. People demonstrated that they were happy in their home by showing warmth to the manager and staff who were supporting them. Staff were attentive and interacted with people that used the service in a warm and friendly manner. Staff were available throughout the day, and responded quickly to people’s requests for help.

The service did not have a registered manager. 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. However, a manager was appointed in March 2015 and is currently applying for registration.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

Staff had been trained in how to protect people from abuse, and discussions with them confirmed that they knew the action to take in the event of any suspicion of abuse. Staff understood the whistle blowing policy and how to use it. They were confident they could raise any concerns with the manager or outside agencies if this was needed.

Where people lacked the mental capacity to make decisions the home was guided by the principles of the Mental Capacity Act (MCA) 2005 to ensure any decisions were made in the person’s best interests. Staff were trained in the Mental Capacity Act 2005 (MCA) and showed they understood and promoted people’s rights through asking for people’s consent before they delivered care.

Staff were knowledgeable about the needs and requirements of people using the service. Staff involved people in planning their own care in formats that they were able to understand, for example pictorial formats. Staff supported them in making arrangements to meet their health needs.

Medicines were managed, stored, disposed off and administered safely. People received their medicines when they needed them and as prescribed.

People were provided with food and fluids that met their needs and preferences. Menus offered variety and choice.

There were risk assessments in place for the environment, and for each individual person who received care. Assessments identified people’s specific needs, and showed how risks could be minimised. People or their representative were involved in making decisions about their care and treatment.

There were systems in place to review accidents and incidents and make any relevant improvements as a result.

The manager investigated and responded to people’s complaints and people said they felt able to raise any concerns with staff.

Staff respected people and we saw several instances of a kindly touch or a joke and conversation as drinks, or the lunch was served and at other times during the day.

People were given individual support to take part in their preferred hobbies and interests.

Staff were recruited using procedures designed to protect people from the employment of unsuitable staff.

Staff were trained to meet people’s needs and were supported through regular supervision and an annual appraisal so they were supported to carry out their roles.

There were systems in place to obtain people’s views about the quality of the service and the care they received. People were listened to and their views were taken into account in the way the service was run.