13 February 2019
During a routine inspection
People’s experience of using this service: The service has on two previous occasions been rated as requires improvement. Some improvements were made in ensuring people who were not able to make a choice were assessed and treated in their best interest. Medicine management had also improved.
• People were supported by a consistent staff team who were kind and caring. Staff had good relationships with people and knew them well. People were encouraged and supported to maintain their independence.
• People received their medicines safely and as prescribed except for prescribed creams which required more direction for staff to follow. Medicine management practices were safe. However, medicine policies did not effectively cover the administration of concealed covert medicines and PRN protocols were not always in place. Handwritten medicine administration records had not been signed by two staff.
• Care plans and risk assessments did not always contain accurate and complete information, particularly in relations to people’s specific health conditions. There was a lack of guidance in how risks should be managed safely.
• Recruitment procedures ensured all relevant checks were completed before new staff began work.
• Audits had not always identified shortfalls we identified.
• An activities time-table was provided to all. An activities coordinator was in post and people were engaged if they wished.
• People spoke positively about the food provided at the service.
• Relationships were supported both within and outside the service. Visitors were welcomed. The service was clean and tidy.
• Feedback was sought from people through direct contact with people and their relatives and staff through meetings and questionnaires. Relatives said the service communicated well with them. People felt comfortable in raising any concerns or issues.
For more details, please see the full report which is on CQC website at www.cqc.org.uk
Rating at last inspection: Requires Improvement (19 December 2017 and 9 January 2018). This service has been rated as requires improvement at the previous two inspections (November 2016 and March 2018).
Why we inspected: This was a planned inspection based on the previous rating.
Enforcement: We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we made one recommendation into guidance for specific health conditions. Please see the ‘action we have told the provider to take’ section towards the end of the report
Follow up: We will review the report on actions the provider intends to take following the inspection. We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.