Background to this inspection
Updated
14 August 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 was planned to check 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.
One inspector carried out this inspection which took place on 19 and 22 June 2015, and was unannounced. Before the inspection we reviewed the information we held about the service and read previous inspection reports.
People living in the home were able to tell us what they thought of the service. We observed the care provided to people who use the service to help us understand their experiences. We spoke with the registered manager, two support workers, one relief worker two relatives and two people who use the service.
We reviewed three care plans and their associated risk assessments and records. We analysed two staff recruitment files plus training, supervision and appraisal records. We checked documents including audits, cleaning schedules, surveys, policies and procedures, medication records, generic risk assessments and staff rotas. We also reviewed the complaints and incident and accident records. In addition we reviewed the daily records made by staff and also records such as team and residents’ meeting minutes. We looked around the premises and observed care practices throughout the day.
Updated
14 August 2015
85 Drove Road is a care home service registered to provide personal care for up to 3 people who have learning disability.
The inspection was unannounced and took place on 19 and 22 June 2015.
The service had a registered manager who was responsible for the day to day running of the home. 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.
The home, a semi-detached house with an enclosed rear garden and parking to the front, was situated on a busy main road on the edge of the town with some shops, and a bus stop close by.
Staff were provided with clear lines of responsibility and accountability. The staffing allocation was usually one member of staff on duty at any time. If a member of the permanent staff was unable to work a shift, the service used its own staff to provide cover. If that was not possible agency staff were used only a last resort.
The service did not have policy and procedure in place when deploying agency staff to ensure they had the necessary qualifications, competence, skills and experience. We did not see a full set of records on risk management and the actions staff should take in emergency situations. This was a breach of Regulation 12 (1) (b) (c) (d) of the Health and Social Care Act (2008) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.
The service had systems in place to keep up to date with best practice and to promote improvement and development. The registered manager said there were very few accidents and incidents and they knew about any that had occurred. This was confirmed by the information the registered manager gave us and records that we read.
The service had arrangements in place to ensure people were protected from abuse. Staff showed good understanding and attitude towards safeguarding. Each person who uses the service had their own personalised support plan which promoted their individual choices and preferences.
People went out into the community to enjoy leisure time and also to attend health appointments. People who use the service were involved in doing household tasks such as: shopping, cleaning, gardening and laundry. On inspection, most communal areas of the house were clean and tidy; some areas were very dusty and needed to be cleaned.
People and their family members were complimentary about the service. There had been no complaints since our last inspection in June 2014. One relative said they thought the service was caring and well led. People said they felt safe and happy living at 85 Drove Road. They said were pleased with the service and if they needed to raise an issue they felt confident that they would be listened to and their concern would be acted on.
The Mental Capacity Act 2005 sets out what must be done to make sure that the rights of people who may lack mental capacity to make decisions are protected in relation to consent or refusal of care or treatment. CQC is required by law to monitor the application of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. This includes decisions about depriving people of their liberty so that they get the care and treatment they need where there is no less restrictive way of achieving this. DoLS require providers to submit applications to a ‘Supervisory Body’; the appropriate local authority, for authority to do so.
We found that the service obtained people’s consent before care and treatment were provided. There was understanding of how to carry out assessments of capacity to follow the MCA best interest decision making process in circumstances when people lack the capacity to give consent. People signed to say they agreed to their support plans, risk assessments and other documents such as positive behaviour support plans. However, there were no records of the service’s assessments of people’s capacity to agree to these important decisions. We have made a recommendation about this.
We observed that staff acted in a caring, respectful way. People who use the service were helped to make choices and decisions about how their care was provided and how the service was run.