11 June 2019
During a routine inspection
People’s experience of using this service:
Systems to monitor and check the service were in place but some of these needed to be more thorough to ensure the service consistently met the required standards.
People’s care needs were assessed, and they received good quality person centred care from staff who knew them well. The registered manager was in the process of updating care plans. However, we found some care plans required more detail to ensure they reflected people's needs and involvement. We found there were limited opportunities for meaningful individualised activities. We have made a recommendation about improving the range of opportunities available to people.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests: the policies and systems supported this practise. Improvements were needed to documentation to fully evidence compliance with the Mental Capacity Act (MCA). We have made a recommendation about updating documentation to reflect people’s involvement.
People and their relatives praised the standard of the care at home. People said they felt safe and they were supported by a consistent and experienced team. People said staff were kind and caring. One person said, “It’s the best place you can stay. I’ll tell anyone. The ladies are all lovely here.”
Staff were knowledgeable and received training, supervision and support to carry out their roles effectively. Staff were committed to providing person centred care and promoting people’s independence.
Medicines were safely managed. There were very close links with health professionals and other agencies to ensure people’s health needs were met and changes responded to promptly.
The registered manager provided people with leadership and promoted an open and inclusive team culture. There was a warm and welcoming atmosphere throughout the home.
More information is in the full report.
Rating at last inspection and update:
The last rating for this service was requires improvement (published 19 June 2018) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. Please see the effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.
Why we inspected:
This was a planned inspection based on the previous rating.
Enforcement:
We have identified breaches in relation to safe governance and audit processes.
Follow up:
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
For more details, please see the full report, which is on the CQC website, www.cqc.org.uk