The inspection took place on 11 May 2015 and was unannounced.
Yews Hill/North Rise is a care home providing accommodation and support to people with a learning disability. The home is registered to provide accommodation and personal care for up to 17 people. Accommodation and support is provided in two houses situated on one site, next to each other. There were nine people living at Yews Hill and five people living at North Rise on the day of our inspection. Yews Hill/North Rise is part of the Bridgewood Trust; a charitable organisation which provides residential and day services to people with learning disabilities
There was a registered manager in place who had been registered since June 2014. 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 who lived their told us they felt safe. Relatives we spoke with also told us their relative was safe at Yews Hill/North Rise. Staff had a good understanding about safeguarding adults from abuse and who to contact if they suspected any abuse.
Risks assessments were individual to people’s needs and minimised risk whilst promoting people’s independence.
Systems were in place to store and administer medicines safely.
Staff had received an induction, supervision, appraisal and role specific training. This ensured they had the knowledge skills to support the people who lived there.
We found a lack of capacity assessments in the care plans and a lack of recording of best interest’s decision making. This meant that for those people unable to give consent because they lacked capacity to do so, the registered person had not acted in accordance with the 2005 Act. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We also found that although there were two authorisations for Deprivation of Liberty Safeguards (DoLS), consideration had not been given to other people whose liberty might be deprived. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
People were supported to eat a good balanced diet and people enjoyed the food served at Yews Hill/North Rise.
Staff were caring and supported people in a way that maintained their dignity and privacy. People were supported to be as independent as possible throughout their daily lives.
People and their relatives were involved in care planning and reviews. People’s needs were reviewed as soon as their situation and needs changed.
The culture of the organisation was open and transparent. The registered manager knew the people who lived their well and how to support the people who lived there and the staff who supported them.
The registered provider had an overview of the service and audited and monitored the service to ensure the needs of the people were met and the service provided was to a high standard.
You can see what action we told the provider to take at the back of the full version of the report.