St Mungo's Broadway - 53 Chichester Road

Updated 29 March 2018

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, and to provide a rating for the service under the Care Act 2014.

We undertook an unannounced inspection on 9 February 2018. The inspection was carried out by two inspectors and one inspection manager.

Before we visited the home we checked the information that we held about the service and the service provider including notifications about significant incidents affecting the safety and wellbeing of people who used the service.

The provider also completed a Provider Information Return (PIR). The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR also provides data about the organisation and service.

We reviewed eight people’s care records, seven staff files, training records and records relating to the management of the service such as audits, policies and procedures. We spoke with eleven people who used the service and one relative. We also spoke with the regional head manager, registered manager, deputy manager and six care staff including project workers and care assistants.

Updated 29 March 2018

This inspection took place on 9 February 2018 and was unannounced. St Mungo's Broadway - 53 Chichester Road is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission [CQC] regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide care and support for 26 people who have used alcohol in the past or currently using it. During the day of our inspection there were 24 people living at the home, four of which receive personal care. Although the service supports men with life-long alcohol addiction, the service is rated because it is registered to provide residential accommodation with personal care.

Our previous inspection on 21 February 2017 found two breaches of regulation and made two recommendations. We rated the service as “requires improvement”. During this inspection on 9 February 2018 we found that the service had taken necessary action and made improvements. The service is now rated as “Good”.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 used the service told us that they were satisfied with the care provided and said that they felt safe in the home and around care staff. People told us they were treated with dignity and respect in the service.

Systems and processes were in place to help protect people from the risk of harm. Staff had received training in safeguarding adults. Risk assessments were in place which clearly detailed potential risks to people and how to protect people from potential harm. We noted that risk assessments had been prepared with the involvement of people and were reviewed regularly.

Systems were in place to ensure people received their medicines safely. Arrangements were in place for the recording of medicines received into the home and for their storage, administration and disposal.

We looked at the recruitment process to see if the required checks had been carried out before staff started working at the home. We looked at the recruitment records and found background checks for safer recruitment had been carried out.

People who lived in the service and care staff told us there were sufficient numbers of staff to safely meet people’s needs. Management explained that there was consistency in respect of staff with a number of staffing having worked for the service for many years. They also advised that there was flexibility in respect of staffing so that they could deploy staff where required.

People in the service were able to smoke in their bedrooms but were not allowed to smoke in communal areas. We discussed this arrangement with management and they explained they ensured people were supported to smoke in a safe manner. Fire and emergency procedures were in place and there was evidence to confirm that necessary checks were carried out regularly.

On the day of the inspection, the home was clean and there were no unpleasant odours. However, we noted that there were several areas of the environment that were 'tired' looking. The bathrooms on the first and second floor were in need of renovation. We also noted that some carpets in communal areas were old and in need of replacing. We have made a recommendation in respect of this.

Our previous inspection found that there were gaps in staff training and staff had not received yearly appraisals. We found a breach of regulation in respect of this. Our inspection in February 2018 found that the service had made improvements in this area. There was documented evidence to confirm that staff had received training and an appraisal.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Care support plans contained information about people's mental state and communication.

Arrangements were in place to ensure that the nutritional needs of people were met. An external catering company prepared meals in the home. People had a choice of a daily cooked breakfast, cooked hot lunch and a light dinner.

People were supported to maintain good health and have access to healthcare services and received on-going healthcare support and we saw documented evidence of this. Care records included information about appointments with health and social care professionals.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS ensure that an individual being deprived of their liberty is monitored and the reasons why they are being restricted is regularly reviewed to make sure it is still in the person’s best interests. The registered manager informed us that none of the people who used the service were subject to any orders depriving them of their liberty. We noted that people could freely go out when they wanted to.

Our previous inspection found there was limited information in care support plans about their care needs and preferences. This inspection in February 2018 found that the service had taken action and updated care support plans so that they included a detailed care support plan which provided information about people’s communication, mobility, special interests, mental health, health needs and cultural/religious beliefs.

People told us that there were enough activities in the home. During the morning of the inspection we did not observe a formal activity taking place. However, in the afternoon we observed people interacting with one another in the lounge and playing pool.

Our inspection in February 2017 found that there were some areas where the quality of the service was not effectively checked and we found a breach of regulation in respect of this. During this inspection in February 2018, we found that the service had taken appropriate action and implemented effective checks and audits.

Care staff had a positive attitude and were of the opinion that the home was well managed and management were supportive and approachable. Care staff told us that the service had improved since the last inspection.