18 May 2016
During a routine inspection
There were three people living in the home at the time of the inspection.
This was an announced inspection that took place 18 and 20 May 2016.
Mrs Linda Joyce Fennell 17 Wheatfield Drive had a registered registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like 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.
Systems to monitor the risks to people’s safety and welfare were not effective. The registered manager completed monthly checks which identified health and safety checks had not been completed for three months but no action was taken, for example there was no evidence of Legionella or water temperature checks or portable appliance testing (PAT). Fire evacuation plans and procedure information was in place in event of an emergency evacuation.
The registered manager did not have oversight of staff training needs. However staff received training which they felt was effective and supported them in providing safe care for people which included medication and health care procedures, emergency first aid, epilepsy awareness, and moving and handling. We have made the recommendation that the registered manager has an active role in identifying staff training needs.
The care people received was personalised and they were included in deciding how and when they wanted their needs to be met. Care plans and risk assessments had been completed to ensure the safety and well being of people using the home. We have made a recommendation about risk assessments and care plans. The majority of documentation relating to care was accurate and up to date but in some areas there was conflicting information or information was missing.
There were policies in place for giving people their medicines and evidence that this was being followed. There was regular auditing of medicines and staff competencies were checked to ensure high standards were maintained.
The people using the home have capacity to make decisions about the care they receive and the activities they want to do. Staff were aware of the mental capacity act and used this knowledge appropriately to support people to make their own decisions.
There was a programme of supervision and appraisals for staff. Staffing levels were reviewed regularly with on-going recruitment to fill the current vacancy. Robust recruitment checks were completed before staff began work.
People were encouraged to participate in community activities as well as pursuing their interests at home. People were given choices about their day to day activities and daily routines were flexible around their needs and preferences. People were asked for their consent before care was provided and had their privacy and dignity respected.
People’s nutritional needs were monitored and reviewed. People had a choice of meals provided and staff knew people’s likes and dislikes. People gave positive feedback about the food and said that they were involved in menu planning and shopping to ensure their needs and preferences were met.
Referrals were made appropriately to outside agencies when required. For example GP visits, dentists and Occupational Therapists.
On inspection we found one breach in Regulations. You can see what action we told the provider to take at the back of the full version of the report.