This unannounced inspection took place on 16 and 20 July 2015.
Titchfield Lodge provides support and accommodation for up to four people who live with a learning disability. At the time of our inspection there were four people living in the service.
The service had a registered manager. 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.
Risks associated with people’s care were identified and plans had been developed to reduce any risks. Incidents and accidents were monitored and used to inform the delivery of care. Medicines were stored safely and administered as prescribed. However the records were not always accurate when medicines were being taken out of the home.
Staffing levels were variable with bank and agency staff being used whilst more staff were being recruited. Staff received appropriate training and support to meet people’s needs. Procedures in relation to recruitment of staff were followed. All required information was obtained to ensure recruitment decisions were keeping people safe.
People had developed good relationships with staff who were kind and caring in their approach. People were treated with dignity and respect. Three of the four care plans had been updated to reflect people’s current needs. Staff had tried to include people in the development of the care plans. People were provided with activities but these were not always matched to meet individual needs.
Relatives told us they felt their relatives were well looked after and safe at the home. There were clear procedures in place for safeguarding people at risk and staff were aware of their responsibilities and the procedures to follow in keeping people safe.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager and staff had a good understanding of DoLS and the action they needed to take. Appropriate applications had been made to the local authority.
Staff demonstrated a good understanding of the need for consent and an understanding of the Mental Capacity Act 2005. The registered manager and staff knew how to undertake assessments of capacity and when these may need to be completed.
People were provided with a choice of healthy food and drink ensuring their nutritional needs were met. People’s physical and emotional health was monitored and appropriate referrals to health professionals had been made.
Details of the complaints procedure were displayed around the home in a pictorial format. The home had a complaints procedure and a log of complaints.
The registered manager operated an open door policy and encouraged staff to make suggestions or discuss any issues of concerns. A system of audits was in place and used to identify where improvements could be made. Action plans were developed to ensure identified improvements were taken forward.
We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.