Archived: 21a Victoria Road

At our last inspection of the service on 10 May 2016, we rated the service as "Requires Improvement". This was because we found deficiencies in the way medicines and risk were managed. This meant the provider was in breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the inspection the provider sent us an action plan setting out the actions they would take to meet the regulation. During this inspection we found the provider had appropriate systems in place to manage people's medicines and risk in a safe way.

There was 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.

People were protected from risks to their health and wellbeing. The service had updated their fire policy following the last inspection which was reviewed monthly. Up to date plans were in place to manage risks, without unduly restricting people's independence. There were sufficient numbers of staff to support people and safe recruitment practices were followed. The provider managed medicines safely.

Procedures were in place which safeguarded people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Capacity to make specific decisions was recorded in people's care plans. People had maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The provider submitted relevant deprivation of liberty applications to the local authority.

Appropriate training, supervision and appraisals were in place to enable staff to provide appropriate care to people. There was an induction, training and development programme, which supported staff to gain relevant knowledge and skills.

People received regular and on-going health checks and support to attend appointments. People were supported to eat and drink enough to meet their needs and to make informed choices about what they ate.

We saw staff interacting well with people and treated people with dignity and respect. People’s individual communication needs were recorded in their care files. Care plans contained information about people's wishes and preferences and documented people's skills in relation to tasks and what support they required from staff, in order that their independence was maintained. People were involved in regular reviews of their care and support.

People were encouraged to pursue their interests and to maintain links within the community.

There was a clear management structure in the service which provided clear lines of responsibility and accountability. The provider checked the quality and safety of the service.

There were four people living in the service when we inspected on 10 May 2016. This was an unannounced inspection.

There was a registered manager in post. 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.

We found a breach 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 the report.

There were not always procedures and processes in place to ensure the safety of the people who used the service. The fire risk assessment did not highlight all of the risks associated in the event of a fire and the action to be taken to reduce these risks. The hot water temperatures had been above the recommended temperature and no action had been taken to address this.

There were appropriate arrangements in place to ensure people’s medicines were obtained and stored safely. However, guidance for staff on how and when to administer ‘as and when required’ medicines was not always in place. The recording of when medicines were taken was not always clear.

There had been a lack of oversight of the service by the provider to ensure the service delivered was safe. Although the provider had quality assurance systems in place, these had not been effective in allowing the management team to identify concerns and take the required action.

Procedures were in place which safeguarded people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

Staff were trained and supported to meet the needs of the people who used the service. There were sufficient numbers of staff to meet people’s needs. Recruitment processes checked the suitability of staff to work in the service.

People were supported in accordance with the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). People’s nutritional needs were met. People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

People were treated with kindness by the staff. Staff knew people well and had good relationships with people who used the service. Staff respected people’s privacy and dignity and interacted with people in a caring, respectful and professional manner.

People were provided with personalised care and support which was planned to meet their individual needs. People were encouraged to pursue their interests and to maintain links within the community. People were involved in making decisions about their care and support.

A complaints procedure was in place. People’s comments, concerns and complaints were listened to and addressed in a timely manner.

Staff understood their roles and responsibilities in providing good quality care to the people who used the service. There was an open and transparent culture in the service.