This inspection took place on 30 November 2016 and 5 December 2016. It was an unannounced inspection. Mon Choisey is registered to provide accommodation for up to 28 older people who require personal care. At the time of the inspection there were 21 people living at the service.
At the previous inspection on 19 October 2015 we found that people’s care plans did not always contain information guided by the principles of the Mental Capacity Act 2005 (MCA). This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.
We also found that the registered manager had not taken reasonable steps to mitigate the risks to the health and safety of service users receiving care. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.
At this inspection we found that the home had made some improvements to address the areas of concern and start bringing the service up to the required standards.
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.
The service had introduced mental capacity assessments for people who may be deemed as lacking capacity to make certain decisions. These capacity assessments included information that was guided by the principles of the MCA. However, staff did not always follow the principles of the MCA.
Appropriate contingency plans were not always actioned in the event of an untoward event that impacted on the service..
People received their medicine as prescribed. However, staff did not always follow the providers protocols when administered 'as and when required' medication.
Where risks to people had been identified risk assessments were in place and action had been taken to reduce the risks.
The registered manager had not always notified CQC of reportable events. Audits were conducted to monitor the quality of service. However, these audits were not always effective and did not identify the concerns we found.
There were sufficient staff to meet people’s needs. Staff were not rushed in their duties and had time to chat with people. Throughout the inspection there was a calm atmosphere and staff responded promptly to people who needed support. The service had robust recruitment procedures and conducted background checks to ensure staff were suitable for their role.
People were confident they would be listened to and action would be taken if they raised a concern. People told us the service was responsive and well managed.
People received person centred care. People were cared for by a service that understood the importance of getting to know the people they supported. People had access to meaningful activities.
People told us they enjoyed the food provided by the home. Where people required special diets these were provided by a chef who clearly understood the dietary needs of the people they were catering for.
Staff spoke positively about the support they received from the registered manager. Staff had access to effective supervision.
We found two 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.