This was an announced inspection which took place on the 7 October 2015. The service had not been inspected previously as the service had recently registered with the Care Quality Commission.
Leighton House offers short-term support accommodation to people over the age of 18 who have a learning disability. They provide respite to parents and carers of people who are cared for in their own home. Leighton House is adapted to meet the needs of profoundly disabled individuals. There are a number of communal areas including a lounge area, activity room and a garden. There were five people staying for a short break at the service on the day of our inspection.
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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
During our inspection 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 this report.
We looked at the storage of medicines and saw each person’s medicines were stored separately and in a secure cupboard. We saw a thermometer was in place for the medicines cupboard and asked to see the record of temperature checks. We were informed that these checks had not been undertaken. This meant the service was unaware if medicines were being stored at the recommended temperature.
We also found that controlled drugs were not managed safely. Records did not match medicine administration records, there was not always two signatures in the controlled drugs record, numerous pages of the controlled drugs record showed crossing out and balances were not amended when people were discharged.
We have made a recommendation that the service considers contacting the local fire service for further advice on evacuation procedures.
The service had a safeguarding policy in place which gave staff example of abuse, what they needed to look for and what they needed to report.
People who used the service told us there was always enough staff on duty to meet their needs and to support them. Staffing levels were dependent upon the needs of people using the service each day.
Robust recruitment processes were followed when employing new staff members. Policies and procedures were in place for managers to follow when recruiting.
Staff knew their responsibilities in relation to infection control. We saw that personal protective equipment (PPE) was available throughout the service.
Records we looked at and staff we spoke with showed that an induction was completed when they commenced work for the service. One new staff member told us they had also ‘shadowed’ experienced members of staff.
Training records showed that staff were trained in a number of areas such as, equality and inclusion, first aid and food hygiene.
Staff did not receive supervisions every eight weeks as defined by the service policy and procedure. The registered manager informed us this would be reviewed and realistic timeframes would be agreed and the policy amended.
The service contacted relatives prior to people using the service to find out if their needs had changed. Staff would also inform relatives how the stay had been.
Policies and procedures were in place in relation to the Mental Capacity Act (MCA) 2005 and Depravation of Liberty Safeguards (DoLs). Staff had also received training in this area. The registered manager knew their responsibilities in relation to these and had recently arranged a best interests meeting for one person who used the service.
People who used the service and their relatives told us that staff were kind and caring. We observed staff interacting with people in a kind and sensitive manner.
We found the atmosphere in the service was warm and friendly. Staff members we spoke with told us they would be happy for one of their relatives to stay in the service.
The service had an activity room where people who used the service had access to free Wi-Fi, a play station, computer, board games and music. We also saw posters advertising a Halloween party and bonfire night.
The service had a compliments and complaints policy in place. This detailed timescales for dealing with any complaints that the service received. The service had a compliment and complaints form available on the notice board for people who used the service, relatives and visitors to use.
There was a recognised management system which staff understood and meant there was always someone senior to take charge. We spoke with the registered manager throughout our inspection and found them to be approachable and helpful.
We looked at some policies and procedures that were in place within the service. We found the service was in the process of renewing all their policies and procedures, the majority of which had been completed. Staff were also expected to complete a workbook in relation to policies and procedures to evidence their understanding of these.
Also in place was ‘The Big Idea’. This was designed as a way to encourage staff to be involved in driving up quality within the service. Staff had a form to complete in order to present their ideas for improvement.
The service had a targets and objectives plan in place. This showed areas for growth such as building a sensory garden, to promote holidays with activities for people who used the service and the offering of a bespoke day service where people could learn new skills.