Lustrells Vale

Updated 14 November 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection site visit took place on 19 and 24 September 2018 and was unannounced. The inspection team consisted of two inspectors.

Prior to the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give key information about the service, what the service does well and any improvements they plan to make. We reviewed the PIR and other information we held about the service. This included statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. A notification is information about important events, which the service is required to send to us by law. We used all this information to decide which areas to focus on during our inspection.

On the day of inspection, we spoke to two visiting professionals. We also contacted professionals from health and two local authorities to gather feedback from them about the service.

During the inspection, two people were at college and returned home after 3pm and two people were at home all day when we inspected. We observed the care given by staff to people and spoke to everyone living at the service. Due to the nature of people's needs, we were not able to ask everyone direct questions, but we did observe people as they engaged with their day-to-day tasks and activities. We spoke in more depth to two people and one visiting relative.

We spoke with the registered manager, a team leader, one staff member. We looked at care plans and associated records for two people and ‘pathway tracked’ one person. This is where we check that the care detailed in individual plans matches the experience of the person receiving care. It was an important part of our inspection, as it allowed us to capture information about people receiving care.

We reviewed other records, including the registered manager's internal checks and audits, medicines administration records (MAR), health and safety maintenance checks, accident and incidents, compliments and complaints, staff training records and staff rotas. Records for two staff were reviewed, which included checks on newly appointed staff and staff supervision records.

This was Lustrells Vale first comprehensive inspection.

Updated 14 November 2018

This inspection site visit took place on 19 and 24 September 2018 and was unannounced.

Lustrells Vale is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Lustrells Vale provides care and support for up to 4 people with learning disabilities. At the time of our inspection there were 4 people living at the home. Accommodation was arranged over two floors with stairs to the first floor. The ground floor had a communal lounge with a dining area and garden.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion.

The provider had two other services in the area one of which was next door to Lustrells Vale. Staff worked across the three homes and people had established friendships within the other services.

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 registered manager was appointed in April 2017.

Lustrells Vale registered with the CQC on 31 August 2017 and this was the services first comprehensive inspection.

Staff were aware of their responsibilities in relation to keeping people safe and knew who to contact externally should they feel their concerns had not been dealt with appropriately.

Systems were in place to identify risks and protect people from harm. Risk assessments were in place and reviewed monthly. Where someone was identified as being at risk, actions were identified on how to reduce the risk and referrals were made to external agencies as required.

Premises, equipment and safety checks were carried out regularly to ensure that people were living in a safe setting.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely.

People were protected by infection control policies and procedures and the service was clean and tidy.

There were sufficient staff to meet people's needs and keep them safe. Safe staff recruitment procedures meant that only those suitable to work in a care setting were employed.

Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and people were encouraged to make decisions about their care and treatment. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The members of the management team and care staff we spoke with had a full and up to date understanding of DoLS. These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals. Appropriate DoLS applications had been made, and staff were acting in accordance with DoLS authorisations.

People were supported to have 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.

Staff had undertaken appropriate training to ensure that they had to skills and competencies to meet people’s needs. Staff attended regular supervision meetings with the registered manager.

People were supported to maintain good health and had access to health professionals. Dietary needs and nutritional requirements had been assessed and recorded. Weight charts were seen and had been completed appropriately.

Staff were caring, knew people well, and treated people with dignity and respect. Staff acknowledged people's privacy and had developed positive working relationships with them. Relatives spoke positively about the registered manager and staff.

The care that people received was responsive to their needs. People’s care plans were person-centred and had been developed around people’s needs.

People were supported to follow their interests and take part in activities that were meaningful to individuals living at the service.

Complaints were listened to and managed in line with the services policy and procedures.

The registered manager had robust quality assurance systems in place to review the quality of the service that was provided.

People, relatives and staff were involved in developing the service through meetings, annual surveys and quality assurance audits.

Staff and relatives continued to speak positively about the registered manager and said there was an open-door policy.