Nottingham Mencap Short Breaks Service was rated 'Inspected but not rated' overall at its November 2020 inspection, with 'Requires Improvement' in Safe and Well-Led due to gaps in individualised risk assessments, absent behaviour-support training, and limited management knowledge of CQC regulatory requirements. Strengths included consistent, person-centred staffing, robust infection control, and a well-regarded registered manager, with no evidence of actual harm to the three people receiving personal care at the time.
Concerns (6)
moderateCare planning: “plans to evacuate people from their homes in case of a fire were not individualised and did not consider their ability to understand the danger.”
moderateStaff training: “training records stated that staff had not received formal training to assist them with safely managing these situations. This could place people's safety at risk.”
moderateGovernance: “nominated individual and manager did not always have a thorough understanding of the regulatory requirements of their role.”
moderateIncident learning: “it did not include a reminder to inform the CQC of a notifiable incident. The registered manager told us they would amend the form to include these areas.”
moderateSafeguarding: “policies did not include reference to ensuring the CQC were notified of concerns... Whistleblowing policy only referred to internal reporting procedures.”
minorComplaints handling: “complaint policy did not contain details of The Local Government and Social Care Ombudsman whom people could refer their complaint if they were not satisfied.”
Strengths
· People felt safe and staff were knowledgeable about people's needs; a person said staff help them stay safe.
· Robust infection control procedures in place, including COVID-19 adaptations in line with government guidelines.
· Staff were recruited safely with appropriate pre-employment suitability checks completed.
· People had a small, consistent team of staff; relatives confirmed carers always arrived on time.
· People, relatives and staff praised the registered manager's caring and supportive approach.
Quality-Statement breakdown (11)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: How the provider understands and acts on duty of candour responsibilityRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood
Nottingham Mencap Short Breaks Service improved from Requires Improvement to Good overall, with all five key questions rated Good at this May 2022 inspection. The service demonstrated person-centred care, effective safeguarding, low staff turnover, and strong leadership driving continuous improvement.
Strengths
· Staff were matched with people to build trusted relationships, with low staff turnover supporting consistency of care.
· Risk assessments improved since last inspection and were being transferred to an electronic system.
· Care plans were person-centred, regularly reviewed, and reflected holistic assessment of needs and choices.
· Staff were well trained across all mandatory areas including safeguarding, infection control, and medicines.
· People's communication needs were assessed and met, with staff using Makaton and pictorial formats.
Quality-Statement breakdown (24)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood