Community Living Ltd, a supported living service for up to eight people with mental health needs and learning disabilities, was rated Good overall at its first inspection in September 2021, with four of five key questions rated Good. The Well-Led domain was rated Requires Improvement due to absent formal audit processes for care records and infection control, and delayed DoLS notifications, though no regulatory breaches were cited.
Concerns (5)
moderate
Governance
: “whilst there was regular review of people's care and support records, there was not a formal care records audit in place.”
moderateRecord keeping: “notifications relating to DoLS authorisations had not always been sent in a timely manner.”
minorInfection control: “whilst cleaning schedules were maintained, there was not a formal infection prevention and control (IPC) audit in place.”
minorPerson-centred care: “the provider was aware that they needed to formalise systems in place to get feedback from people using the service and those important to them.”
minorMedication management: “medicines prescribed to be taken 'when required'...protocols in place...were not always easily accessible”
Strengths
· People were protected from the risk of abuse and relatives confirmed family members felt safe at the service.
· Comprehensive risk assessments and positive behaviour support plans were in place with a traffic light system for managing behaviours.
· Staff learned from incidents using ABC charts; frequency and intensity of incidents had decreased since people moved in.
· Safe recruitment practices including DBS checks, references, and eligibility to work verification were in place.
· Sufficient staffing levels with rotas clearly identifying staff allocated to specific individuals.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Learning lessons when things go wrongGood
safe: Using medicines safelyGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Working in partnership with others; Continuous learning and improving careGood