Winterfell

Medicines were not always clearly documented in one central place, there were multiple sheets to record the information on which made it difficult to understand. This was brought to the registered managers attention who took steps to rectify this. Temperature recordings for the medication fridge had not been recorded for a few days due to the thermometer not working. The registered manager ordered a new thermometer during day 2 of the site visit. There were concerns over the administration of medicines, the registered manager addressed the concerns and ensured all staff were assessed as competent. People and their relatives felt safe. They were able to raise concerns if they felt necessary. Safeguarding policies and procedures were in place and staff were aware of how to raise a concern. Staff were aware of their roles and responsibilities to safeguard people from abuse. Safe recruitment systems were in place and were being followed to ensure people were safely recruited and suitably qualified and trained to provide safe support.

Not all care plans were up to date and contained the correct information for example, ages and GPs. This was discussed with the registered manager who was in the process of reviewing care plans and rectified this immediately. People’s individual needs were assessed, and risk assessments implemented to mitigate any risks identified. Communication care plans were detailed to ensure staff knew how to communicate with people to ensure they are involved in aspects of their care. People and their families were actively involved in care planning. Care plans were personalised and contained lots of informative information about how to meet people’s needs safely and their likes and dislikes. Referral to other services were made in a timely manner. People attended their health appointments with the support from staff if appropriate. Information was shared between staff during daily handovers and communication records to ensure all relevant information was shared. Staff told us they were involved in care plan reviews and other services and agencies were involved in the care of people. Staff received training relevant to peoples needs to ensure they could support people safely and had the right skills and knowledge. Compliments and complaints were logged and acted upon. A home development plan highlighted annual objectives for the service, which included a consistent approach to goal setting and activity planning with people.

People were treated with dignity and respect. Staff were aware of peoples likes and dislikes and supported people in a way they wanted. People who lived at the service were central to all support provided. We observed staff were responsive and kind when interacting with individuals. Interactions varied between different people for example, the use of touch and eye contact was more appropriate for some people. Family members were encouraged and supported to visit and were involved in all aspects of people’s care. People’s needs and choices were assessed effectively, care plans were personalised and included involvement from specialist services. This included support required in relation to their culture, religion, lifestyle choices and diet preferences. There was a wide range of activities available for people which could be changed on a daily basis to meet the needs of people. Multi-agency meetings took place frequently, this ensured the appropriate advice was taken to mitigate any risks identified and ensure support was person centred.

Detailed and personalised communication support plans were in place. Accessible information was available to ensure staff were able to communicate effectively to people. The provider had policies available in easy-to-read formats for people who needed more accessible language. People were involved in decisions about their care and support, where people were unable to make these decisions there was evidence decisions were made in the best interests of people. People were asked their long-term goals and plans for their future. Goals and aspiration forms were completed with the support from the person, their family members and professionals. Family members were kept informed of any changes and involved in decision making, they were encouraged to give feedback to drive improvements. People were listened to, and their opinions were valued. Training was available for people living at the service if they wanted this. This promoted people’s independence and knowledge. Communication between staff was effective to ensure relevant information was shared accordingly. Feedback from partner agencies was positive.

Staff received a thorough induction which included shadow shifts, reading care plans and completing mandatory training to ensure they had the skills and knowledge to provide safe, person-centred support. Staff felt valued and supported within their roles and were confident within their role and able to seek advice from the manager if required. The manager was visible in the service and provided support if required. People and their relatives were happy with the support from the management team. Support is provided internally by different specialist services to ensure the needs of people living at the service are met safely. The appropriate team provided support when incidents arise to prevent and mitigate risks. External support ensures there is someone independent overseeing the care being provided. Supervisions took place to allow staff to reflect on the support they provide however, this has not been in line with the companies’ policy. The manager is aware and has ensured all staff have received supervision. The registered manager completed regular audits and if any concerns were identified this was brought to the staff’s attention.