About the service:

Underhall respite and resource centre is a residential care home that also provides a short-breaks (respite service) to older adults. The service also provides a day service, which was outside the scope of consideration for this inspection. The home is based on a single level and there is parking outside the premises. The service is registered to provide care and support to up to 14 people.

People’s experience of using this service:

• The service was caring and provided people with person-centred support. However, there were some shortfalls in relation to records and systems and processes to help monitor and improve the quality and safety of the service.

• People received support from a small, consistent staff team. There were numerous examples of where the service had gone ‘above and beyond’ to provide people with support that met their needs and preferences.

• The registered manager and staff had a good understanding of people’s needs and social histories. They used this information to provide person-centred support. However, care plans did not always reflect the information known to staff.

• We found staff took reasonable actions to help keep people safe from harm. However, there was limited formal, recorded risk assessment.

• The registered manager aimed to provide a ‘homely’ service, and demonstrated caring values that were reflected by the staff team.

• The registered manager had a good oversight of the service. However, this was not always reflected in the records or by systems and processes in place to assist them in monitoring the service. We found this to be a breach of the regulations.

• People received their medicines as prescribed. However, there were some shortfalls in relation to records kept, and requirements in relation to the safe storage of medicines. We have made a recommendation in relation to the management of medicines.

• We identified some shortfalls in relation to the implementation of the Mental Capacity Act (MCA), primarily in relation to records kept. We have made a recommendation in relation to implementing the MCA.

• People were positive about the kind and caring nature of staff. Whilst we did not identify any concerns about the staff employed, we found there were gaps in the processes followed to ensure staff recruited were of suitable character. We found this to be a breach of the regulations.

• We received positive feedback about the food provided. The service took people’s dietary requirements and preferences into account when preparing meals.

• The service had good working relationships with other health and social care services. We received positive feedback from social care professionals with recent involvement with the service.

• The provider was not always meeting regulatory requirements. We found required notifications in relation to expected deaths had not been submitted as the provider was unaware of this requirement. Prior to the inspection, the service had breached conditions of its’ registration with CQC by admitting more people to the service than it was registered for.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

This is the first time we have inspected this service.

Enforcement/improvement action:

Please see the ‘action we have told the provider to take’ section towards the end of the full report.

Follow up:

• We will request an action plan from the provider setting out how they intend to make improvements to meet the requirements of the regulations.

• We will continue to monitor the service.