Care Quality Commission report published in April 2015

Report Summary:


This inspection was unannounced and took place on the 14 November 2014.

The Hermitage Charity Care Trust provides accommodation and personal care support for up to 30 older women. There were 29 people who used the service at the time of our visit.

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.

At the last inspection on 9 May 2014 we asked the provider to take action to make improvements. This was because capacity assessments were not in place for people that lacked capacity to make decisions for themselves, and not all identified areas of need had a risk assessment and care plan in place to ensure people’s safety and welfare was maintained. The provider sent us an action plan after the inspection to confirm that these improvements would be in place by 31 July 2014.

At this inspection all areas of people’s identified need were included in the care records seen, this meant that
staff had the information needed to support people effectively.

The manager had undertaken best interest meetings for people that lacked capacity but mental capacity assessments had not been completed for these people.

This meant that the provider had not always acted in accordance with legal requirements. The registered manager had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for people who used the service, even though their liberty may have been restricted.

Sufficient staffing levels were provided to meet the needs of people. Staffing levels were monitored and actions had been taken to recruit additional staff to meet people’s needs.

People received their medication as prescribed but staff were not recording the actual dose administered for
variable dose medicines, such as ‘as required’ medicines for pain relief. Therefore if a person asked for more pain
relief staff would not be able to determine from the records, whether they had already had the maximum dose or not. This meant that people’s ‘as required’ pain relief was not managed appropriately.

Staff had a good understanding of the safeguarding adults procedure and demonstrated that they knew how to report any concerns disclosed to them. People who used the service told us they felt safe at the home.

The care and support provided to people met their identified needs and preferences and staff demonstrated a good understanding of people’s individual needs.

Care plans were reviewed regularly to ensure people’s needs continued to be met.

People liked the staff and told us that their needs and preferences were met and confirmed that their opinions
and views were sought and listened to.

Staff told us that they were supported by the management team and provided with the relevant training to ensure people’s needs could be met. Audits were undertaken and regularly monitored and assessed to drive improvement; however no written audits were undertaken regarding the management of medicines.

You can see what action we told the provider to take at the back of the full version of the report.


To view the full report, please visit this link.