159 Wensley Road

Updated 20 May 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

One inspector carried out this inspection.

Service and service type

159 Wensley road is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

Prior to the inspection we looked at all the information we had collected about the service including previous inspection reports and notifications the manager had sent us. A notification is information about important events which the service is required to tell us about by law.

The provider had completed a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We also looked at recent positive feedback received about the service. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who use the service about their experience of the care provided, one staff member and the new manager. We reviewed a range of records. This included three people’s care records and medicine records. We looked at three staff files in relation to recruitment and specific training. A variety of records relating to the management of the service, quality assurance, maintenance and incidents/accidents, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found such as staff information, further training data, premises and quality assurance records. We spoke with three relatives of the people who use the service. We also contacted a further three staff but received no responses.

Updated 20 May 2022

About the service

159 Wensley Road is a small care home without nursing providing care and accommodation for up to four people with a learning disability. At the time of the inspection there were three people living at the service.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

People’s experience of using this service and what we found

Right Support

¿ The registered person did not use safe recruitment procedures to ensure people were supported by staff who were of good character, suitable for their role and had appropriate experience. There was a risk people could be supported by unsuitable staff putting them at higher risk of harm.

¿ Staff supported people with their medicines in a way that promoted their independence. However, other aspects of medicine management such as record keeping, medicine stock checks and training needed improvement.

¿ The service gave people care and support in a safe, clean, and well-furnished environment that met their sensory and physical needs. However, some aspect of premises safety such as maintenance checks, fire and legionella risk assessments and action plans needed improvement.

¿ People had a choice about their living environment and were able to personalise their rooms. People invited us to view their rooms and showed us how they sorted their rooms.

¿ The service and staff supported people to have the maximum possible choice, control and independence be independent and they had control over their own lives.

¿ Staff focused on people’s strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.

¿ Staff supported people to achieve their aspirations and goals.

¿ Staff supported people to take part in activities and pursue their interests in their local area with people who had shared interests.

¿ Staff enabled people to access specialist health and social care support in the community.

¿ Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

¿ Staff supported people to play an active role in maintaining their own health and wellbeing.

Right Care

¿ The service had enough staff to meet people’s needs and keep them safe. However, further evidence was not provided to show that staff were appropriately skilled to meet some people’s specific needs.

¿ People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs.

¿ Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

¿ People could communicate with staff and understand information given to them because staff supported them consistently and understood their individual communication needs. Staff spoke to people politely giving them time to respond and express their wishes.

¿ People’s care, treatment and support plans reflected their range of needs and this promoted their wellbeing and enjoyment of life.

¿ Staff and people cooperated to assess risks people might face. Where appropriate, staff encouraged and enabled people to take positive risks.

Right culture

¿ We found the registered person did not ensure we were notified of reportable events within a reasonable time frame.

¿ The registered person did not follow their quality assurance policy effectively so they could assess, monitor and mitigate any risks relating the health, safety and welfare of people using services, the service and others.

¿ The registered person did not follow and accurately record and keep a copy of all the actions taken as required in the duty of candour regulation when a notifiable safety incident occurred.

¿ Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing.

¿ Staff turnover was very low, which supported people to receive consistent care from staff who knew them well.

¿ Staff placed people’s wishes, needs and rights at the heart of everything they did.

¿ People and those important to them were involved in planning their care. Staff valued and acted upon people’s views.

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

Rating at last inspection and update

The last rating for this service was requires improvement (report published on 16 December 2019) and there were three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made/sustained, and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the second time in a row.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Why we inspected

We undertook this inspection to assess that the service is applying the principles of right support right care right culture.

We carried out an unannounced comprehensive inspection of this service on 14 October 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, fit and proper persons employed and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 159 Wensley road on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicine management, premises, recruitment, duty of candour, submitting notifications and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.