Archived: Royal Mencap Society - 45 Park Road

Updated 20 March 2020

The inspection

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Royal Mencap Society 45 Park Road is a 'care home'. People in care homes receive accommodation and nursing or personal care as 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 had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We announced our inspection on the day. This was because the service is small, and we needed to be sure that the provider or registered manager would be available to support the inspection.

We undertook the inspection on 24 February 2020.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with four members of staff including the area operations manager, service manager and care staff.

We reviewed a range of records. This included three people's care records, and a variety of records relating to the management of the service.

Updated 20 March 2020

About the service

Royal Mencap Society 45 Park Road is a residential care home providing personal care to seven people with a learning disability and autism. The service can support up to eight people.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

Systems and processes had not identified where there were concerns with the safety of the home environment or people’s equipment. Risk assessments had not been completed for all areas of risk to identify measures that could be put in place to reduce people’s risks and keep them safe from harm. Some accidents and incident reports had not been reviewed to identify learning.

The registered manager had been absent for a period, this had impacted on the governance within the service as staff were not easily able to identify where information relating to the delivery of the regulated activity was stored. Legally required notifications were not always submitted to the CQC.

The service had identified improvements needed to the living environment. However, there had been a delay in undertaking improvements to the building and décor. We saw areas of damp, damaged flooring and walls and communal areas needing redecoration. We received feedback that the carpets had not been replaced for some time.

Decision specific mental capacity assessments and best interest decisions had not been undertaken. However, we found people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were not always enough staff available to support everyone to be able to access community activities at the time they wished. However, staff knew people well and enjoyed supporting people to engage in their hobbies and interests. Care plans were person centred and pictorial, so people could be involved in planning and reviewing their care plans. The service planned to implement end of life care plans and provide end of life training for staff.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent

Staff knew how to recognise, and report suspected abuse. Staff had been safely recruited and people received their medicines on time. Staff had a good knowledge of infection controls requirements and had access to personal protective equipment.

People told us they were happy with the food available and were able to choose what they wanted to eat and drink. Staff contacted health professionals as needed and had received specific training to meet people’s individual needs. Staff received an induction before they started work with the service and felt well supported by the management team.

People were supported by staff that were kind and caring and treated them as if they were a member of their family. Staff respected people’s privacy and dignity and involved them in decisions about their care.

The service understood their requirements in relation to duty of candour and were open and honest with us during our inspection. They worked with partner agencies such as commissioners and healthcare professionals to meet the needs of the people living at the service. There had been no complaints. People and relatives knew how to complain and told us, they felt confident action would be taken should they complain.

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

Rating at last inspection

The last rating for this service was good (published 29 April 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to people safety, consent and quality assurance systems and processes.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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.