Trafalgar Street

Updated 24 March 2023

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 Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

Trafalgar Street is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Trafalgar Street is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 3 relatives about their experience of the care

provided. We spoke with 4 members of staff including the registered manager and support workers. We reviewed a range of records. This included 1 person’s care and medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records and training information.

Updated 24 March 2023

About the service

Trafalgar Street, also known as Priory Lodge, is a care home providing personal care to 3 people at the time of the inspection. The service can support up to 4 people.

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.

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

Right Support

Improvement needed to be made to the environment people lived in to ensure it was clean and well maintained. We have made a recommendation to the provider about this. Staff were aware of people's strengths and what they could do and supported people to make their own choices about their care and support needs. People were being supported by staff to be actively involved and engaged in cooking and completing their own household tasks. 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 .Staff learned from incidents and how they might be avoided or reduced. Staff followed safe practices when wearing personal protective equipment (PPE).

Right Care

People and their families told us staff were kind and supported them well. Staff understood how to protect people from poor care and abuse, they had received training on how to recognise and report abuse and were able to tell us when they would report any concerns. We observed staff interacting with people in a kind and compassionate way and in a way that promoted people's independence. People received support from staff who knew them well, understood their needs and considered their preferences.

Right culture

Quality assurance processes had not identified all the concerns in the service. The service had a registered manager who was also registered manager at another 2 care homes. People and staff were very positive about the registered manager. However, we identified shortfalls in systems used by the provider and registered manager to check the quality and safety of the service. These needed strengthening and embedding into practice. Managers understood further work was needed.

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 (published 02 March 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 26 March 2020. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve 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.

When aggregating ratings with those from a previous inspection add the following wording. Note, ratings cannot be aggregated with ‘inherited ratings’ awarded to a predecessor location.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. 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 Trafalgar Street on our website at www.cqc.org.uk.

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.

Following the inspection, the provider responded by taking actions to improve. You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to safety and management. 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 continue to monitor information we receive about the service, which will help inform when we next inspect.