Background to this inspection
Updated
20 June 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.
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
This inspection was completed by an Inspector and an Assistant Inspector.
Service and service type
68 West Park Road 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. 68 West Park Rd 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 the inspection
We reviewed the information we had received about the service. 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 communicated with 11 people who were living at 68 West Park Road about their experience and views of the service. People who were unable to talk to us used different ways of communicating including British Sign Language, pictures, and symbols, writing on a board and their body language. We spoke with 6 relatives about their experience of care provided. We spoke with 10 staff including, the registered manager and deputy manager, regional managers, team leads, the resourcing business partner, and day and night support workers. We reviewed a range of records. These included 5 people’s care records and multiple medication records. We looked at 2 staff files in relation to recruitment and staff supervision. We reviewed a variety of records relating to the management of the service, including policies and procedures. We also contacted 2 professionals who work regularly with the service.
Updated
20 June 2023
About the service
68 West Park Road is a residential care home providing personal and nursing care for up to 14 people. The service provides support to people with learning disabilities and autism. At the time of our inspection there were 13 people using the service. Each person had their own flat within the home including a living room, bedroom, and bathroom. All but one person had their own kitchen. People had access to a shared lounge area and a shared kitchen. They also had access to a shared garden.
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
Systems had not always highlighted health and safety risks within the home. When health and safety concerns were identified, they were not always addressed in a timely way. Recording of incidents was not always detailed and records had not always been checked by management. This meant a safeguarding concern had been missed but was investigated when we highlighted it.
Right Care
People’s care records were not always up to date regarding the possible need for the use of restrictive practice as a last resort. This led to confusion amongst staff. Although staff could tell us about some people’s wishes and plans, it was not easy to see how their long-term goals and aspirations were being met.
Right Culture
Staff did not always receive regular supervision, which meant some opportunities to identify gaps in their knowledge could be missed. Agency staff were not given the same training in restrictive practices as the established staff team. This could create a risk of confusion about appropriate practice amongst the staff team.
People were not always supported to have maximum choice and control of their lives. It was not always clear staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.
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 20 January 2022).
Why we inspected
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.
We received concerns in relation to the management of health and safety risks and recording and monitoring of incidents in the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
During the inspection the provider took steps to address many of the concerns we raised. All the immediate health and safety risks which had been identified in the home had been addressed shortly after the completion of our inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 68 West Park Road on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to ineffective systems to protect people from possible harm, poor maintenance of equipment designed to keep people safe and failings in the oversight and quality assurance systems in the home at this inspection.
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 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.