6 May 2021
During an inspection looking at part of the service
11 Wembook Close is a residential home, providing care and accommodation for up to four people. It provides care to people living with a learning disability and other support needs including autism. At the time of our inspection visit two people lived at the home.
People's experience of using this service and what we found
People did not receive safe care. Risks associated with people’s care were not always identified, managed or mitigated. The provider had not effectively assessed staff had the skills, knowledge or experience they needed to provide care which ensured people living at the service were safe and others’ safety was maintained. People’s care plans did not always contain detailed or accurate information to help staff support people safely. The provider had not always ensured detailed records were kept of important healthcare visits or guidance.
People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support least restrictive practices. Where restrictive practices were used the provider had not always acted in line with the Mental Capacity Act 2005.
An 'infection prevention control' audit was carried out by CQC during the inspection. We found the provider was not consistently following government guidelines. Risks related to Covid-19 were not consistently well managed.
People were not cared for in premises that were consistently safe. Fire safety deficiencies had not always been acted on in a timely way. The provider had not ensured staff consistently had the equipment needed to keep people safe.
An admission to the home had not been well-managed by the provider and meant systems to manage potential abuse were not effective.
Governance systems, and management and provider oversight of the service were inadequate. Systems and processes designed to identify areas of improvement were ineffective. The providers policies and procedures did not always provide staff with the guidance they needed. Audits and checks had not identified the concerns we found.
The management of individual and environmental risks continued to require improvement.
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. (Report published 21 February 2018).
Why we inspected
We undertook this focused inspection because emerging risks had been identified by us and other professional bodies including the Local Authority and Fire Service. We had also received information of concern from staff and members of the public prior to our inspection visit in relation to the management of risks at the home and how people’s needs were met. As a result, we undertook a focused inspection to review the key questions of Safe and Well Led only.
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 our 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 identified breaches in relation to the risks associated with people’s care and management oversight of the service. The provider had not ensured effective systems and processes were in place to monitor the quality of the service and drive improvement.
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 our inspection is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider to agree our ongoing monitoring of the service and discuss how they will make changes to ensure they improve. We will work with the 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.
Special Measures
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within six months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.