27 April 2022
During an inspection looking at part of the service
About the service
Sense 12 Oakfield Road is a supported living service providing personal care to six people at the time of the inspection.
People’s experience of using this service and what we found
Based on our review of Safe, Effective and Well led the service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.
Right Support
¿ The provider had not always assessed, monitored and mitigated the risks associated with people’s care.
¿ The provider had not always ensured incidents were reviewed to reduce the chance of reoccurrence and take learning from them. As a result appropriate responses to incidents had been delayed.
¿ Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcome.
¿ 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.
Right Care
¿ Not all staff had received the training deemed necessary by the provider. Those staff who had received training informed us how they applied it in supporting people with their individual needs.
¿ People’s care and support plans, on the whole, reflected their range of needs and this promoted their wellbeing. We found that staff’s knowledge of people’s support needs had not been consistently incorporated into these care plans.
¿ People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language), pictures and symbols could communicate with staff and others involved in their care and support. However, we received feedback that staff needed additional training to facilitate this communication further and to gain the necessary skills to understand all of people’s communication 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.
¿ The service had enough staff to meet people’s needs and keep them safe.
Right culture
¿ Staff and relatives evaluated the quality of support provided to people. However, people had not always been involved in these reviews.
¿ Relatives had been involved in planning people’s care. However, we found that systems for new admissions to the service had not been consistently followed and as such all the information about a person’s care had not been formulated.
¿ Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing.
¿ The service enabled relatives to work with staff to develop the service.
¿ Staff felt well supported in their role, felt able to raise any concerns and enjoyed their roles in supporting the people who lived at the service.
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 20 March 2020). There were 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 we found improvements had been made and the provider was no longer in breach of the previous regulation. However, a different breach of regulation was identified in relation to the manner in which the service was monitored. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
We undertook this inspection to assess that the service is applying the principles of Right support, right care, right culture. This focused inspection was also carried out to follow up on action we had told the provider to take at the last inspection and was in part prompted by a notification of a specific incident where a person sustained a serious injury.
This report only covers our findings in relation to the key questions safe, effective and well led. 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 the same based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sense 12 Oakfield Road on our website at www.cqc.org.uk.
Enforcement and Recommendations
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 monitor the service and will take further action if needed.
We have identified a breach in relation to the systems to ensure safe and good quality care 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.