Background to this inspection
Updated
23 November 2021
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 Care Act 2014.
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
One inspector completed this inspection.
Service and service type
Mandela House Therapeutic Unit is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Notice of inspection
We gave the service 24 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We sought feedback from Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.
We used all of this information to plan our inspection.
During the inspection
We spoke with the person who lived at Mandela House Therapeutic Unit about their experience of the care provided. We spoke with two members of staff including the registered manager and a trainee assistant psychologist. We reviewed a range of records. This included a care record and two 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 training data and information related to the safety of the service. We also spoke with another member of staff via the telephone.
Updated
23 November 2021
About the service
Mandela House Therapeutic Unit provides accommodation and personal care to six people with a learning disability or autistic spectrum disorder. At the time of our inspection, only one person lived at Mandela House Therapeutic unit.
People’s experience of using this service and what we found
Although systems and processes were in place to check the quality of the home, some environmental risks had not always been identified, assessed or managed.
Behavioural risks had been identified but care records contained limited information to instruct staff what action to take should these risks be presented.
People were protected from the risk of abuse. Staff understood their safeguarding responsibilities and what action to take to protect people from abuse.
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 this practice. However, consent was not always recorded where potential restrictions were in place.
The home was clean and there were good infection control procedures in place. We were assured people were protected from the risk of infection.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
Right support:
•The model of care and setting maximises people’s choice, control and independence.
Right care:
• Care is person-centred and promotes people’s dignity, privacy and human rights
Right culture:
• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 23 January 2020 and this is the first inspection.
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 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.
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 this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified a breach in relation to regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection.
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 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.