Background to this inspection
Updated
28 June 2022
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 carried out the inspection.
Service and service type
Shirlett Close 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. Shirlett Close is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Shirlett Close also provides personal care to people living in their own homes.
Registered Manger
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
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 sought feedback from the local authority and professionals who work with the service such as 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 all this information to plan our inspection.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with two relatives about their experience of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with six members of staff including the registered manager, deputy manager and four support workers.
We reviewed a range of records. This included three people’s care records and two medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were also reviewed. We spoke with two healthcare professionals who were involved in people’s care and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
Updated
28 June 2022
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.
About the service
Shirlett Close is a residential care home providing personal care for up to four people. Shirlett Close also provides personal care to people living in their own homes. At the time of the inspection four people lived at Shirlett Close and two people were provided support in their own homes.
People’s experience of using this service and what we found
Right Support
People had limited opportunities to leave the service and pursue social interests within their local community. There were missed opportunities to engage people in meaningful activities within the home and people were not supported to try new things or develop new skills. People’s care records detailed pastime they may like to take part in, but these activities were not always encouraged. There was limited guidance to inform staff how to enrich people’s lives through positive engagement and meaningful activities. People’s goals and aspirations were not always identified with people or those involved in their care. Where a goal had been identified, staff did not always know how to support the person to achieve their goal. Progress in reaching their goal had not been reviewed.
Right Care
People were not always involved in making decisions about their care. People were not always given information in a way they could understand. There was limited consideration given to the varying ways people could be empowered to make everyday choices using different communication methods.
Right culture
The service did not always have a person-centred culture which empowered people to achieve their goals and aspirations. Systems were not effective in identifying if people were receiving person centred care in line with Right Care, Right Support, Right Culture. There was insufficient recording and reviewing of behaviours where a person had experienced distress.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
We undertook this inspection due to a change in provider. We also wanted to assess that the service is applying the principles of Right Support, Right Care, Right Culture.
Rating at last inspection
This service was registered with us on 26 July 2019 and this is the first inspection. The last rating for the service under the previous provider was good, published on 6 January 2017.
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 and will take further action if needed.
We have identified breaches in relation to person centred care and governance 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 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.