LIGHT AND HOPE

Updated 10 May 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

The inspection was undertaken by 1 inspector.

Service and service type

Light and Hope 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. Light and Hope 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 was in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought and received feedback from health and social care professionals who work with the service. 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. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service about their experience of the care provided. We observed how staff interacted with people in areas such as the lounges and dining areas. We spoke with 2 members of staff, the provider and the registered manager.

We reviewed a range of records. This included 2 people's care records and medication records. We looked at 3 staff files in relation to recruitment and a variety of records relating to the management of the service were reviewed.

After the inspection

We continued to review variety of documents relating to the management of the service, including audits and quality assurance documents were reviewed. We liaised with the local environmental health service and local authority commissioning team.

Updated 10 May 2023

About the service

Light and Hope is a care home providing accommodation for up to four people who require personal care some of whom may be living with a learning disability. At the time of our inspection there were two people living at the service.

People's experience of using this service and what we found

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.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right Support

Support plans were not always kept up to date with the most recent information to support people with their care and support needs. People were not always encouraged to plan for aspirations and goals. 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 this practice. The service did not provide care and support within a homely and well-maintained environment. Parts of the home needed repair and people’s rooms and communal areas were not decorated in line with people’s preferences or to reflect their personalities. People received their medicines as prescribed, although medicines had not been managed effectively. Staff competencies to administer medicines were reviewed.

Right care

Staff acted promptly to protect people from poor care. Incidents or concerns were reported but some incidents involving people did not trigger a review of the care they received. Staff had training on how to recognise and report abuse. We have made a recommendation that the provider reviews themes and trends and takes appropriate action. People were not always supported through planned person-centred practices. Care and support plans did not contain personalised plans or outcomes for people with achievable goals. We have made a recommendation that the provider develops links for advocacy to ensure people have an independent voice. People were not always encouraged to take positive risks. Keyworker meetings did not support people in positive risk taking to achieve personal change or growth. Further development was required to manage risks in ways which improve the quality of life of the person, to promote their independence or to stop deterioration if possible.

Right culture

People did receive good quality care in their day to day care support and treatment. People could lead more inclusive and empowered lives which the provider continued to work towards. The quality assurance processes were not always effective and failed to identify and address shortfalls in a timely manner. Safe recruitment processes were followed to ensure suitable staff were employed.

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 inadequate (published 12 August 2022)

We served the provider warning notices in relation to a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also served requirement actions for breaches of regulations 9 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 regulation 12. The provider remained in breach of regulation 9 and regulation 17 in relation to planning person centred care and effective risk management and effective governance and oversight.

This service has been in Special Measures since 11 August 2022. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service between 04 July 2022 and 12 July 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safety, person centred care and governance.

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 undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

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 inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Light and Hope on our website at www.cqc.org.uk.

Enforcement

We have identified a continued breach in relation to governance, provider oversight and monitoring at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.