29 Bushy Hall Road

Updated 12 January 2024

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.

Inspection team

The inspection team consisted of 1 inspector.

Service and service type

This service provides care and support to people living in 6 ‘supported living' settings, so that they can live as independently as possible. People's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people's personal care and support.

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 not a registered manager in post, however the provider had recently recruited a new manager who was due to start soon. There was a manager based at the service who had applied for their registration.

Notice of inspection

We gave the service 24 hours' notice of the inspection. This was because we needed to be sure that the provider would be in the office to support the inspection. Inspection activity started on 24 October and ended on 29 October.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We reviewed a range of records related to 3 people's care and support. This included people's care plans, risk assessments, medicines records for 1 person and 2 staff files in relation to recruitment and training. We reviewed records related to the management of the service, which included training records, safeguarding incidents, quality assurance records and a range of policies and procedures. We spoke with the area manager and 1 manager. After the inspection we contacted 1 professional and we spoke with 4 staff and 4 relatives and 1 stakeholder.

Updated 12 January 2024

About the service

29 Bushy Hall Road is a supported living service providing personal care for 5 people. The service supports people with a learning disability and autistic people. At the time of our inspection there were 6 people using the service.

People’s experience of the 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 assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

Risks to people were not always properly assessed and updated which meant some information about people was not correct. We made a recommendation to the provider ensure there was appropriate information to guide staff. People were supported by staff who did not always know the people well or understood their needs. People were not supported to have maximum choice and control of their lives and staff did not 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. Staff did not always receive the necessary training to safely care for people. The home had recently recruited a new manager who had worked at the home previously. They had made positive changes immediately and were open and transparent and responsive to all our feedback throughout the inspection.

Right Care

People were not always supported in a caring way. Staff were not always meeting people’s communication needs. Staff were undergoing refresher training to make sure they had the necessary training to care for people. Staff were starting to support people to make independent choices and support them to attend activities which they enjoyed doing.

Right Culture

There had been changes in managers at the home and this had impacted on how care was been delivered however the provider had not identified people were not supported to achieve their potential when they were visiting the home completing quality assurance visits.

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 under this previous provider was good published (18 December 2017)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for 29 Bushy Hall Road on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to consent, staffing and good governance. We made a recommendation to the provider to review all risk assessments to ensure they provide the correct information to support people safely. 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.