59 Bury Road

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our previous inspection we found a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as systems to assess and improve the quality of care and drive improvement were not effective. At this inspection we found sufficient improvement had not been made and the service remained in breach. Although audits were undertaken of service users care plans and risk assessments and action plans had been put in place. Care plans and risk assessments had not been reviewed in over 12 months and did not always contain all of the required information. Action plans were in place to update support plans and risk assessments, however this work had not yet started. There were shortfalls in how the systems and processes within the service supported people to have maximum possible choice and control over their own care. The systems in the service did not reflect the principles of the guidance Right Support, Right Care, Right Culture. This was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

All staff told us they felt valued, supported and motivated since the new manager had been in post. They told us previously they did not feel supported in their role. All staff said they found the new manager to be supportive and knowledgeable. They acknowledged there was work to be done and felt confident the manager would make the required improvements. They told us they monitored staff through observation and the use of competency assessments. The manager was able to confidently describe the process of when and how to submit notifications to CQC and referrals to the relevant bodies including the local authority. The manager told us they kept up to date with the latest guidance by viewing the CQC website, and the provider informed them of any changes. They also told us they kept their training up to date. The manager told us, “I want them [people] to have more activities and I want them to be in a safe environment and not be afraid. I want staff to use safe practices so people are safeguarded I want people to have choices and live the best lives that they can. Updating care plans and support plans and working from there.”

During our onsite visit the manager was still to complete their assessment to become a registered manager with CQC. After the onsite visit the manager was successful in becoming registered with the commission as the registered manager of the service. The provider recognised there were shortfalls in the service. The new manager and the area manager had completed audits along with their quality assurance support team and had devised an action plan. Business continuity plans were in place and actions had been picked up on the audit. Although the manager and provider have picked up the concerns, we found it had taken some time to get to this point. Lack of effective quality monitoring was a concern at our previous inspection. We still could not be assured the provider’s oversight was effective in promptly identifying and addressing concerns for example, in relation to care plans and people’s anxiety management. The provider had also not identified all the concerns we identified at this inspection such as staff recruitment records. Some service records such as team meeting notes were also not available for staff to refer to.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

All staff told us they felt valued and supported by the manager. They they were approachable, and they could raise any concerns with them, and they would deal with it appropriately. The manager told us to ensure safe record keeping they do daily spot checks. The manager talked about their action plan and said it was a big piece of work and there was lots to do but said they were working to reduce the actions.

The provider told us they had completed surveys with people, their relatives and staff last year. They were going to send this evidence through, however we had not received this information. We were concerned as some people told us they did not always feel safe living at the service, due to how some people’s anxiety were being managed. The provider was working towards addressing the actions from audits and in particular the quality audit. There were several overdue actions on the action plan. During this inspection we identified 4 breaches of regulations and the previous inspection had also identified shortfalls in relation to governance. We could be assured the new manager and the provider had completed thorough audits and picked up most of the concerns we found on inspection. The manager was new to the service and more time was needed before we could be assured that all of the actions will be completed in a timely manner. We could see the manager had made some positive changes and the staff were grateful to have a manager on board who was starting to make improvements. Policies and procedures were in place. The recruitment policy was issued in January 2021 with a review date of January 2023. All other policies were in date and detailed. These were accessible on their online system.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.