Archived: 57 Bury Road

Updated 12 August 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

This inspection was carried out by two inspectors.

Service and service type

57 Bury Road 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.

The service had a manager registered with the Care Quality Commission. 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.

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 feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We carried out observations of people's experiences throughout the inspection. We spoke to four relatives about their experience of the care provided. We spoke with four members of staff including the regional manager, registered manager and care workers.

We reviewed a range of records. This included three people’s care records and five people’s medication records. 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 quality assurance records. We looked at three staff files in relation to recruitment and staff supervision. We reviewed policies and a variety of documents the registered manager sent to us. We spoke with a further five members.

Updated 12 August 2022

About the service

57 Bury Road is a residential care home providing accommodation and personal and care to five people at the time of our inspection. The service predominantly supports people living with a learning disability and/or autism and can support up to six people.

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

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

The model of care and setting did not fully maximise people's choice, control and independence. For example, people lived in an environment where safety issues had been identified and was not clean or homely. The registered manager told us following the inspection, the refurbishment of people’s bedrooms had begun. The environment did not meet people's sensory needs. However, people had privacy for themselves and their visitors and the service was located so people could participate in the local community.

Ethos, values, attitudes and behaviours of leaders and care staff did not fully ensure people using services led confident, inclusive and empowered lives. It was not clear how people had been empowered to have as much choice and control over their care as possible. Staff were motivated to do the best they could for people.

The service was not always maximising people's choices, control or independence. Care was not always person-centred. For example, while staff knew people well and were caring in their approach and treated them with kindness and respect, care plans were not always person centred. We have made a recommendation about this.

The provider had not established an effective system to ensure people were protected from the risk of abuse. Risks to people's health and wellbeing had not been monitored or mitigated effectively.

People were at risk of harm because staff did not always have the information they needed to support people safely. Medicines were not always managed safely. The provider had not ensured there were enough numbers of competent and skilled staff to support people safely.

People did not receive a service that provided them with safe, effective, compassionate and high-quality care. The provider had not established an effective system to ensure people were protected from the risk of abuse. A lack of timely action by leaders to ensure the service was well staffed and safeguarding incidents were responded to meant people did not lead inclusive or empowered lives. Although staff had a good understanding of safeguarding the registered manager had not always reported safeguarding concerns to the local authority and CQC.

Leadership was poor, and the service was not well-led. Governance systems were ineffective and did not identify the risks to the health, safety and well-being of people or actions for continuous improvements.

The provider did not have enough oversight of the service to ensure that it was being managed safely and that quality was maintained. Quality assurance processes had not identified all of the concerns in the service and where they had, sufficient improvement had not taken place. Records were not always complete. People and stakeholders were not always given the opportunity to feedback about care or the wider service. Staff morale was low. This meant people did not always receive high-quality care.

People were supported with equality and diversity however, this impacted on other people using the service.

People were not always given the opportunity to feedback about care or the wider service.

People had access to various activities and were involved in the preparation of a weekly ‘fun day.’

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 26 January 2021 and this is the first inspection.

The last rating for the service under the previous provider was Good (published on 20 August 2018).

Why we inspected

The inspection was prompted in part due to concerns received about document recording, medicines, restrictive practices, failure to notify the local authority of incidents, inappropriate management of incidents. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive 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.

The provider had responded to some of our concerns immediately and told us they would put plans in place to make improvements for the other concerns.

The overall rating for the service is Inadequate. 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 57 Bury Road on our website at www.cqc.org.uk.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, medicines management, infection prevention and control, safeguarding, staffing and recruitment, following the mental capacity act, environment, duty of candour, failure to report incidents of concern and quality assurance at this inspection.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.