29 January 2021
During an inspection looking at part of the service
People’s experience of using this service and what we found
Our inspection identified a breach in relation to good governance because systems did not always effectively assess, monitor and improve the quality and safety of the service. Our inspection was prompted in part by concerns that were brought to CQC’s attention about the service. Before our inspection we had also asked the provider to investigate potential concerns but they had not done so in a thorough or robust way. We also found records were not accurately and fully maintained in relation to people’s needs and risks. This was an ongoing area of improvement identified at our last inspection, which had still not been fully addressed. Audits had not identified this and ensured records were always accurately maintained. This did not demonstrate and reflect the positive support described otherwise by people using the service.
Before our inspection, we had been notified of a number of financial abuse and theft allegations at the service since and before our last inspection in June 2019. The provider had also alerted the police and local authority of these concerns as required. People we spoke with told us they felt safe and had no such concerns.
Discussions during our inspection indicated people were appropriately supported including in response to incidents. The registered manager told us how incidents were responded to however we found records were not maintained about this to demonstrate the full learning and analysis carried out to prevent future risks.
People who received support with their medicines told us they were satisfied with this support. While improvements had been made to medicines management since our last inspection, we saw one area of improvement identified at the last inspection had still not been fully addressed.
Staff were recruited safely and there were enough staff to meet people's needs. Staff followed the infection control procedures the provider had in place. Staff spoke positively about their roles and told us they felt supported.
People told us they would feel comfortable speaking up if they had any concerns. People were routinely asked for their feedback about the service although people’s individual care reviews were less frequent. People expressed very positive experiences of using the service when giving feedback to the service and during discussions as part of our inspection.
The registered manager understood their legal responsibilities in regard to safeguarding and notifications.
Rating at last inspection
The last rating for this service was Good (published 24 August 2019).
Why we inspected
We received concerns about people’s experiences including in relation to allegations of abuse and infection control. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.
We have found evidence that the provider needs to make improvements. Please see the Safe 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.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Housing 21 - Alrewych Court on our website at www.cqc.org.uk.
Follow up
We will request an action plan for 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.