Bentinck Crescent

Updated 23 November 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 carried out by 1 inspector, a regulatory coordinator and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Bentinck Crescent 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. Bentinck Crescent 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 in post. The registered manager was out of the business at the time of the inspection. The home was being supported by another manager in their absence.

Notice of inspection

This inspection was unannounced.

What we did before the 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 reviewed the information we held about the service. We met with the local authority and the provider to discuss Bentinck Crescent 3 months prior to the inspection. We used all of this information to plan our inspection.

During the inspection

We spent time observing care. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with 1 person and 4 relatives about their experience of care and support at the service. We spoke with 4 staff members including the temporary manager and care staff. Care records for 4 people were reviewed, along with multiple medicines records, and records relating to the management of the service.

Updated 23 November 2023

About the service

Bentinck Crescent is a small residential care home which can support a maximum of 7 people. The home provides care and support to people with physical disabilities, people with a learning disability and autistic people. At the time of the inspection 7 people were living at the home.

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.

Right Support

People were not always 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. Best interest decisions and mental capacity assessments were not in place for all decisions made. DoLS were not up to date for all people living at Bentinck Crescent.

Although people had aspirations recorded in care documentation, they were not always supported to achieve these.

Medicines were not always managed safely. We could not be assured people received their medicines with sufficient time between doses. Some people did not have appropriate paperwork in place for ‘as required’ medicines.

Staff did support people to make decisions about their care, and people, relatives and healthcare professionals were involved in care decisions.

Right Care

Risks to people had been assessed and mitigated in most cases. However, the service had not taken action to mitigate risks around fire evacuations in a timely manner.

People were supported by enough staff to meet their needs. Staff were trained to support people. However, some staff had not received specialist training to meet people’s individual needs.

People and their relatives were happy with the care people received. People felt safe and that staff were kind. Staff understood how to protect people from poor care and abuse. The service worked with other agencies to do so. Staff had training on how to recognise and report abuse.

Right Culture

The culture of the service was not always person-centred. Some aspects of the service, such as the times of shifts, were not considered with people’s needs in mind.

Quality assurance and monitoring systems were in place. However, these were not always effective. At the time of the inspection some improvements were being made but were not yet embedded.

Staff said the interim manager was supportive. Relatives thought the service was friendly, people enjoyed living there, although needed more activities.

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 for this service was good (published 22 September 2022).

Why we inspected

We received concerns in relation to the management of the service. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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 good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, 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.

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

Enforcement and Recommendations

We have identified breaches in relation to medicines management, mitigating risks, person-centred care and consent to care at this inspection. We have also made a recommendation in relation to staffing.

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

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.