24 August 2020
During an inspection looking at part of the service
37 Spenser Road is a residential care home providing personal care to 11 people the time of the inspection. The service can support up to 13 people in two buildings.
Services for people with learning disabilities and or autism are supported
The service was registered to provide support to up to 13 people and there were 11 people using the service at the time of our inspection. The service is larger than recommended by best practice guidance. The service was not person centred, and people were not supported to maximise their independence.
People’s experience of using this service and what we found
There had been very little improvement since our last inspection in May 2019. There remained serious short-falls within the service which exposed people to risk.
Risk assessments were not in place to support people living with health conditions including constipation, and epilepsy. Manual handling guidelines were not in place for a person who required support moving and transferring. Most of the staff team did not have in date manual handling training.
Environmental risks had not been assessed, as there was a bath hoist that had not been serviced. Provider audits did not identify this issue.
Staff lacked the training guidance and support to fulfil their roles. For example, staff had not received training in key areas such as positive behaviour support. The provider did not recruit staff in a safe way to ensure people were suitable to work with vulnerable adults.
Risks relating to covid-19 had not been identified by the provider. For example, staff were not using the appropriate personal protective equipment in line with government guidelines.
There was a lack of oversight and learning in relation to incidents and accidents. Improvements had not been implemented and embedded and as a result incidents re-occurred.
The culture of the service was not positive. The changes in management had left staff morale low. There had not been a registered manager at the service since July 2018. This had impacted on the quality of the service, and outcomes for people.
Checks and audits had been ineffective. Issues identified at our last inspection remained and we identified further concerns. There was a lack of leadership, consistency and oversight at the service. Regulatory responsibilities had not been met.
The service didn’t always (consistently) apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; lack of choice and control, limited independence, limited inclusion for example, people were not engaged in meaningful activities.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was Requires Improvement (published 3 July 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.
Why we inspected
We received concerns in relation to staffing, risks to people, lack of management oversight. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. 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 Requires Improvement to Inadequate. 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 key question 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 37 Spenser 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 risks to people not being mitigated, people being at risk of abuse, staff not being recruited safely, notifications not being submitted and checks and audits being ineffective at this inspection.
We imposed positive conditions on the providers registration.