Archived: Overbrook

Updated 19 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was unannounced and was carried out on 22, 24, and 26 August 2017 by one inspector.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and the improvements they plan to make. We reviewed the information in the PIR, along with other information that we held about the service including previous inspection reports and notifications. A notification is information about important events, which the service is required to send us by law.

People living at the home were not able to communicate with us verbally. We observed care and support being delivered in communal areas of the home. 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 the families of two people.

We spoke with two members of the staff, a senior care staff member and the registered manager. We also spoke with the Service Manager - ASC Short Term and Learning Disability Services, who was the provider’s representative. We looked at care plans and associated records for all four people living at the home, staff duty records and other records related to the running of the service, including recruitment files, records of complaints, accidents and incidents, policies and procedures and quality assurance records.

This home was previously inspected in July 2015 and was rated good.

Updated 19 October 2017

Overbrook is a local authority run care home registered to provide accommodation for up to four people living with a learning disability. At the time of our inspection there were four people living in the home. The inspection was unannounced and was carried out on 22, 24 and 26 August 2017.

There was a registered manager in place at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

The provider was not fully engaged in the running of the home. They did not have an effective system in place to monitor the quality and safety of the home; the records relating to people’s care were not always accurate and up to date.

There was not enough staff available at the home to safely meet people’s needs. The registered manager had not always fully assessed the risks associated with people’s care and support.

People medicines were not always managed safely and they did not always receive their medicine in the correct way. Staff did not always protect people from the risk of infection.

People’s ability to make decisions was not assessed and staff did not follow legislation designed to protect people’s rights.

People did not always receive support from staff who had received the appropriate training to meet their needs.

Staff were task focused and did not always treat people with dignity and respect; or respect people’s choices and their privacy.

People’s records of care were not always personalised and staff were not always responsive to people’s needs.

People were not able to engage in individual activities and access the community on an individual basis. They did not receive appropriate mental and physical stimulation.

People were supported to have enough to eat and drink; however, mealtimes were not always a social experience for people.

People’s families and staff had the opportunity to become involved in developing the service, however the provider did not always respond to feedback provided. The provider had a process in place to deal with any complaints or concerns, although the process was not always followed. People’s families were involved in discussions about their care.

Staff received an appropriate induction into their role and were aware of their responsibilities to safeguard people from abuse. Recruiting practices ensured that all appropriate checks had been completed.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

During our inspection, we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.