78 Stubbington Lane

78 Stubbington Lane is a small residential care home providing personal care to up to 6 people. The service provides support to people who live with learning disabilities and autistic people. At the time of our inspection there were 6 people using the service.

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 supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. For example, people had not been involved in developing their support plans and were not involved in reviews about their care. Where people lacked capacity to make choices the principles for the Mental Capacity Act (MCA) were not always followed. People did have privacy for themselves and their visitors, and the service was in a location where people could participate in their local community

Right Care

Care was not fully person-centred. For example, staff did not always know people well. People were not always treated with dignity and respect and care plans were not always person centred. We have made a recommendation about this.

Right Culture

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.

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.

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 safeguarding incidents were reported meant CQC and the local authority did not have the information required to monitor the safety of the people using the service. Some staff did not always have a good understanding of safeguarding, they did not always recognise safeguarding concerns or highlight them to the management team. This meant safeguarding concerns had not always been referred to the local authority and notified to CQC.

People were not always involved in decisions about their care. We have made a recommendation about this.

The Accessible Information Standard (AIS) was not always followed. We have made a recommendation about this.

Leadership at the service had been poor until recently, and the service was not well-led. Governance systems were not always effective and did not always identify the risks to the health, safety, and well-being of people. The regional manager had set up an action plan to make improvements.

The provider did not always 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 always taken place. Records were not always complete. People and stakeholders were not always given the opportunity to feedback about care or the wider service. This meant people did not always receive high-quality care. The provider had identified these areas of concern and was taking action to ensure good governance.

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 1 December 2020 under a new legal entity, and this is the first inspection under this provider.

The last rating for the service under the previous provider was good, published on 4 February 2020.

Why we inspected

The inspection was prompted in part due to concerns received about medicines management, the cleanliness of the environment and lack of suitably trained staff. A decision was made for us to inspect and examine those risks.

The provider had taken action to mitigate some of the risks.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to assessing risk, medicines management, safeguarding, the Mental Capacity Act (MCA), person centred care, training, managing feedback, management oversight and failure to notify CQC of required incidents at this inspection.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.