South Street

Updated 6 March 2024

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.

Inspection team

The inspection was conducted by a CQC Operations Manager who visited the service. A Regulatory Coordinator worked remotely to make calls to relatives of people who used the service.

Service and service type

South Street 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. South Street 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people and 2 relatives about their experience of the care provided. We also spoke with 3 members of care staff and the registered manager.

We reviewed a range of records, these included 2 people’s care records, medicines administration records, as well as governance and quality assurance records. We also looked at 3 staff recruitment files.

Updated 6 March 2024

About the service

South Street is a care home for people who may have a learning disability or autism. The service was registered for up to 9 people; 8 people lived there at the time of our inspection.

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.

People’s experience of using this service and what we found

Right Support:

Care records were mostly detailed and informative. However, some records did not always contain all the information required to keep people safe. Despite this, staff knew people’s care needs well and people and their relatives told us they felt safe and supported.

Records did not always show that appropriate action was taken in response to incidents at the service. Safety incidents did not always trigger a review of people’s risk assessments and management plans.

The systems in place to monitor safety and quality at the service were not always fully effective. The registered manager and provider did not always report notifiable incidents to us and the local authority as required.

Right Care:

Improvements were needed to ensure people’s weight was monitored effectively to identify any significant changes in weight.

There were sufficient numbers of suitable staff at the service. However, improvements were required to ensure the risks associated with delays in pre-employment checks were formally risk assessed.

Staff supported people in line with their individual preferences and agreed care plans. People were supported to receive their medicines when they needed them and were protected from the risk of infection as staff followed safe infection prevention and control practices.

Right Culture:

The auditing systems in place to assess and monitor safety and quality were not always effective.

People told us they were supported to have maximum choice and control of their lives. However, records did not always evidence that the requirements of the Mental Capacity Act 2005 were consistently applied.

People were able to receive visitors without restrictions in line with best practice guidance.

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 good (published 24 November 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We planned to complete a focused inspection to review safe and well-led only. However, due to concerns identified during the inspection with regards to the application of the Mental Capacity Act 2005, we also reviewed the effective key question.

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 to requires improvement. This is based on the findings at this inspection

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for South Street on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified regulatory breaches in relation to; the application of safeguarding processes, the processes in place for assessing and obtaining consent to care and the systems in place to assess, monitor and improve the quality of care at the service.

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