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Archived: Integra Care Homes Limited - 105 Water Lane Inadequate

Inspection Summary

Overall summary & rating


Updated 24 October 2019

About the service

105 Water Lane is a residential care home providing accommodation and personal care to older and younger adults with a learning disability or autism. At the time of the inspection there were four people living at 105 Water Lane, some with complex needs. The service can support up to eight people.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to eight people. Four people were using the service. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

People were not safe from potential harm because known risks to people were not effectively being monitored by the management and staff team. People who had known risks of ingestion, and where incidents had already occurred, still had access to items that could cause them potential harm.

There were inadequate numbers of permanent staff and the service was reliant on agency staff.

There were not sufficient staff with suitable skills, knowledge and experience deployed to meet the needs of the people.

Relevant recruitment checks were conducted before staff started working at the service to make sure staff were of good character and had the necessary skills. However, there were unexplained gaps in staff employment histories.

Environmental risks were not managed effectively; fire alarm tests were not up to date as recommend by fire safety regulations. People did not have regular fire evacuations to keep them safe. The home was dirty and in need of cleaning and the service needed redecoration.

People were not supported to eat a balanced diet. There were not meaningful activities and access to the community for people to reduce the risk of social isolation. People were not always treated with dignity and respect.

Medicines were not always safe, and people did not have pain relief available to them when needed.

Staff did not receive regular support and one to one sessions or supervision to discuss areas of development and to enable them to carry out their roles effectively. Training had fallen behind, and we could not be assured staff had appropriate training in place to keep people safe.

People’s rights were not always protected because staff did not always understand and work within the principles of the Mental Capacity Act 2005 or Deprivation of Liberty Safeguards. These were in the process of being reviewed.

Each person had care plans in place although there was not always sufficient detail to guide staff and plans were not always up to date. We found staff did not always follow the guidance and some plans contained inaccuracies and missing information. There were concerns with missing entries and gaps in charts to monitor people’s food and fluid and bowel movement.

During our inspection we found there was a lack of effective management and leadership in the home. Staff felt unsupported and let down by management and m

Inspection areas



Updated 24 October 2019

The service was not safe.

Details are in our safe findings below.



Updated 24 October 2019

The service was not effective.

Details are in our effective findings below.



Updated 24 October 2019

The service was not caring.

Details are in our caring findings below.



Updated 24 October 2019

The service was not responsive.

Details are in our responsive findings below.



Updated 24 October 2019

The service was not well-led.

Details are in our well-Led findings below.