Background to this inspection
Updated
10 January 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 team consisted of 1 inspector.
Service and service type
Jigsaw Creative Care Limited - 77 Russell Street is a ‘care home’ and respite care service. 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. 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
The inspection was unannounced.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. 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 observed people receiving care and support. We spoke with 3 relatives. We spoke with 8 members of staff, including the registered manager. We reviewed a range of records including 2 people's care records and 3 medicines records. We looked at 4 staff files in relation to recruitment, and a variety of records relating to the management of the service, including policies and procedures.
Updated
10 January 2024
About the service
Jigsaw Creative Care Limited - 77 Russell Street is a respite care service. It can provide accommodation and personal care for up to 3 people at any one time. 10 people used the service at different times. On the day of the inspection 2 people were using the respite service.
People’s experience of the 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 assessment and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Support:
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. Systems in the service supported this practice.
People were put at increased risk of fire. During the inspection we found risks relating to fire safety had not been adequately mitigated. People using the service did not have access to the garden, however, actions were taken by the management team after the inspection to ensure people had access to the garden. There was no cleaning schedule for the entire property and protocols were not in place for cleaning bedrooms in between respite stays.
Care plans were individualised and contained a comprehensive assessment of people’s needs and abilities.
Right Care:
Medicine administration records were not always fully completed.
Safeguarding policies and procedures were in place, and staff knew how to report any concerns. Staff received training in safeguarding adults and children.
Right Support:
People were supported by staff who knew them well. Relatives told us and we observed, staff respected people and treated them with dignity and compassion. People were supported to maintain their privacy and promoted their independence. The service had training appropriate to staff roles, this included training in learning disabilities and autism and positive behaviour support.
People were supported to access the community; partake in activities they enjoyed and socialise with peers. Staff at the service knew how to communicate with people effectively to ensure people’s views were heard and respected.
Right Culture:
Systems and processes did not always effectively ensure good oversight of the service. Audits had not always identified the areas that required improving found on inspection.
Complaints procedures were in place. Staff and relatives told us they knew how to complain, however there had been no complaints raised.
The management team were open and transparent throughout the inspection process. Feedback from relatives was positive.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
At the last inspection the service was rated good in all domains. At this inspection we found the rating for the domains of safe and well led was requires improvement with the overall rating for the service now being requirements improvement.
Why we inspected
The inspection was prompted by the length of time since we had last inspected. We undertook a focused inspection to review the key questions of safe and well-led only. During the inspection we found concerns relating to premises and documentation within people’s care files, so we widened the scope of the inspection to include effective, caring and responsive.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment, and good governance. We have made a recommendation in relation to recruitment. Please see the action we have told the provider to take at the end of this 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.