1–3 Emily Jackson Close is a care home providing personal care to up to 18 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 17 people using the service. The service is set across 3 individual bungalows.
People’s experience of using this service and what we found
Staff provided effective support to identify people's aspirations and goals and assisted people to plan how these would be met. Staff focused on people's strengths and promoted people’s independence. There was a consistent approach to supporting people to learn new daily living skills. Staff enabled people to access health and social care support in the community.
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; the policies and systems in the service supported this practice.
Staff understood the risks to people's health, safety and welfare. Risk assessments provided guidance for staff about individual risks. However, some risk assessments did not have enough guidance for staff to ensure people were as safe as possible. Whilst staff knew people well, positive behavioural support plans were still in the process of being reviewed and updated. Without robust plans and information there was a risk people were not supported in a consistent way.
People were protected from the risks of harm, abuse and discrimination because staff knew what action to take if they identified concerns. Accidents, incidents and near misses were recorded and reviewed. However, the level of detail recorded varied and there was a risk of action not being taken in a timely way.
There were enough staff to provide the support people needed.
Staff provided care to people which was person-centred and promoted people's dignity, privacy and human rights. People's individual choices were recognised and respected. Staff promoted equality and diversity in their support for people and their protected characteristics were considered.
People could communicate with staff as staff understood their individual methods of communication. People were empowered to take part in activities of their choice. People were supported to keep in touch with people who were important to them. Relatives spoke positively about the support their loved ones received.
Checks and audits were being regularly completed. Shortfalls were identified and action taken to address these. However, we found some shortfalls around risk assessments and accidents and incidents which had not been identified. We discussed this with the manager who agreed to take action to remedy these.
The service enabled people and those important to them to work with staff to develop the service.
Feedback was requested from people, relatives and health care professionals.
Safe recruitment practices were followed. Staff knew and understood people well. The provider and staff worked hard to develop strong leadership. The management structure had been changed following the last inspection and staff spoke about the positive impact this had had.
Quality monitoring systems were being developed and embedded. Morale within the staff team was good and staff felt valued.
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 inadequate (published 23 October 2023). The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made. We found the provider remained in breach of regulation 17 (good governance).
This service has been in Special Measures since 23 October 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 1-3 Emily Jackson Close on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified a breach in relation to good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
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.