St Ann's Lodge 1

Updated 20 January 2023

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

St Ann’s Lodge 1 is a care home. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. St Ann’s Lodge 1 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

We gave the service 48 hours’ notice of the inspection. This was because the service is small and people are often out and we wanted to be sure there would be people at home to speak with us.

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 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 used all this information to plan our inspection.

During the inspection

We spoke with three people who use the service and made contact with one healthcare professional. We also spoke with six staff members including care workers, the deputy manager, registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed 3 care files and 3 staff recruitment files. We looked at incidents and accidents, medicines records and records relating to quality assurance. After the inspection the deputy manager sent us policies, quality assurance questionnaires and other records in relation to the management of the service.

Updated 20 January 2023

St Ann’s Lodge 1 is a residential care home providing personal care to up to 6 people. The service provides support to people with mild to severe learning disabilities or autistic spectrum disorder. At the time of our inspection there were 6 people using the service. The care home accommodates people in one adapted building in the borough of Kingston Upon Thames.

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

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support

People’s medicines were not always managed safely. People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. The service worked well with other agencies to do so. The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted. People received supported from staff to make their own decisions about medicines wherever possible.

Right Care

Staff supported people to express their views using their preferred method of communication. People had the opportunity to try new experiences, develop new skills and gain independence.

Right Culture

The registered manager worked hard to instil a culture of care in which staff truly valued and promoted people's individuality, protected their rights and enabled them to develop and flourish. Staff felt respected, supported and valued by senior staff which supported a positive and improvement-driven culture.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 22 November 2017).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 from good to requires improvement based on the findings of this 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 St Ann’s Lodge 1 on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to medicines management at this inspection. We have also made a recommendation in relation to records management, specifically incident and accident recording and auditing systems.

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.