Archived: 44 Broad Green Avenue

Updated 28 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 25 September 2017 and was unannounced. The inspection was undertaken by two inspectors.

Prior to the inspection we reviewed the information we held about the service, including any statutory notifications received. These are notifications about key events that occurred at the service which are required to be sent by law. We also liaised with representatives from the local authority safeguarding team and the police.

During the inspection we spoke with two people and observed interactions between a third person and staff as they were unable to have a conversation with us. We spoke with the registered manager and the support worker on duty. We reviewed three people’s care records and four staff records. We viewed medicines management procedures, the environment and records relating to the management of the service. After the inspection we received feedback from a representative from a referring authority regarding the care of one person at the service.

Updated 28 November 2017

44 Broad Green Avenue provides accommodation, care and support to up to six people with a learning disability. At the time of our inspection four people were using the service.

At our last inspection of the service on 29 June 2016 the service was rated ‘good’ overall and for all key questions. We undertook an unannounced comprehensive inspection on 25 September 2017. We undertook this inspection because we received concerns about whether people using the service were adequately protected from abuse. At the time of inspection there was an ongoing safeguarding investigation and police investigation due to the concerns raised. The outcome of which could not be considered as part of this inspection.

The registered manager remained in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people’s health, safety and welfare had not been adequately assessed and mitigated. We found risk assessments did not contain detailed information about how risks were to be mitigated and there was some conflicting information in the risk assessments completed. The provider had not sufficiently protected people from environmental risks. The registered manager had not protected people from the risk of burns from hot water or uncovered radiators, or protected people from accessing harmful chemicals as these were not stored securely.

Staff were not up to date with their required training meaning there was a risk that staff’s knowledge may not be in line with good practice guidance. We also saw some staff had not completed training related to people’s specific needs including epilepsy and autism which may impact on their ability to support people with these needs.

Staff did not always adhere to the principles of the Mental Capacity Act (MCA) 2005. There was a lack of information about what aspects of their care people had the capacity to consent to. Where staff felt people did not have the capacity to understand certain decisions, there was no information relating to MCA assessments or best interests’ decisions. Staff had not applied to lawfully deprive a person of their liberty when they required this level of support in order to safe.

Accurate, complete and contemporaneous records were not maintained in regards to people’s care. Care records were not always regularly reviewed and updated in line with changes in people’s needs. The records lacked information regarding the level of support people required and how this was to be delivered.

Robust and effective systems were not in place to review the quality of service delivery and ensure timely and appropriate action was taken to address any concerns identified. Sufficient systems were not in place to mitigate risks to people’s health, safety and welfare. The provider’s policies were not regularly reviewed and updated.

Staff knew the people they were supporting and provided them with the support they required. They encouraged people to develop their skills and to become more independent. People participated in a variety of activities in line with their hobbies and interests, and where able were supported to undertake work opportunities. Staff were aware of how people communicated and enabled them to make choices about how they spent their time.

Staff supported people to access healthcare services and accompanied them to appointments. Staff were aware of people’s dietary requirements and enabled them to eat and drink sufficient amounts to meet their needs. Staff assisted people with their medicines and people received their medicines as prescribed.

There were sufficient staff to meet people’s needs and provide them with the level of support they required. Staff were aware of their responsibility to safeguard people from avoidable harm and were aware of the reporting procedures if they did have concerns about a person’s safety. Staff supported people to raise any concerns about their care and a process was in place to record, investigate and respond to any complaints made.

There were processes in place to obtain staff, people and their relatives’ views about the service through regular meetings and completion of satisfaction surveys.

At the time of inspection the registered manager was aware of their requirements of their CQC registration responsibilities in regards to the submission of statutory notifications. We had received notifications about recent events, including allegations of abuse and incidents involving the police.

We found the provider was in breach of legal requirements relating to safe care and treatment, need for consent, staffing and good governance. After the inspection we contacted the provider asking what action they had taken to address the concerns raised. They provided us with information and evidence of the action taken to address some of the concerns raised which showed some of the risks identified at time of inspection had been minimised. We took this information into account when deciding what action we took. You can see what action we have asked the provider to take at the back of the report.