Background to this inspection
Updated
22 June 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was 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.
Inspection team
The inspection was carried out by three inspectors. Two inspectors visited the home. One inspector gathered information from the head of care via telephone conversations and email and spoke with staff and with a relative over the telephone.
Service and service type
Wembrook Close is a ‘care home’. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
Our inspection was announced. We gave the provider 24 hours’ notice of our visit because the service was inspected during the coronavirus pandemic and we wanted to be sure we were informed of the service’s coronavirus risk assessment for visiting healthcare professionals before we entered the building.
What we did before the inspection
We reviewed the information we had received about the service since the last inspection and recurrent themes of any concerns. This included concerns shared with us from staff members and members of the public during 2021. Information of concern was shared with us from the Local Authority (LA) following a quality monitoring visit they had undertaken during March 2021. A Fire Service inspection undertaken during March 2021 had found numerous discrepancies where the provider was failing to meet the Fire Safety Regulations. This information helps support our inspections.
We used all this information to plan our inspection.
During the inspection
During our on-site visit to the service, we observed staff interactions with people and spoke with the head of service, care manager and a staff member on shift. We reviewed two people’s care plans, risk management and medicine records in detail. We looked at a sample of records relating to the management of the service, policies and procedures and a sample of completed audits and checks.
During our off-site work we spoke with one person’s relative and four staff. This included the head of care and regional manager.
After the inspection
We wrote formally to the provider to inform them of our serious concerns and requested additional documentation to be sent to us by 12 May 2021. We asked them to share evidence with us about immediate actions taken, which they did.
Updated
22 June 2021
About the service
11 Wembook Close is a residential home, providing care and accommodation for up to four people. It provides care to people living with a learning disability and other support needs including autism. At the time of our inspection visit two people lived at the home.
People's experience of using this service and what we found
People did not receive safe care. Risks associated with people’s care were not always identified, managed or mitigated. The provider had not effectively assessed staff had the skills, knowledge or experience they needed to provide care which ensured people living at the service were safe and others’ safety was maintained. People’s care plans did not always contain detailed or accurate information to help staff support people safely. The provider had not always ensured detailed records were kept of important healthcare visits or guidance.
People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support least restrictive practices. Where restrictive practices were used the provider had not always acted in line with the Mental Capacity Act 2005.
An 'infection prevention control' audit was carried out by CQC during the inspection. We found the provider was not consistently following government guidelines. Risks related to Covid-19 were not consistently well managed.
People were not cared for in premises that were consistently safe. Fire safety deficiencies had not always been acted on in a timely way. The provider had not ensured staff consistently had the equipment needed to keep people safe.
An admission to the home had not been well-managed by the provider and meant systems to manage potential abuse were not effective.
Governance systems, and management and provider oversight of the service were inadequate. Systems and processes designed to identify areas of improvement were ineffective. The providers policies and procedures did not always provide staff with the guidance they needed. Audits and checks had not identified the concerns we found.
The management of individual and environmental risks continued to require improvement.
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. (Report published 21 February 2018).
Why we inspected
We undertook this focused inspection because emerging risks had been identified by us and other professional bodies including the Local Authority and Fire Service. We had also received information of concern from staff and members of the public prior to our inspection visit in relation to the management of risks at the home and how people’s needs were met. As a result, we undertook a focused inspection to review the key questions of Safe and Well Led only.
Enforcement
We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of our inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We identified breaches in relation to the risks associated with people’s care and management oversight of the service. The provider had not ensured effective systems and processes were in place to monitor the quality of the service and drive improvement.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during our inspection is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider to agree our ongoing monitoring of the service and discuss how they will make changes to ensure they improve. We will work with the Local Authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Special Measures
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within six months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.