Endsleigh Care Limited

Endsleigh Care Limited is a residential care home providing personal care to eight people with mental health needs at the time of the inspection. The service can support up to 11 people. The premises consisted of two houses that had been converted into one on a residential street.

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

Risk assessments were in place for people, but these did not provide adequate guidance about how to mitigate risks associated with violence and aggression. The premises were not safe, as dangerous equipment was accessible to people and locks on bathroom doors could not be opened by staff in the event of an emergency. Infection prevention and control measures were not sufficiently robust. Quality assurance and monitoring systems were not always effective. Pre-admission assessments did not cover needs in relation to equality and diversity. The provider did not seek people’s views about end of life care.

People spoke positively about the service and the support they received. Steps had been taken to safeguard people from the risk of abuse. There were enough staff working at the service and robust staff recruitment practices were in place. Medicines were managed in a safe way. Lessons were learnt from accidents and incidents.

Staff undertook training and supervision to support them in their role. People were able to make choices about what they ate and to have a healthy and nutritious diet. The provider worked with professionals to help meet people’s health care needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People told us staff were caring and that they were treated with respect. Staff understood how to support people in a way that promoted their privacy, independence and dignity.

Care plans were in place for people, which set out how to meet their needs in a person-centred manner. Information was provided to people in a way that was accessible to them. People were supported to follow their interests and access the local community. Systems were in place for dealing with complaints.

People and staff told us there was an open and positive culture at the service and they spoke positively about the registered manager. People were supported to express their views. The provider was aware of their legal obligations, and worked with other agencies to develop best practice and share knowledge.

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 2 November 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the physical environment. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive 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 Endsleigh Care Limited on our website at www.cqc.org.uk.

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 this inspection.

We have identified breaches in relation to risk assessments, the safety of the premises, infection prevention and control measures and quality assurance systems at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Endsleigh Care Ltd is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

It is a care home for up to 11 people with mental health needs. At the time of our inspection, the home was fully occupied, although one person was staying in the home for a short period.

The environment was safe and works were being carried out to protect the home from fire risks. We made a recommendation for people’s individual evacuation plans to be updated following the works. There were procedures to control infections and the home was clean and suitable for peoples’ needs. Accidents and incidents in the home were used to learn lessons so they were minimised in future.

Staff knew how to keep people safe and understood safeguarding procedures to protect people from abuse. Risks to people were identified and there was guidance in place for staff to minimise these risks. People were supported by staff who had received training to ensure they had the skills to support them.

There were enough staff on duty to support people. Recruitment processes were safe, which ensured that staff were suitable to work with people who needed support. Systems were in place to ensure medicines were administered safely and when needed.

People’s nutritional needs were met. Staff worked with health and social care professionals, such as community psychiatric nurses and GPs, to ensure people remained healthy.

People were supported to have choice and remain as independent as possible. The service was compliant with the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People and relatives were involved in decisions about their care.

Staff were attentive to people’s needs and supported them to maintain their personal care and engage in the community with activities and vocational work that they enjoyed. Staff were responsive to people and knew them well. The staff were caring and treated people with respect. People's privacy and dignity were maintained. People were involved in the review of their care plans, which were personalised. They were able to provide feedback and make suggestions about what they wanted from the home.

Staff felt supported by the registered manager and told us the home was well-led. Quality assurance systems were in place. The registered manager ensured the service was monitored regularly and was supported by an external consultant.

Endsleigh Care is a care home that is registered to provide accommodation and support with personal care for eleven people with mental health and psychiatric needs. The service aims to provide rehabilitation and recovery to people with psychiatric and forensic histories who want to move into their own home after they have made sufficient progress in their recovery.

The service had a registered manager in place at the time of our inspection. 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.

The service was divided into two residential units with six bedrooms in one unit and five bedrooms in another unit. They were supervised by the registered manager and a deputy manager. At the time of the inspection nine people were using the service. During our last inspection on 11 January 2014, we found that the service was compliant with all regulations we checked.

The service provided care and support to people to enable them to become more independent. We found that people were cared for by sufficient numbers of qualified and skilled staff. Staff also received one to one supervision and received regular training. People were supported to consent to care and the service operated in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People were given choices over what they wanted to eat and drink and they were supported to access healthcare professionals. People’s finances were managed and audited regularly by staff so that their money was kept safely and securely. People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. The care plans contained a good level of information setting out exactly how each person should be supported to ensure their needs were met. The care plans included risk assessments as some people had restrictions placed upon them by the Ministry of Justice. However, the service did not have up to date outcome and recovery systems which measured people’s progress.

Staff had very good relationships with people living in the service and we observed positive and caring interactions. Staff respected people’s wishes and their privacy and supported people to express their views. People pursued their own individual activities and interests, with the support of staff. The environment was safe and clear of any health and safety hazards.

There was a structure in place for the management of the service. People, relatives and visitors could identify who the registered manager was. People felt comfortable sharing their views and speaking with the registered manager if they had any concerns. The registered manager demonstrated a very good understanding of their role and responsibilities. Staff and people told us the registered manager was supportive. There were systems to routinely monitor the safety and quality of the service provided.

We found one area where we have made a recommendation to the service, which is detailed in the report.

People told us they were happy with the staff who worked at the service. One person said "I like it here, they (staff) are a nice lot." We found that the service had robust staff recruitment procedures in place, including obtaining employment references and Criminal Records Bureau checks. Records at the service were stored securely, and were accessible by appropriate persons.

We found that medications were not all securely stored, and that record keeping in relation to medication was not up to date. The service must address this issue.