17 York Avenue

Updated 30 June 2022

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 and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

17 York Avenue is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. 17 York Avenue 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection, the service had a registered manager.

Notice of inspection

We gave the service 24 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.

Inspection activity started on 17 May 2022 and ended on 19 May 2022. We visited the service on both dates.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. 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 four people who used the service and two relatives about their experience of the care provided. We spoke with three care staff and two managers. We observed a shift handover between staff. We reviewed four people’s care records including their medication files. We looked at three staff files in relation to recruitment. We reviewed a range of records relating to the management of the service including audits and policies.

Updated 30 June 2022

About the service

17 York Avenue is a residential care home that provides accommodation and personal care to up to four people. The service provides support to people with a range of needs including learning disability, mental health and physical disabilities. At the time of our inspection, there were four people living at the service.

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

The service had simple paper-based care records. Staff assessed people’s risks and needs and drew up care plans to address them. However, we found some gaps and inconsistencies in the records, for example, some lacked dates, some had not been updated and some of the templates used were inappropriate. People’s self-medication care plans lacked detail about the support needed from staff, and staff did not always review risk assessments when medicines changed. The manager started to address these issues immediately.

Most of the home was clean and tidy but there were stains and coatings of grease on the kitchen cupboards and some appliances. Staff started to address this during our inspection. The décor in the care home’s communal areas and in one bedroom needed updating. The provider shared their plans for redecorating and refurbishing the communal areas of the home but these plans did not include people’s bedrooms as the provider did not think this was their responsibility. We have made a recommendation in relation to the standard of décor in the home and the provider clarifying their responsibilities for the premises.

Some people administered their own medicines. Staff followed systems and processes to safely administer, record and store medicines for those people they supported fully with their medicines. The service had a stable staff team and enough staff to meet the needs of people all of whom had low support needs. People received support to live full and active lives as independently and safely as possible and to pursue their interests, aspirations and goals. Most people had full weekly schedules that included voluntary work, social events, family visits, day centre attendance and daily living activities. People took part in activities that were culturally relevant to them.

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.

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

The service had a positive culture that focused on person-centred care and meaningful outcomes for people. People had the maximum possible choice, control and independence over their own lives. People’s care records showed what support each person needed to make their own decisions and choices.

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

Rating at last inspection

The rating at the last inspection was Good, (published on 21 March 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement and Recommendations

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 will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to good governance associated with care records. We have made recommendations relating to the standard of décor in the home and the provider's responsibility for the premises.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.