59 Bury Road

Updated 1 March 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.

Inspection team

The inspection was carried out by 1 inspector.

Service and service type

59 Bury Road 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. 59 Bury Road 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 beginning of our inspection there was a registered manager in post. However, after the second day of the inspection the provider informed CQC that the registered manager (referred to in the report as the previous registered manager) had resigned after working a period of notice and they were in the process of recruiting a replacement. In the interim, a registered manager working for the provider who is supporting the service (referred to as ‘the manager’ in this report) and the deputy manager will oversee the running of the service.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and spoke to 2 health and social care 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

Inspection activity started on 29 November 2022 and ended on 12 January 2023. We visited the service on 29 November, 20 December 2022 and 12 January 2023. We spoke to 4 people living at the service and 3 relatives via telephone. We received written feedback from 1 further relative. We spoke to 8 staff members including; the previous registered manager, the manager, the deputy manager, the regional manager and care staff. We reviewed 4 people’s care plans, medicines administration records, incident forms, policies, records of safeguarding investigations, maintenance records, risk assessments and staff recruitment files.

Updated 1 March 2023

About the service

59 Bury Road is a residential care home providing accommodation and personal care to up to 6 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 6 people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Based on our review of the key questions safe, effective and well led, the service was not able to demonstrate they were fully meeting the underpinning principles of Right support, right care, right culture.

Right Support: People had their own individualised care plans in place, but they were not always reviewed or updated to ensure they reflected people’s most current needs. There were ineffective systems in place to monitor incidents, which meant there were missed opportunities to avoid and reduce reoccurrence. There were policies and systems in place to support people’s choice, control and independence, but these were not always followed, People were not always supported to have the maximum possible choice, control and independence in their daily lives. Care was not always documented to accurately reflect how staff had supported people in a positive way.

Right Care: Staffing levels impacted on people receiving person-centred care. People were not always provided with opportunities to utilise their commissioned 1 to 1 support, tailored to them to enhance and enrich their lives. However, staff had a good understanding of people’s needs and the provider recognised where people responded positively to specific staff members when supporting them when anxious or upset. People were comfortable and happy in staff’s presence and staff we spoke to were knowledgeable about people’s needs.

Right Culture: There was inconsistent leadership at the service which resulted in ineffective governance and quality assurance systems. There were audits and action plans in place to improve the quality of care. However, these were not consistently completed and in some cases actions were not followed up or documented. This meant that improvements were not always implemented, the provider’s governance systems were not always followed and issues around the quality of care and safety of the environment at the service were not always addressed. Relatives and health and social care professionals told us there had been communication difficulties with the provider, which at times had not promoted a positive working relationship around planning and reviewing people’s care.

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

Rating at last inspection

This service was registered with us on 1 December 2020. We carried out an Infection prevention and control inspection of the service in January 2021, where the service did not receive an inspection rating.

Why we inspected

We received concerns in relation to staffing and safeguarding people from the risk of suffering abuse. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. The overall rating for the service is requires improvement.

We have found evidence that the provider needs to make improvements. Please see the safe, effective 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.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

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.