Background to this inspection
Updated
27 August 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.
Inspection team
The inspection was carried out by two inspectors.
Service and service type
This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.
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 there was a registered manager in post, however the registered manager was not present during the inspection.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 9 August 2022 and ended on 15 August 2022. We visited the location’s office on 9 August 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and 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
We spoke with four people using the service and 10 staff members including, care workers, care coordinators, the regional business manager and the compliance manager. We reviewed a range of records including six care files, six staff recruitment files, policies and procedures and medicines records.
Updated
27 August 2022
About the service
Cheviot Gardens is an Extra care housing scheme providing personal care to people. The service provides support to older people living in rental and shared ownership homes. At the time of our inspection there were 31 people using the service.
Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.
People’s experience of using this service and what we found.
People were not always protected against the risk of avoidable harm as risk management plans did not give staff clear guidance how to mitigate risks. People’s medicines were not always recorded in line with good practice. As and when required medicines protocols were not always in place. Staff personnel files did not always contain staff’s full employment history.
People did not always receive a service that was well-led. Systems and processes in place failed to identify all the issues found during this inspection. Records were not always easily accessible or in place at the time of the inspection.
People continued to be protected against the risk of abuse as staff knew how to identify, respond to and escalate suspected abuse. People continued to receive support from sufficient numbers of staff deployed.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People and staff were complimentary about the registered manager and their management style. The registered manager worked in partnership with other healthcare professionals and services to drive improvements. People confirmed their views were frequently sought and action would be taken on any issues identified.
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 19 November 2019).
Why we inspected
We received concerns in relation to staffing levels, fire safety and management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe 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 Cheviot Gardens 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 will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to medicines management, risk assessments and good governance at this inspection.
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.