6 December 2022
During an inspection looking at part of the service
People’s experience of using this service and what we found
The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
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. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.
Right Support
People’s medicines were not always managed safely. People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse. The service worked well with other agencies to do so. The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted. People received supported from staff to make their own decisions about medicines wherever possible.
Right Care
Staff supported people to express their views using their preferred method of communication. People had the opportunity to try new experiences, develop new skills and gain independence.
Right Culture
The registered manager worked hard to instil a culture of care in which staff truly valued and promoted people's individuality, protected their rights and enabled them to develop and flourish. Staff felt respected, supported and valued by senior staff which supported a positive and improvement-driven culture.
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.
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 22 November 2017).
Why we inspected
We undertook this inspection as part of a random selection of services rated Good and Outstanding.
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.
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 St Ann’s Lodge 1 on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to medicines management at this inspection. We have also made a recommendation in relation to records management, specifically incident and accident recording and auditing systems.
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.