Archived: Shifa Lodge

Updated 26 January 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 one inspector

Service and service type

This service is both a domiciliary care agency and supported living service. It provides personal care to people living in their own houses and flats. It also provides care to people living in a ‘supported living’ setting, so they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

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 time of our inspection there was not a registered manager in post. The manager of the domiciliary care service told us they were in the process of applying to become registered but no applications to register had been submitted.

Notice of inspection

We gave the service a short notice period before the inspection. This was because it is a small service and we needed to be sure that the provider or registered manager would be in the office to support the inspection.

What we did before the inspection

We reviewed the information we had received from the service, including the information they submitted to demonstrate they were now delivering regulated activities. We sought feedback from the local authority.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

The inspection activity started on 8 December and finished on 21 December. We visited the office on 8 December. We spoke with 6 members of staff including three service managers, the director of the company and 2 support workers. We also spoke with an advocate. We received feedback from the local authority safeguarding team. We reviewed the care files of the 2 people who received support with personal care including needs and risk assessments, care plans and records of care. We reviewed 2 staff files including recruitment and training records. We reviewed other records, policies and procedures relevant to the management of the service.

Updated 26 January 2023

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.

About the service

Shifa Lodge is registered to provide personal care. The service provides personal care to one person living in their own home and one person living in a supported living setting. The provider has multiple supported living shared houses and flats, with varying levels of staffing depending on the needs of people living in the setting.

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

Right Support:

The model of care in place did not consistently maximise people’s choice, control and independence. We are looking into the model of care as it was not clear that the supported living setting offered people the rights and protections it should have. 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. The provider had not ensured consent had been sought appropriately and had not identified that people were restricted by their support. This meant they had not sought the appropriate authorisations to ensure the restrictions were safe and legal.

Right Care:

People received care that was personalised from staff who knew them well. However, the provider had failed to capture people’s preferences or plan their care in line with best practice guidance. Staff had not received the training they needed to ensure autistic people were supported in line with their preferences. People were supported to access healthcare services, but the provider was not following best practice guidance for supporting autistic people and people with learning disabilities with their healthcare needs. Although staff spoke about the people they supported with kindness and compassion, the language in the records did not always support this.

Right Culture:

The management team had created a culture where staff felt well supported. Staff and management knew people well and were open to improving the quality of support they provided to people. There were systems in place to involve people, relatives, staff and the community in the development of the provider’s services.

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 14 February 2014 and this is the first inspection. The service did not deliver any Personal Care until recently.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We had been informed that the service was not delivering any regulated activities. In October 2022 they informed us they were delivering personal care to 2 people.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well Led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding adults, consent, person centred care, staff training and good governance. We have also made recommendations about ensuring people’s healthcare needs and diverse characteristics are met in line with best practice guidance.

We will require an action plan in relation to the breaches of safe care and treatment, safeguarding adults, consent, person centred care and staff training. We issued a warning notice requiring the provider to be compliant with regards to governance by a fixed date.

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.