Archived: 33 Egmont Road

Updated 14 April 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 Care Act 2014.

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 one inspector over three days and two inspectors on one of those days.

Service and service type

33, Egmont Road is a 'care home'. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with six members of staff, the registered manager, one of the deputy managers, the director of operations, the head of area operations, the environmental health officer, and an assistant from the provider’s positive behavioural support team.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included four people’s care records and medication records.

We looked at four staff files in relation to staff supervision, training and recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We spoke with five relatives of people. We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visited the service.

Updated 14 April 2022

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

33, Egmont Road is a residential care home providing accommodation and personal care for up to six people. These people live with a range of complex conditions, including profound and multiple learning disabilities, autism, sensory and communication impairments and complex behavioural needs. At the time of this inspection the service supported six people.

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

The service did not give people care and support in a safe, clean, well equipped, well-furnished and well-maintained environment that met their sensory and physical needs.

We found systems and processes used to ensure the service were not safe or effective.

The whole environment of the home was in need of redecoration, refurbishment and regular maintenance.

Incidents and accidents were not effectively reviewed or reported to ensure lessons were learnt to drive improvements.

We were not fully assured people were protected from the risk and spread of infection.

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.

Systems in place to safeguard people from abuse were not effectively implemented.

The service was not well-led. Governance arrangements and quality assurance audits were not effective in identifying shortfalls in the quality of the service.

CQC had not always been informed of incidents and events at the service which the registered manager and the provider are required to do. This is so we can be assured that events and incidents have been appropriately reported and managed.

Staff supported people to take part in activities and pursue their interests in their local area and to interact with people who had shared interests.

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care.

People received kind and compassionate care. Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs.

Staff placed people’s wishes, needs and rights at the heart of everything they did.

People and those important to them, including advocates, were involved in planning their care.

People were supported by staff to enjoy a wide range of activities when it was possible due to the COVID-19 pandemic restrictions.

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 30 September 2021).

Why we inspected

The inspection was prompted because we received information of concern from a whistle-blower about the environment and the care and support people were receiving. A decision was made for us to inspect and examine those risks.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection. We have found evidence the provider needs to make improvements. Please see the safe, effective and well-led sections of this full support.

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.

You can see what action we have asked the provider to take at the end of this full report.

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 to keep people safe and to hold providers to account where it is necessary for us to do so. We have identified breaches in relation to people's safety and the safety of equipment; the safe administration of medicines; people's dignity and respect; person-centred care, protecting people from abuse, the condition of the environment, how the service is managed, how staff are trained and supported and a failure to notify the CQC of important events and serious incidents at this inspection.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

Follow up

The provider took immediate action to mitigate the risks in all the areas we found of concern. The head of area operations at Achieve Together have provided the CQC with a comprehensive action plan and agreed to send the CQC weekly updates as to progress being made against the action plan. We saw work had started on improving the environment on day two of our inspection. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.