Archived: 33 Egmont Road

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.

33 Egmont Road is a residential care home for people with learning disabilities and/ or autism, providing personal care to up to six people. At the time of the inspection there were six people using the service.

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

People received the right support in relation to risks, such as those relating to behaviour which challenged the service. There were enough staff to support people safely. The provider checked staff were suitable to work with people through recruitment checks. Staff received training in infection control practices, including the safe use of personal protective equipment (PPE) to reduce the risk of COVID19 transmission. People received the right support in relation to their medicines and the registered manager had good oversight of this. The provider carried out the necessary health and safety checks of the premises.

Staff received the training and support they needed to meet people’s needs. People were supported to maintain their health and to maintain contact with professionals involved in their care. People received food and drink of their choice. The service was adapted to meet people’s needs. 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 were comfortable with the staff who supported them and had good relationships with them. People received consistency of care from a small number of staff who knew them well and understood the best ways to communicate with each person. People were encouraged to be involved in the running of the home. Staff treated people with kindness, dignity and respect. People were involved people in their care and their care plans were based on their individual needs and preferences. Relatives were encouraged to raise any concerns or complaints and staff worked closely with people to check they were happy with their care.

The registered manager understood their role and responsibilities, as did staff. The registered manager engaged and consulted well with people using the service, relatives and staff. Staff felt well supported by the registered manager. A system of audits was in place to check people received a good standard of care and the home was run in line with the regulations and best practice. The registered manager notified CQC of significant events as required by law.

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

Rating at last inspection

This was the first inspection since the service registered with us on 1 December 2020. This is an established service which registered under a new provider on this date. The people using the service, the registered manager and many of the staff remained the same under the new provider.

Why we inspected

The inspection was prompted in part due to concerns received about infection control and prevention practices. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.