Archived: Gordon Road

About the service

Gordon Road is a supported living service providing personal care to people living in their own homes. The provider supported people with a learning disability and/or mental health needs. At the time of our inspection they were supporting three people who lived in one shared house.

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

Right Support

• People were supported to live a fulfilling and meaningful life.

• The service worked with people to plan for when they experienced periods of distress so that their freedoms were restricted only if there was no alternative.

• Staff enabled people to access specialist health and social care support in the community.

• Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Right Care

• People received kind and compassionate care. Staff protected and respected people’s privacy and dignity.

• People received personalised care, meaning staff understood and responded to people's individual needs.

• Staff and people cooperated to assess risks people might face.

• People’s care, treatment and support plans reflected their range of needs and this promoted their wellbeing and enjoyment of life.

Right Culture

• The provider demonstrated a commitment to creating a culture of continual improvement that provided good quality care to people. However, the success of this approach had been affected by unstable leadership and quality assurances processes not always being effective. Checks to ensure that staff were suitable to work at the service had not always been completed appropriately.

• Staff knew and understood people well and were responsive, supporting their aspirations to live the life they chose.

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

Staff were not recruited safely. The provider has made plans to address this.

The provider was not always following Government guidance regarding infection control. We have made a recommendation about this and signposted the provider to current guidance. Some improvements were made at the time of inspection and we received assurances that other concerns we found would be addressed promptly.

There were enough staff to support people safely and staff knew people well. Staff received training to manage risks related to people’s care and support. However, we found this could be enhanced to develop a greater and more in depth understanding for staff, by delivering face to face training. We have made a recommendation about this.

Staff had a good understanding of safeguarding people from abuse. People could make choices and had the freedom to live their lives in the way they wanted to.

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.

Quality assurance processes were not always effective in ensuring the safety and quality of the service. The provider was making changes to their quality assurance systems at the time of our inspection.

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

Rating at last inspection and update:

We carried out a focused inspection in July 2021 (published 7 September 2021) looking at the key questions Safe and Well Led. Both these key questions were rated requires improvement and there were breaches of regulation in relation to safeguarding, safe care and treatment, good governance and a failure to notify CQC of significant events. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

You can read the report from our last inspection, by selecting the ‘all reports’ link for Gordon Road on our website at www.cqc.org.uk.

At this inspection not enough improvement had been made and the provider was still in breach of regulation 17. We also found a new breach of regulation in relation to recruitment.

Why we inspected

The inspection was prompted in part due to concerns received about the leadership, the management of risks to people and quality assurance processes. We also undertook this inspection to assess that the service is applying the principles of Right support, right care, right culture.

We have found evidence that the provider needs to make improvements. Please see the full details of the report which is on the CQC 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 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 recruitment and governance.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Gordon Road is a supported living service providing personal care to people living in their own homes. The provider supported people with a learning disability and/or mental health needs. At the time of our inspection they were supporting two people who lived in one shared house.

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

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.

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.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. Some practices in relation to the management of risks were restrictive to people’s choice, control and independence. Although the provider’s intention was to promote people’s safety, they did not always consider people’s capacity to make unwise choices and their legal right to do so. The provider had recognised they needed to develop less restrictive practices but needed time to embed this consistently into people’s care and support.

Risks were not always managed robustly. Staff did not always receive training in key areas which had been identified as being part of risk management plans.

The provider had not informed CQC about significant events which had occurred at the service.

People’s care plans did not reflect a positive behaviour support approach. Strategies identified to support people were often reactive and did not focus on promoting people’s communication or developing their skills.

People’s medicines care plans did not always reflect their needs. We have asked the provider to review their polices around the management of some medicines.

There was not a registered manager in place. A new manager had recently started, who told us they intended to register as manager of the service. Staff told us the new manager was having a positive effect on the atmosphere at the service. The new manager had committed to stopping restrictive practices and had started to make changes to reflect this new ethos.

People told us they liked living in their home and that staff were supportive.

The provider needed to develop systems to engage people to have meaningful choice and control about their support. The manager was adapting documentation to ensure it was accessible in line with people’s needs.

The new manager was developing quality monitoring systems to help give them a better insight into the quality of care.

There were enough staff in place to meet people’s needs. The provider’s recruitment processes were safe and helped to ensure new staff had undergone appropriate pre-employment checks.

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 18/01/2021 and this is the first inspection.

Why we inspected

We received concerns in relation to safeguarding, reporting of incidents and staff training. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections for more details of these concerns.

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

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.