Susan Hampshire House

Updated 18 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.

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.

Service and service type

Susan Hampshire House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Susan Hampshire House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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 a registered manager in post.

Notice of inspection

This inspection was unannounced. The second day we gave 24 hours notice to ensure the registered manager was available.

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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all 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 and spent time with others observing interactions with staff. 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 spoke with three members of staff, the registered manager, the deputy manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We spoke with three relatives and contacted three health and social care professionals about their experience of the service of which we had one response .

We reviewed a range of records. This included two people's care records, daily records and medication records. We looked at the records relating to Deprivation of Liberty for people that had this in place. A variety of records relating to the management of the service, including training data, duty rotas and quality assurance records.

Updated 18 January 2023

About the service

Susan Hampshire House accommodates 15 people who have a learning disability and/or autistic people. At the time of the inspection there were 14 people living at Susan Hampshire House. The service is located in a large house in close proximity to Yate shopping centre and other leisure facilities.

Despite being a large service, it was operated in line with some of the values that underpin the Right support, right care, right culture guidance and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autistic people using the service can live as ordinary a life as any citizen.

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

Right Support:

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 supported to do the things they liked to do. People, staff and professionals were involved with decision making where appropriate.

There were enough staff that were skilled to meet people’s needs safely. This was kept under review as people’s needs changed. Staff recruitment and induction training processes promoted safety.

Right Care:

Care was planned with people to ensure their goals and aspirations were being met. Staff supported people to keep in contact with relatives and friends.

Staff understood how to protect people from poor care and abuse. Risks to people had been identified and clear plans of care were in place to keep people safe.

Right Culture:

Improvements were needed to ensure the governance arrangements identified shortfalls found during our inspection. We found improvements were needed in respect of the safe domain relating to the premises, food hygiene practices and infection control. Action was taken during our inspection to address these shortfalls. However, these had not been identified in the provider’s quality checks that had been completed.

There was an open culture, where people, relatives and professionals worked together to achieve good outcomes for people. People’s views were sought to make improvements to the service and to ensure care was person centred. People were at the heart of the service.

Some areas of the home would benefit from a refurbishment, including soft furnishings in both the lounges and conservatory. The registered manager had requested an additional budget to make improvements and was waiting for the provider to approve.

The registered manager and staff understood their role in making sure people were at the centre of the care they received. They provided care that was person centred and protected and promoted their human rights.

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

The last rating for this service was good (published 25 July 2018).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding. We inspected the domains of safe and well led.

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.

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

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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Susan Hampshire House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach as the provider’s governance arrangements was not robust and had not identified the shortfalls in the safe domain found at this inspection.

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.