Background to this inspection
Updated
11 November 2023
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 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
St Anne's Community Services - Cardigan Road 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. St Anne's Community Services - Cardigan Road 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
The first day of the 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 Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England 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 spent time in communal areas observing the care and support provided by staff. We spoke with 8 people who used the service and 7 members of staff including support workers, registered manager, deputy manager and area manager.
We reviewed a range of records. This included 2 people's care records and 3 people’s medicine records. We reviewed 2 staff recruitment files and a variety of records relating to the management of the service.
Updated
11 November 2023
About the service
St Anne's Community Services - Cardigan Road is a residential care home providing accommodation and personal care to up to 8 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 8 people using the service.
People’s experience of the service and what we found:
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.
Right Support:
Systems were not robust enough to demonstrate safety was always effectively managed. Staff were inconsistent when recording and reporting incidents. Medicines were not always managed safely. These shortfalls had not been picked up through the provider’s governance arrangements although prompt action was taken once we brought this to the attention of the management team.
There was enough staff available to support people when they were at home and in the community.
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.
Right Care:
People told us they were happy living at Cardigan Road and we saw people were relaxed in the company of staff and others they lived with.
Care plans had some detailed person-centred information but other information was not up to date. Gaps in care records meant it was sometimes difficult to monitor people's health and well-being.
The service worked effectively with external stakeholders.
Right Culture:
People were encouraged to live as full a life as possible in relation to social activities and accessing the community. However, opportunities within the service were less so and routines were sometimes not person centred.
The provider had a range of systems and processes to monitor the quality of the service although they did not always drive the required outcome.
Everyone had opportunities to share their views. Staff felt well supported by the management team who worked at the service.
The management team was responsive to the inspection findings and keen to deliver a high-quality service.
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 26 October 2018).
At our last inspection we recommended that the provider improve standards of cleanliness at the service. At this inspection we found the provider had acted on the recommendation and had made improvements.
At our last inspection we recommended that the provider continued in their efforts to ensure staff received regular supervision in line with their policy and improve communication and decision-making processes for the service. At this inspection we found the provider had acted on the recommendation and had made improvements.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for St Anne's Community Services - Cardigan Road on our website at www.cqc.org.uk.
Recommendations
We have made a recommendation in relation to medicines and person-centred care.
Follow Up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.