50 Burton Road

Updated 3 October 2020

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 following concerns being raised by the local authority. 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.

Inspection team

The inspection was carried out by two inspectors on the first day of the site visit and one inspector on the second day.

Service and service type

50 Burton Road is a ‘care home’. People in care homes receive accommodation and nursing or 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

The first day of inspection was unannounced. We agreed with the registered manager to return the following day.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The registered provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We made observations in the home as people were not always able to speak with us in depth about the care they received. We spoke with two relatives over the phone. We spoke with four members of staff including senior care workers and care workers. We also spoke to the registered manager and deputy manager. 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 some medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including audits and procedures were reviewed.

After the inspection

We continued to seek clarification from the registered provider to validate evidence found. We looked at an action plan the registered provider and registered manager had developed prior to our inspection.

Updated 3 October 2020

About the service

50 Burton Road is a care home providing personal care and accommodation for up to six people. At the time of the inspection there were five people living there. People living at the service had learning disabilities.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

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

Quality assurance systems had failed to fully implement and embed actions to ensure people’s care was sufficiently monitored. Risks were not always accurately assessed and planned for and people were not always protected. Care plans were not always fully reflective of people’s needs; however, staff knew people well. Some people had missed medical appointments as systems were not effective. Infection control measures were not always consistently applied which could pose a cross infection risk.

People were supported by enough staff, although staffing levels varied. Medicines were managed safely. Lessons were learned when things went wrong. People were protected from abuse by staff who knew how to recognise and report concerns. People and staff were engaged in the service. Relatives and staff felt there had been many improvements to the service since the new registered manager started. The provider acted upon their duty of candour responsibilities.

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 20 March 2018). At this inspection, there had been a deterioration and safe and well-led were rated requires improvement. There were no breaches of regulations.

Why we inspected

We received concerns about people’s safety and staffing. 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. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has deteriorated to requires improvement overall. This is based on the findings at this inspection.

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.

We have identified breaches in relation to people not always being protect from risks and systems are not always effective at identifying areas to improve.

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

Follow up

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