Hail - Bedford Road

Updated 11 May 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.

Inspection team

This inspection was carried out by 1 inspector.

Service and Service Type

HAIL- Bedford Road is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. HAIL- Bedford 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 not a registered manager in post. The acting manager was in the process of applying to become the registered manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we held about 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 the acting manager. We reviewed a range of records. This included 6 people's care plans, risk assessments, recruitment records, quality audits, daily records, and training records. We spoke with 4 staff and 3 relatives.

We reviewed a variety of records relating to the management of the service, including policies and procedures, staffing rotas, accident and incident records and safeguarding records. We completed a tour of the building and we looked at medicines' management and food safety.

Updated 11 May 2023

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. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

About the service

HAIL- Bedford Road is a 'care home' for people who have a learning disability. The service accommodates a maximum of six people. At the time of our inspection there were six people living in the home. People using the service had been living at the homes for many years. Most of the staff team had also been working at the home for some time and everyone knew each other well.

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

Right Support:

Not all people were supported in the least restrictive way possible and best interest meetings were not always completed. We found during our inspection that there was a bathroom and a toilet on the first floor locked and 1 person’s wardrobe was also locked. The acting manager informed us that this was due to a person’s support needs. However, this was not recorded on their deprivation of liberty documents or their care plan.

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.

People were safeguarded from the risk of harm and abuse as the provider had systems in place to protect people. Staff supported people to take their prescribed medicines safely. Staff had completed safeguarding training and understood their role and responsibilities in reporting any concerns of abuse.

Right Care:

Staff came across caring and supportive and we saw positive interactions between staff and people. There were sufficient staffing levels to meet people's needs. During the inspection there were music activities taking place and some people were accessing the community with support from staff.

The provider had systems in place to carry out recruitment checks to ensure that staff were recruited safely. Staff received up to date training to meet people’s support needs.

The service needed redecorating, and in some of the communal area’s maintenance was also required as there were cracked tiles in the kitchen. The bathrooms were very dated, and the floors needed replacing. The first-floor shower room needed a deep clean, which was an infection control concern.

At the time of the inspection the provider was having a meeting with the landlord about the housing issues.

During the inspection we noted that 5 bedrooms had locks were placed on the doors the wrong way round, which meant that there were a risk of people being accidentally locked in their rooms and not able to get out, which could also be a fire risk. The manager reported this concern to the landlord at the time of the inspection.

Right Culture:

People’s relative’s spoke positively about the support people received, the acting manager and staff team. There was evidence of positive person-centred care plans in place to meet most people support needs. However, we did identify that 1 person’s care records was missing information regarding environmental restrictions that had been put in place to help manage risks. The acting manager agreed to update this information.

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

Rating at last inspection

At the last inspection we rated this service good (published 05 July 2018)

Why we inspected

This inspection was prompted by a review of the information we held about this service. We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for HAIL- Bedford Road - on our website at www.cqc.org.uk.

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.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, risk assessments and people’s deprivation of liberty, controlling infection, staff supervision and appraisals and the condition of the premises. We have made 2 recommendations in relation to the provider sending feedback questionnaires to people and relatives and ensuring that statutory notifications are completed and sent to CQC.

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.