Underhall Respite and Resource Centre

Updated 29 June 2022

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

This inspection was carried out by an inspector and an inspection manager.

Service and service type

Underhall Respite and Resource Centre 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. Underhall Respite and Resource Centre 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This 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 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 four people who used the service and four relatives of people who used the service. We spoke with seven members of staff including support workers, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records including six people’s care records, medicine administration records and some records relating to the management of the service.

Updated 29 June 2022

About the service

Underhall Respite and Resource Centre is a residential care home providing personal and nursing care to up to 14 people. The service provides short term respite placements as well as permanent placements. The service provides support to older people, including those with dementia, people with physical disability, sensory impairments and mental health needs. At the time of our inspection there were 14 people using the service.

The home is based on a single level, with communal lounges and dining spaces as well as a pleasant outdoor garden.

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

Medicines were not always managed in line with best practice guidance.

The provider’s governance systems in place were not always effective in identifying areas for improvement.

The registered manager and staff understood people’s risks and how to support them safely, however this information was not always clearly recorded.

People felt safe at the service and there were enough staff to meet both the care needs and emotional needs of people.

People had a good relationship with staff and the registered manager and told us they felt listened to. There were opportunities for people, their relatives and staff to feed back into the running of the service.

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.

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 requires improvement (published 12 April 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended that the provider makes improvements in relation to the management of medicines. At this inspection we found the provider had not made the necessary improvements required and was now in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 26 February 2019 and breaches of legal requirements were found in relation to governance and fit and proper persons employed. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Underhill Respite and Resource Centre on our 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 and will take further action if needed.

We have identified breaches in relation to safety and governance 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.