Endsleigh Care Limited

Updated 11 December 2021

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 Care Act 2014.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Endsleigh Care Limited 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. The registered manager of the service was also the provider.

Notice of inspection

This inspection was unannounced.

What we did before 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service about their experience of the care provided. We spoke with four members of staff including the registered manager, deputy manager and two support workers. We observed how staff interacted with people.

We reviewed a range of records. This included three people’s care records and multiple medicine records. We looked at three staff files in relation to recruitment and staff training. A variety of records relating to the management of the service were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies and procedures, staff supervision records and the training matrix.

Updated 11 December 2021

About the service

Endsleigh Care Limited is a residential care home providing personal care to eight people with mental health needs at the time of the inspection. The service can support up to 11 people. The premises consisted of two houses that had been converted into one on a residential street.

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

Risk assessments were in place for people, but these did not provide adequate guidance about how to mitigate risks associated with violence and aggression. The premises were not safe, as dangerous equipment was accessible to people and locks on bathroom doors could not be opened by staff in the event of an emergency. Infection prevention and control measures were not sufficiently robust. Quality assurance and monitoring systems were not always effective. Pre-admission assessments did not cover needs in relation to equality and diversity. The provider did not seek people’s views about end of life care.

People spoke positively about the service and the support they received. Steps had been taken to safeguard people from the risk of abuse. There were enough staff working at the service and robust staff recruitment practices were in place. Medicines were managed in a safe way. Lessons were learnt from accidents and incidents.

Staff undertook training and supervision to support them in their role. People were able to make choices about what they ate and to have a healthy and nutritious diet. The provider worked with professionals to help meet people’s health care needs.

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 told us staff were caring and that they were treated with respect. Staff understood how to support people in a way that promoted their privacy, independence and dignity.

Care plans were in place for people, which set out how to meet their needs in a person-centred manner. Information was provided to people in a way that was accessible to them. People were supported to follow their interests and access the local community. Systems were in place for dealing with complaints.

People and staff told us there was an open and positive culture at the service and they spoke positively about the registered manager. People were supported to express their views. The provider was aware of their legal obligations, and worked with other agencies to develop best practice and share knowledge.

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

Rating at last inspection

The last rating for this service was good (published 2 November 2018).

Why we inspected

The inspection was prompted in part due to concerns received about the physical environment. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

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 Endsleigh Care Limited 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 have identified breaches in relation to risk assessments, the safety of the premises, infection prevention and control measures and quality assurance systems at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.