About the service Albert Road is a care home providing accommodation and personal care for up to 7 adults with an acquired brain injury. At the time of this inspection there were 4 adults living at Albert Road.
The home is a large, converted semi-detached house with four floors. Bedrooms and dining areas are situated to the first and second floor. There is some communal living space to the ground floor, although this is limited. The basement has been converted to accommodate a games room and a small, independent living unit for one person. This was out of use as repairs were needed. There is a car park to the rear of the home, although not used for this purpose, and a large, wooden gazebo.
People’s experience of using this service and what we found
There were significant and widespread shortfalls in the governance of the service. The provider and managers had failed to identify issues we found with medicines, person centred care and record keeping.
Systems were ineffective in driving improvements and high quality care. The provider had failed to act on concerns and errors with the management of medicines identified by their own staff. This left people at risk of harm.
People were at risk of avoidable harm because risks were not recorded accurately, monitored or managed.
Health and safety of the premises was not well managed. No control measures had been actioned to reduce the risk of legionella in water systems. People were at risk of potential harm.
Staff had not received adequate training or support to equip them for their roles and responsibilities. Staff had not always completed aspects of training relevant to people’s needs.
Good outcomes were not always achieved for people living at the service. The environment did not always meet people’s needs, as there was limited communal areas. The outside space was a disused car park and a gazebo with steps, therefore not accessible to all.
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's had some independence but not all staff were confident in engaging and involving people in tasks such as household chores or cleaning their own personal rooms.
People had access to the wider community with support from staff however, more meaningful activities had not been discussed or fully explored. There had been improvements in the variety and frequency of activities since the arrival of the new manager.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
A focused inspection of the service at Albert Road was carried out in June 2018. This was in response to concerns raised with the Care Quality Commission shortly after the service opened. We looked at the key areas of safe, caring and well led and all were rated requires improvement.
The provider of this service changed on 17/10/2018. This was an internal move following a restructure within the parent company.
Why we inspected
This was a planned inspection based on the new provider’s registration date.
Enforcement
We identified three breaches during the inspection. These related to safe care and treatment, need for consent and good governance. 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within six months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.