Creative Support - Dove Lane

Updated 25 January 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 Care Act 2014.

Inspection team

This inspection was completed by one inspector

Service and service type

Creative Support- Dove Lane 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

We gave the service 2 hours’ notice of the inspection. This was because the service is small, and people may have been out, and we wanted to be sure there would be people at home to speak with us.

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 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 this information to plan our inspection.

During the inspection

We spoke with four relatives about their experience of the care provided to their family member. We spoke with six members of staff including the service director, registered manager and support workers. We spent time observing the support that people received from the staff team.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies, procedures and audits were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 25 January 2022

About the service

Creative Support- Dove Lane is a residential care home providing personal care to five autistic people or people living with a learning disability, at the time of this inspection. The service can support up to six people. People had their own personalised bedrooms and shared communal areas such as a kitchen, bathrooms, living room and a garden.

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

Staffing levels were not adequate to provide a consistently safe and effective service to people. People who required support with needs such as epilepsy were left unsupported for short portions of the day, putting them at potential risk of harm. For this reason, some risk assessments were not possible to follow in areas such as supporting people living with epilepsy. These issues were known by the provider and being discussed with the local authority but had not been resolved.

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. The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

People were at risk of not having their personal preferences met due to poor staffing levels. They were unable to leave their home to explore social interests and there were not enough staff to support people with their interests in their home at all times. However, people were happy living in their home, having lived there for a long time.

The registered manager and provider completed audits to monitor the quality of the service. These were effective in identifying improvements to areas such as health and safety and medicines. However, audits had failed to pick up on people’s experiences of care regarding following interests and past times. We were not assured that best practice guidance was being followed at the service in relation to Right Support, Right Care, Right Culture.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. Improvements were needed to some areas of the service to ensure that it fully met people’s needs.

Despite our findings feedback from people and relatives was positive. One relative said, ‘‘I have complete faith in the registered manager and the staff team. I think they all do a great job.’’

Risk assessments were detailed and guided staff how to support people safely. Staff were trained in safeguarding and knew how to report any concerns to the appropriate authorities. Staff were recruited in line with legislation to help ensure they were appropriate for their job roles. People were supported safely with their medicines. Good infection control measures were in place, including for COVID-19 to help ensure that people were kept safe.

People’s needs were assessed before they started living in their new home. Food and drink looked appetising and people were supported in line with their dietary needs and preferences. People were supported to see health professionals if this was needed and staff supported people to follow advice from these professionals to help keep people healthy.

Staff knew people well as individuals and treated them with kindness and compassion. People were supported to make some choices in their day to day life and staff supported their independence, privacy and dignity. People and their relatives had access to a complaint’s procedure and complaints were responded to appropriately. The registered manager and staff team supported people to put plans in place for the end of their life if required.

The registered manager was passionate about providing a positive culture at the service. Feedback about them from relatives of people using the service was very positive. People, their relatives and the staff team were asked for their feed back about the service. The staff team worked with other organisations to help promote good outcomes for people.

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, when it was managed under a different provider was good (report published 19 February 2019).

Why we inspected

This was a planned inspection based on the previous rating and when the service was taken over by Creative Support.

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.

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

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 staffing levels, person centred care and the governance of the service 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.