Archived: 25 Percival Way

About the service

25 Percival Way is a residential care home providing accommodation and personal care to one person at the time of the inspection. The service can support up to two people.

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

Right Support:

The service supported the person who lived at the service to achieve good outcomes. They had support to access inclusive activities in the wider community. The protocols within the service encouraged clear communication between the person and their staff teams.

The premises were well maintained and tailored to the needs of the person. The provider supported the person with transition plans for their future wishes towards more suitable and independent living.

The person was supported to have maximum choice and control of their life 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.

Right Care:

The care the person received was tailored to their individual needs. At our previous inspection we saw evidence of kind and compassionate care from the staff team. Staff treated the person with dignity and respect and promoted their right to privacy.

Right Culture:

The culture within the home empowered the person who used the service. There had been changes in management of the service since our last inspection which had impacted on the governance and oversight of the service. however, the wellbeing of the person who used the service had not been impacted by this. They were supported to live a full life, their rights and aspirations were promoted.

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 25 February 2022)

At this inspection we found improvements had been made.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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 changed from requires improvement to good based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. However, we found no evidence during this inspection that people were at risk of harm from this concern. Please see the Well-led sections of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 25 Percival Way on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

25 Percival Way is a four-bedroom residential care home, based in a residential area. It was providing personal care to one person at the time of the inspection. The service can support up to two people.

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

Right Support

Best practice was not followed to support the person with making decisions about certain aspects of their life. Whilst the services approach was to provide the least restrictive care, they did not follow best practice guidance and legislation to evidence this.

Staff focused on the persons strengths and promoted what they could do, so they had a fulfilling and meaningful everyday life. Staff communicated with the person in ways that met their needs. They enabled the person to access specialist health and social care support in the community.

The service provided care and support in a safe, clean, well equipped, well-furnished and well-maintained environment that met the persons sensory and physical needs.

The person was able to personalise their room and benefitted from the interactive and stimulating environment.

Right Care

The service and provider did not have systems in place to monitor the quality and safety of the service. This meant they had not identified areas of concern we found on this inspection. Where appropriate, staff encouraged and enabled the person to take positive risks. However, not all risks for the person had been assessed.

The person received their medicines on time and as prescribed. However, medicines administration records (MAR) were not written in line with best practice guidance. We have made a recommendation about medicines.

There were not enough permanent staff employed, however the service made sure staffing levels met the person’s needs and kept them safe. When agency staff were used, disruption was minimised by using the same agency staff members and the person was always supported by a familiar and preferred member of staff.

The person received kind and compassionate care. Staff protected and respected their privacy and dignity. They understood and responded to the persons individual needs. They understood how to protect the person from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

The person could communicate with staff and understand information given to them because staff supported them consistently and understood their individual communication needs. The person could take part in activities and pursue interests that were tailored to them.

Right culture

The service undertook assessments to consider the support the person living at the service may have relating to the wide range of strengths, impairments or sensitivities autistic people may have. This meant the person received compassionate and empowering care that was tailored to their needs. The person received personalised care from staff that knew them well.

Staff ensured risks of a closed culture were minimised so that the person received support based on transparency, respect and inclusivity.

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

Rating at last inspection

This service was registered with us on 06 August and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about fire safety. A decision was made for us to inspect and examine those risks and to assess that the service is applying the principles of Right support right care right culture.

We have found evidence that the provider needs to make improvement. Please see the safe, effective 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.

Enforcement and Recommendations

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 the application of the Mental Capacity Act (MCA) 2005 and the governance of the service.

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 with the 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.