165 Point Clear Road

Updated 9 December 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

The inspection was completed by one inspector.

Service and service type

165 Point Clear Road 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. 165 Point Clear Road 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, however they had just started a 3-month planned absence and had an interim manager was covering their role.

Notice of inspection

This inspection was unannounced and included an ‘out of hours’ visit to the service.

What we did before the inspection

We sought feedback from the local authority and professional who work with the service. We used information gathered as part a CQC monitoring activity that took place on 15 September 2022 to help the inspection and inform our judgements.

We also 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 reviewed information we had received about the service since they registered with the CQC. We used all this information to plan our inspection.

During the inspection

We met the 4 people living in the service, enabling them to engage with us if they chose to. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We visited the service 3 times, spending time observing people’s different day and evening routines.

During the inspection we reviewed 2 people’s care files and daily notes and 2 staff’s recruitment paperwork. We looked at a variety of records which included people’s medicine records, safeguarding investigation reports, minutes of staff meetings, staff induction and training records. We looked at cleaning processes in the service, and the service’s quality assurance arrangements.

We spoke with the registered manager, acting manager, the divisional head of quality and 6 members of staff. This included senior support worker, support workers and agency staff. We also spoke with or received written feedback from 2 social care professionals.

After the inspection

We spoke with the new area manager and continued to seek clarification from the provider to validate evidence found. Additional information relating to staff training and end of life care plans were sought.

Updated 9 December 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

165 Point Clear is a residential care home providing personal care to four people at the time of the inspection. The service can support up to five men.

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

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.

Right Support:

People were not always supported in a safe, clean, and well-maintained environment. Areas of the home and equipment people used was not always clean enough, fit for purpose, or well maintained.

Staff knew how people preferred to take their medicines to achieve the best possible health outcome. Staff enabled people to access specialist health and social care support in the community.

Staff supported people to play an active role in maintaining their own health and wellbeing and encouraged people to eat a healthy diet.

Staff supported people to make decisions following best practice in decision-making. Staff communicated with people in ways that met their needs.

Right Care:

Potential risks to people’s safety were not always identified and acted on at the time to ensure people were kept safe. Not all staff used a face mask effectively to prevent potential germs being passed from person to person. Cleaning fluids were not being safety stored.

People received kind and compassionate care. One person’s relative told us their family member, “Is settled and likes the staff who are the kindest people ever.”

People could communicate with staff and understand information given to them because staff supported them consistently and were knowledgeable about their individual needs.

Right Culture:

The service’s quality assurance, monitoring and oversight arrangements were not robust and required improvement.

The service enabled people and those important to them to work with staff to develop the service. Staff valued and acted upon people’s views. People and those important to them, including advocates, were involved in planning their care.

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 23 July 2020 and this is the first inspection. The last rating for the service under the previous provider was good, published on 11 December 2018.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement

We have identified breaches in relation to risk, infection control and the provider’s governance arrangements 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.