Background to this inspection
Updated
23 November 2023
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 carried out by 1 inspector.
Service and service type
Satash Community Care Project 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. Satash Community Care Project 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.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 03 November 2023 and ended on 09 November 2023. We visited the location’s service on 06 November 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We 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 used all this information to plan our inspection.
During the inspection
We spoke with 3 relatives and 4 people about their experience of the care provided. We spoke with 2 members of staff, the registered manager and the 2 directors.
We reviewed a range of records. This included 2 care records and plans. We looked at 3 staff files in relation to recruitment and staff supervision and a variety of records relating to the management of the service.
Updated
23 November 2023
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
Satash Community Care Project is a residential care home providing the regulated activity of accommodation and personal care to up to 8 people. The service provides support to people with learning disabilities and autism. At the time of our inspection 7 people were using the service.
People's experience of using this service and what we found
The service was able to demonstrate how they were meeting the underpinning principles of Right support, Right care, Right culture. However, improvements were needed to the systems and governance of the service to ensure people received safe care. We found concerns with the providers lack of oversight and poor recruitment practice.
Right Support:
Care and support were provided in a safe, homely, well equipped, well-furnished environment which met people's physical and sensory needs. People living at the service had adapted their bedrooms to their likings. People's independence was promoted.
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 Care:
There was limited information in the support plans we reviewed relating to people's end of life wishes. We have made a recommendation about end of life wishes.
Care and treatment was planned and delivered in a way which was intended to ensure people's safety and welfare. There were enough staff to meet people's needs. There were systems in place to minimise the risk of infection and to learn lessons from accidents and incidents. Medication was dispensed by staff who had received training to do so and assessed as competent
Right Culture:
Support focused on quality of life and followed best practice. Staff involved people, their family and other professionals as appropriate to evaluate the quality of support given and obtain feedback to improve people's day to day quality of life. People living at the service made choices and took part in meaningful activities which were part of their planned care and support. Staff supported them to achieve their aspiration and goals.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The rating at the last inspection was good (published 15 June 2021).
Why we inspected
We undertook this inspection as part of a random selection of services rated good and outstanding.
The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.
You can see what action we have asked the provider to take at the end of this full report.
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 and Recommendations
We have identified breaches in relation to recruitment practices, quality assurance and the notification of incidents. We have made a recommendation about the management of when required (PRN) medicines and end of life wishes.
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 inspect next