1-3 Emily Jackson Close

Updated 12 January 2024

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 2 inspectors.

Service and service type

1-3 Emily Jackson Close 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. 1-3 Emily Jackson Close 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been appointed and had submitted an application to register. We are currently assessing this application.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 29 November 2023 and ended on 7 December 2023. We visited the service on 29 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 2 people and 5 relatives about their experience of the care and support provided. We spoke with 9 members of staff including the regional director, senior operations manager, manager and support staff. We reviewed a range of records including 4 people’s care and support plans and medicines records. We reviewed a range of documents relating to the running of the service, including audits and staff files.

Updated 12 January 2024

About the service

1–3 Emily Jackson Close is a care home providing personal care to up to 18 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were 17 people using the service. The service is set across 3 individual bungalows.

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

Right Support:

Staff provided effective support to identify people's aspirations and goals and assisted people to plan how these would be met. Staff focused on people's strengths and promoted people’s independence. There was a consistent approach to supporting people to learn new daily living skills. Staff enabled people to access health and social care support in the community.

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:

Staff understood the risks to people's health, safety and welfare. Risk assessments provided guidance for staff about individual risks. However, some risk assessments did not have enough guidance for staff to ensure people were as safe as possible. Whilst staff knew people well, positive behavioural support plans were still in the process of being reviewed and updated. Without robust plans and information there was a risk people were not supported in a consistent way.

People were protected from the risks of harm, abuse and discrimination because staff knew what action to take if they identified concerns. Accidents, incidents and near misses were recorded and reviewed. However, the level of detail recorded varied and there was a risk of action not being taken in a timely way.

There were enough staff to provide the support people needed.

Staff provided care to people which was person-centred and promoted people's dignity, privacy and human rights. People's individual choices were recognised and respected. Staff promoted equality and diversity in their support for people and their protected characteristics were considered.

People could communicate with staff as staff understood their individual methods of communication. People were empowered to take part in activities of their choice. People were supported to keep in touch with people who were important to them. Relatives spoke positively about the support their loved ones received.

Right Culture:

Checks and audits were being regularly completed. Shortfalls were identified and action taken to address these. However, we found some shortfalls around risk assessments and accidents and incidents which had not been identified. We discussed this with the manager who agreed to take action to remedy these.

The service enabled people and those important to them to work with staff to develop the service.

Feedback was requested from people, relatives and health care professionals.

Safe recruitment practices were followed. Staff knew and understood people well. The provider and staff worked hard to develop strong leadership. The management structure had been changed following the last inspection and staff spoke about the positive impact this had had.

Quality monitoring systems were being developed and embedded. Morale within the staff team was good and staff felt valued.

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 inadequate (published 23 October 2023). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made. We found the provider remained in breach of regulation 17 (good governance).

This service has been in Special Measures since 23 October 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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

We have found evidence that the provider needs to make improvements. Please see the safe 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for 1-3 Emily Jackson Close on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to good governance 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.