6 February 2023
During an inspection looking at part of the service
Bedborough House is a residential care home providing the regulated activity accommodation for persons who require nursing or personal care to up to 8 people. The service provides support to autistic people, younger adults and people with learning disabilities. At the time of our inspection there were 6 people using the service.
Accommodation is laid out over 3 floors. Communal lounge and dining rooms are located on the ground-floor and bedrooms are located on the 1st and 2nd floors. All bedrooms have en-suite facilities and 4 have lockable kitchenettes. People have access to a communal kitchen and a large garden. The registered manager’s office is located on the 3rd floor.
People’s experience of using this service and what we found
Right Support: Areas of the service were visibly unclean and had not been adequately maintained. We observed staff smoking in close proximity to people’s accommodation. There were sufficient numbers of staff to keep people safe. A positive behaviour support coordinator analysed potential triggers of behaviours that may challenge others to help prevent a recurrence.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Right Care: Staff spoke about and treated people in a person-centred way. The provider had introduced equality and human rights care plans to support staff to identify and promote these needs. People were supported to maintain relationships with relatives and friends important to them.
Right Culture: Audits and checks were not always used effectively and consistently to identify shortfalls and drive improvement in the service. Staff spoke positively about the registered manager. The registered manager said activities provision was an area for development and records did not always reflect what activities people were involved with.
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 good (published 19 January 2021).
Why we inspected
We received concerns in relation to the management of medicines and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 good to requires improvement based on the findings of this 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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bedborough House on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to the application of the Mental Capacity Act (MCA), the safety of the premises and the efficacy of checks and audits.
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.