Date of assessment 26 November 2024 to 29 November 2024. Lee Gordon House is a residential care home and is registered to provide personal care for up to 6 adults who have a diagnosis of a learning disability and/or autism. At the time of our assessment the service supported 5 people. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. This assessment was brought forward due to concerns received in relation to the quality of care provided to people and the culture of the service. This assessment only examined those risks and assessed 17 quality statements; we will assess the other quality statements in future assessments. We found no evidence during this assessment that people were at risk of harm from this concern. At our last inspection we rated the key question safe as requires improvement, this had now improved as sufficient staffing levels were maintained to supervise and keep people safe.
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Lee Gordon House received an overall Good rating at its first inspection under FitzRoy Support, with Safe rated Requires Improvement due to staffing levels that limited community activities and meant known risks were not consistently managed. All other key questions were rated Good, reflecting strong personalised care, skilled and compassionate staff, effective governance, and a well-regarded registered manager.
Concerns (3)
moderateStaffing levels: “staffing levels meant this instruction was not always followed. For example, on two occasions we saw the person in the lounge while both staff were providing support in another area of the home.”
moderateStaffing levels: “we saw a person became upset because they wanted to go outside for a walk. Staff apologised to the person and explained there were not enough staff available to meet the person's request.”
minorPerson-centred care: “staff told us opportunities for people to engage in activities outside of the home were currently limited. One said, 'We can't do as much at the moment because there aren't enough staff.'”
Strengths
· Medicines were managed and administered safely, with regular audits and competency checks of staff practice.
· Staff received comprehensive induction, ongoing training and support including specialist areas such as positive behaviour support, epilepsy and autism awareness.
· Care plans were highly personalised, detailing individual needs, lifestyle choices, communication methods and independence goals.
· People were supported to maintain family relationships with open visiting and no restrictions.
· The registered manager was experienced, approachable and proactive, with strong relationships with staff, relatives and external professionals.
Quality-Statement breakdown (22)
safe: Staffing levelsRequires improvement
safe: SafeguardingGood
safe: Medicines managementGood
safe: Risk managementGood
safe: Infection controlGood
safe: RecruitmentGood
effective: Staff training and inductionGood
effective: Mental Capacity Act and DoLSGood
effective: Nutrition and hydrationGood
effective: Healthcare access and partnership workingGood
caring: Kindness, dignity and respectGood
caring: Independence supportGood
caring: Family involvement and relationshipsGood
responsive: Person-centred care planningGood
responsive: Communication supportGood
responsive: Activities and community engagementGood
This targeted IPC inspection of Lee Gordon House found several infection control shortcomings including an overflowing clinical waste bin, improper PPE use by a staff member, cluttered areas impeding cleaning, and failure to follow the visiting protocol on the inspector's arrival. The service was inspected but not rated, with a number of positive IPC practices noted alongside the identified concerns.
Concerns (5)
criticalInfection control: “A bin in a communal toilet containing used continence pads and used PPE was overflowing which presented an infection control risk.”
moderateInfection control: “The provider's visiting protocol was not correctly followed on our arrival at the home to ensure our visit could take place safely. Signage and instructions were not sufficient.”
moderateInfection control: “We observed one staff member was not wearing a face mask in line with current guidance during our visit.”
moderateInfection control: “Clean laundry was stored in an open basket on the floor. Good practice guidance for linen and laundry was not followed.”
moderateInfection control: “Two bottles of shampoo were located on the back of a communal toilet cistern. Some areas of the home were cluttered so effective cleaning could not take place.”
Strengths
· People were supported to maintain contact with important people via video and telephone calls during the pandemic.
· Risks of staff using public transport were explored and mitigated, e.g. use of taxis.
· Staff felt valued, receiving thank you cards and shopping vouchers from the registered manager and senior leadership team.
· Provider was meeting shielding and social distancing rules.
· Provider was admitting people safely and accessing testing for people and staff.
Quality-Statement breakdown (1)
safe: S5 How well are people protected by the prevention and control of infection?Insufficient evidence to rate