The Hall

The Hall is a residential care home providing accommodation and personal care for up to 10 people who may have a learning disability or autistic spectrum disorder. At the time of the inspection there were no vacancies.

The service had been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. This ensured that people could live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) of Safe, Effective and Well led to at least good. At this inspection we found that staff recruitment checks had been strengthened, New staff now received a good level of induction. A staff appraisal system had been developed. Surveys were sent out to stakeholders to obtain feedback about the service, and this information was used for service development. The provider had implemented a more robust system of quality audits, this gave them greater oversight and assurance of about what was happening in the service.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk

People's experience of using the service:

At this inspection we identified that whilst staff had the right knowledge and skills to provide people with safe care and support, the training matrix recording staff training had not been kept updated to provide a live and accurate picture of completed staff training, this was an area for improvement.

People told us they liked living at the service and happy with the support they received. There was a friendly atmosphere and people were relaxed in the company of staff and actively sought them out. Staff were respectful and kind in their interactions with people.

Staff understood their responsibilities to safeguard and protect people from abuse. Risks to people were assessed and steps taken to reduce the likelihood of harm occurring. Accidents and incidents were appropriately responded to and reported on by staff and learning from these informed updates to care and support information to minimise recurrence.

People lived in a safe well-maintained environment, daily and weekly health and safety checks were conducted by staff and servicing of equipment helped maintain a safe environment for people.

People were consulted about their care and support needs and were enabled to develop preferred activities and interests

There were enough staff to meet people’s needs. A safe system of recruitment was in place for new staff.

Peoples medicines were managed safely and they received appropriate healthcare support when needed.

Peoples consent had been obtained and they and their relatives were consulted and informed about the care provided. Relatives said they felt able to approach the registered provider and manager with any concerns and people were empowered to use the complaints process and felt listened to.

Rating at last inspection:

Requires Improvement (the inspection report was published on 3 May 2018) At this inspection in May 2019 the overall rating of the service has improved to ‘good in four domains.

Why we inspected:

This was a planned inspection based on the rating we gave the service at the last inspection in February 2018.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit in line with our re-inspection programme. If any concerning information is received, we may inspect sooner.

The Hall provides support to up to 10 people who may have a learning disability or autistic spectrum disorder. At the time of the inspection eight people were living at the service.

The Hall was last inspected on the 31 March and 1 April 2016 and rated requires improvement as a result of six breaches of regulation. We found shortfalls in the checks made during staff recruitment, night time staffing levels, staff training, medicine management, care plan personalisation, inadequate health and safety checks and tests of equipment and inadequate mitigation of known risks for one person. The provider had also failed to notify the Care Quality Commission of authorisations approved by a supervisory body and systems for monitoring quality and safety were not always effective. Following that inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Effective, Caring, Responsive and Well-Led to at least good.

At this inspection we noted that clear improvements had been made in most areas with three breaches fully addressed and two others with clear improvements made but more needed to ensure the right level of criminal record checks are made for all staff to ensure they are suitable to work with both adults and children, and the implementation of an appropriate induction programme for new staff and the annual appraisal of staff performance. A system of quality monitoring and assurance remains under developed and lacks a mechanism for gathering the views of relatives and health and social care professionals to help inform improvements and developments. A new breach in respect of the induction of new staff without care qualifications and the lack of staff appraisal has been issued.

The provider is actively involved in the running of the service and a registered manager is in place for the day to day running of the service. A registered manager is a person who has registered with CQC to manage the agency. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the agency is run.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Although this was a challenging behaviour unit staff supported people who were unsettled and expressing behaviours in a calm assured manner, the atmosphere in the service was therefore relaxed. Whilst people were not seen to seek out each other’s company, they were comfortable in the presence of others and enjoyed approaching or engaging with staff. People said they were happy living in the service; they liked their rooms, and the activities they did and liked the staff that supported them. A health professional told us staff knew and understood people’s needs well, staff were knowledgeable about the people they supported they spoke about them respectfully and affectionately. Relatives said on the whole they were satisfied with the care their family members received and they felt able to share their views with staff when they had concerns.

The premises have been redecorated; equipment serviced and weekly and monthly health and safety checks and tests are undertaken. Staff undertook cleaning tasks and enabled people to live in a clean environment. There were enough staff available to support people and this was kept under review. Staff received an appropriate range of training to inform their knowledge and understanding, they felt there was good communication and team work, they felt supported and able to express their views and be listened to.

People had opportunities to express their views and concerns on a one to one basis with staff weekly and through weekly house meetings, they understood the complaints process and used this effectively. Staff were provided with additional support through individual supervisory meetings with the registered manager and also staff meetings. The registered manager and staff used handovers, communication books, and circulated written information to ensure effective communication about people's needs and any changes. Staff were trained to recognise and respond to abuse and were aware of their responsibilities to keep people safe from harm.

The facility existed for people to move through the service to less supported accommodation in a timescale that best meets their needs, there were opportunities for skills development and increased independence. Known risks were well managed, behaviour management strategies were developed with health professionals and these were having a direct impact on the reduction of behaviours for some people. People are supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice

People were supported to keep healthy, and staff were proactive in supporting people to access health professionals. Changes in health needs were incorporated into care plans to ensure staff understood changed support needs. There were clear processes in place for the management of medicines. People were provided with access to drinks when they wanted them, healthy eating was promoted but people’s choices were respected.

A holistic process was used for the assessment of new people referred to the service to ensure their identified needs could be met. Transitional visits and stays were arranged as part of this and consideration was given to the views of existing people and staff. Care plans were developed from this and people had input into these via weekly meetings with key workers; relative’s views about their family members care and support were also sought through reviews and other contacts.

There was ongoing maintenance and investment in upgrading to improve the physical appearance of the premises and make this a more pleasant environment to live in

People were supported to do the things that interested them and to have a visible presence in their local community, they had individual activity plans. They attended a day centre in the community where a range of activities could be offered to them; Learning opportunities and support to seek educational courses and employment if this was appropriate were also available.

We made a recommendation about staff training

We made a recommendation about staff recruitment

This is the second consecutive time the service has been rated Requires Improvement. There was one continued and one new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work there.

Although a manager was registered with the commission they no longer worked at the service. A new manager had been appointed who was present on both days of the inspection; they had applied for registration with the Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home was also registered to provide a supported living service but we were told by the registered manager of this service that this had not been started as yet although there were plans to do so in the future.

There were insufficient staff on shift during the night to support people and keep other people safe. People were requested to go to bed and get up at specific times to minimise the risk of harm.

Recruitment processes were not safe as staff recruitment files lacked information which is required by the Health and Social Care regulations. This included photographs, exploration into employment gaps, reasons for the termination of previous employment, criminal checks and suitable references. This was putting people at risk of receiving care from inappropriate staff.

Risk assessments were not always followed by staff, did not reflect the current needs of people, or were missing. This left people at risk of harm.

When people were prescribed occasional medicines it was not documented how staff would be able to identify when the person required their medicine. One person had been administered occasional medicine without clear protocols in place. Not all medicines were stored safely.

Some staff had not fully completed their in house induction before working without supervision. When areas of concern around staff conduct had been raised evidence of follow up supervision or observation was missing. Some training had lapsed or had not been completed.

Some capacity assessments had been made following the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. The provider had failed to notify the Commission when authorisations had been granted by the supervisory body which is a requirement of the regulations. People had access to advocacy service if they requested or needed this.

There was an inconsistency in care plans and behaviour guidelines. Some contained detailed guidance for staff about how to support people, but others lacked this necessary guidance.

Internal audits had not been successful in identifying the shortfalls found at this inspection. Since the acting manager had taken up post there had been some improvement in areas of the service and acting manager had made plans to further improve the service people received.

Staff had a clear understanding of how to recognise and report safeguarding concerns and knew who to contact and how. Staff understood how to whistle blow and had access to numbers that they could phone in confidence to report concerns.

Staff were in receipt of supervision to support the development of their role and could attend staff meetings.

People had choice around their food and drink and were encouraged to make their own choices and decisions about this. If people declined their meal, an alternative was offered.

The service was good at responding to people who needed help to manage their health needs. People were supported to access outside professionals and the service was adaptable when a person’s needs changed.

When people moved between the service this was completed in a thoughtful and person centred way. Positive steps were taken to ensure people were placed appropriately.

People knew how to complain, when complaints had been made these had been responded to appropriately.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

The inspection was carried out by one Inspector over four hours. We met most of the people who were living in the home, and were able to have short chats with some of them. We were able to talk with some of the staff as well as the manager. We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We found that staff understood safeguarding procedures, and how to safeguard the people they supported. There were systems in place to make sure that the staff learnt from events such as accidents and incidents, complaints, concerns, and investigations. Staff had been trained in regards to the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLs) although it had not been necessary to submit any DOLs applications.

We saw that people felt secure with the staff and looked to them for support.

We found that there were suitable procedures in place to protect people's finances and pocket monies, and to prevent them from financial abuse.

We viewed the premises and saw that they were suitably maintained for the people living in the home. There were some current building changes being carried out, which included a recently constructed summerhouse in the garden. This was available for a variety of activities.

Is the service effective?

We saw that people were enabled to carry out their preferred choices of activities each day. The staff supported people in line with their care plans, and took a flexible approach so that people could change their minds about activities. We found that the home had a relaxed and friendly environment, and people said they were happy living in the home.

We found that the home had provided staff with appropriate training and support, so that the staff could meet the needs of people living in the home.

Is the service caring?

People spoke highly of the manager and staff and one person said 'X is the best!' They said that this was because the staff member always listened to them and helped them to understand things. Other people made comments which included, 'I like it because I have got my independence now'; and, 'I have been here for years. I love it.'

We saw that documentation confirmed that people were supported wherever needed in developing their lifestyles and independent living skills.

Is the service responsive?

The service operated a system to obtain the views of people living in the home, family members and staff. We saw evidence to show that appropriate action had been taken in response to the things that people had identified, and which needed to be addressed. A visitor had commented, "It is a lovely friendly environment. The residents seem very happy."

People knew how to raise a concern or complaint, and had their comments and complaints listened to and acted on.

Is the service well-led?

We saw that the manager had a good rapport with staff and people living in the home, and they found him to be approachable. He said that the home had an open door policy, and people knew that they could talk to him at any time.

The service worked well with other services and health professionals to make sure that people received the care that they needed.