Archived: Loreto Cottage

Loreto Cottage is a residential care home providing personal care and support for up to 16 people with learning disabilities or autistic spectrum disorders. The care home accommodates people in one adapted building and one person in a small self-contained flat onsite. 12 people were using the service at the time of our inspection.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can 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. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

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.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of this thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people.

The service used positive behaviour support principles to support people in the least restrictive way. No inappropriate restrictive intervention practices were used.

Care files were personalised to reflect people's personal preferences. People were supported to maintain a healthy balanced diet. Health and social care professionals and advocates were regularly involved in people's care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff treated people with dignity and respect when helping them with daily living tasks. The service ensured people led meaningful and fulfilled lives.

There were effective staff recruitment and selection processes in place. People received effective care and support from an established management and staff team who were well trained and competent and who knew people well.

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

Rating at last inspection

The last rating for this service was Good (published 1st February 2018).

Why we inspected

The inspection was prompted in part due to a complaint received about medicines and a specific incident relating to a person using the service which was investigated by the local authority adult safeguarding team. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, Responsive and Well Led sections of this full report.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Loreto Cottage is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Loreto Cottage accommodates 15 people living learning disabilities and or an autistic spectrum disorder. On the day of our inspection 13 people were living at the service.

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.

Since our last inspection there had been a change to the registered manager. The previous registered manager had de-registered and was the home manager who had day to day responsibility for the service. A new registered manager was in place who was also the registered manager for the provider’s second service. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

During the home’s previous inspection in December 2016 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 and one breach of the Registration Regulations 2009. Following this inspection the registered provider was required to send us an action plan, to inform us of the action they would take to make the required improvements. We also identified further improvements were required in all the key areas we reviewed.

The breaches in regulation identified in 2016 were; Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was in relation to the way people were safeguarded from avoidable harm and abuse. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. The registered person had implemented some systems to assess and monitor and improve checks on quality and safety but these were not as effective as they should have been. Regulation 18 of the Registration Regulations 2009. The registered person had failed to notify the Care Quality Commission of incidents of abuse in relation to people using the service.

During this inspection we checked to see whether improvements had been made, we found the breaches in regulation had been met and all areas of the service had improved resulting in positive outcomes for people.

People received safe care and support. Staff had received safeguarding refresher training and had information and instruction of how to respond to any allegations or suspicions of abuse. Risks in relation to people's needs including the environment were assessed, planned for and monitored. Some improvements had been made to the environment that increased safety and supported people’s needs. There were sufficient staff employed and deployed to support people. People received their prescribed medicines safely and these were managed appropriately. People lived in a clean, hygienic service and the registered manager agreed to review the prevention and control of infections policy and procedure guidance. Staff supported people effectively during periods of anxiety that affected their mood and behaviour. Accidents and incidents were reported, monitored and reviewed to consider the action required to reduce further reoccurrence.

People received an effective service because their needs were assessed and understood by staff. Staff received an appropriate induction, ongoing training and the frequency of formal supervision meetings had increased. People's dietary needs had been assessed and planned for and they received a choice of meals and drinks. Systems were in place to share relevant information with other organisations to ensure people's needs were known and understood. People were supported to access healthcare services and their health needs had been assessed and were monitored. Staff worked well with external health and social care professionals in managing people’s health needs and outcomes. Improvements had been made to the signage around the service to support people with short term memory needs. People had choice and control of their lives and staff supported them in the least restrictive way possible. The principles of the Mental Capacity Act (2005) were followed when decisions were made about people's care. Deprivation of Liberty Safeguards were in place for some people where required.

People were supported by staff who demonstrated a good understanding of their needs and were found to be caring and kind, showing empathy and compassionate in their approach. People's diverse needs were known and understood by staff, and they were encouraged as fully as possible to be involved in discussions and decisions about their care and support. People were provided with information about how they could access independent advocates. There were no restrictions of when people's relatives could visit them.

People received a responsive service that met their individual needs, routines and preferences. Improvements had been made to the information to support staff to understand and meet people’s needs effectively. Social inclusion was promoted and people led active and fulfilling lives where they were supported with interests and hobbies. People were treated equally, without discrimination and systems were in place to support people who had communication needs. People had access to the provider's complaint procedure that was provided in an appropriate format to support people's communication needs. Discussions had started with people and or their relatives where appropriate, about making plans for people’s end of life wishes.

The service was well-led by an experienced registered manager. Improvements had been made to the systems and processes in place to check on quality and safety. Staff were positive about the improvements made and were clear about their role and responsibilities. People who used the service, relatives and others were invited to give feedback about the service.

Loreto Cottage provides accommodation and personal care for up to 15 people living with a learning disability. On the day of our inspection there were 13 people who used the service.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At our last inspection in October 2015 we found the provider was in breach of one Regulation of the Health and Social Care Act 2008. This was in relation to the systems in place that assessed monitored quality and safety and mitigated risks to people who used the service. The provider sent us an action plan detailing what action they would take to become compliant with this regulation. At this inspection we found the provider had implemented some changes but these were not fully effective. This therefore meant that this regulation had not been completely met and continues to be a breach.

People and relatives told us that staff supported them safely and that Loreto Cottage was a safe environment. Staff were aware of their role and responsibilities in protecting people from harm and had recorded safeguarding incidents appropriately. The registered manager had not adhered to the local authority safeguarding policy and procedure to report safeguarding incidents. Nor had they taken action to analyse incidents for trends and patterns to reduce further risks to people.

Safety concerns were identified with the environment that had not been assessed. This included fire door exists not being alarmed, radiators being hot and not protected to reduce injury to people, there was no visitors signing in and out book and the external environment had potential risks that had not been fully risk assessed. Risks to people’s needs had not always been assessed appropriately or risk plans put in place to manage known risks.

Some staff felt staffing levels were a concern due to the additional domestic tasks they had to complete and the impact this had on spending time with people. Agency staff were used to cover any staff shortfalls such as sickness and vacancies.

Improvements had been made to the administration and management of medicines. However, the medicine policy and procedure had not been updated and reviewed. This was a recommendation made in January 2016 by the local clinical commissioning group following their pharmacy and medicines management review at the service.

Staff received an induction on commencement of their employment. However, one member of staff that started at the service during 2016 did not have any documentation that confirmed they had completed an induction. Staff received appropriate training but support continued to be informal, a concern identified at the last inspection. The registered manager was unable to effectively monitor staff performance and needs.

People had not signed their support plans to show that they had given consent to their care and support or had been involved in discussions and decisions about how their needs were met. The principles of the Mental Capacity Act (2005) were understood by staff. Whilst we saw examples of MCA assessments and best interest documentation, we were aware that some people’s mental capacity to consent to aspects of their care and support had reduced. Records did not show that people’s changing capacity had been considered and reassessed.

The registered manager had submitted one Deprivation of Liberty Safeguards (DoLS) application. However, this was found during the inspection not to have been received by the supervisory body and had to be resubmitted.

People were supported with their dietary and nutritional needs but it was not clear how people were involved in menu planning and how choices promoted. People were supported with their health needs and staff worked with external healthcare professionals to support people to maintain good health.

People and relatives were positive and complimentary about the approach of staff. On the whole staff were found to be caring, kind and compassionate. Staff had a good understanding about people’s preferences and what was important to them. Concerns were identified about how staff engaged with one person who used the service and the lack of understanding and knowledge about different communication tools and methods. These concerns were identified at the last inspection.

There was no information available for people about independent advocacy information. The provider’s representative took immediate action to ensure this was made available for people.

People were supported to participate in a range of activities that were important and of interest to them. This including accessing local community opportunities and being supported with an annual holiday.

People had access to information about the provider’s complaint policy and procedure but this was not easily seen on the display board in the kitchen. Nor was it provided an appropriate format for people with communication needs.

Resident meetings were arranged where people received opportunities to share their views about the service and make suggestions.

Auditing processes were in place, but these were not always effective and had not identified many of the areas highlighted in this report. The registered manager had not fully complied with their registration requirements. They had failed to notify CQC of notifiable incidents they are required to do.

We found the service was in breach of three 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.

We found that people had been informed about their care and treatment and had signed consent forms if they were able. When people lacked the capacity to make decisions we saw that they had been supported appropriately. We also found that people's care and treatment had been planned, reviewed and delivered to meet their care needs.

We spoke with three people who lived at the home. One person told us; "I like it here, I feel safe". Another person said; "I know how to complain, I would tell my family".

We found that the arrangements for the management of medicines were inadequate. We also found that the provider had not ensured there were always enough staff on duty to provide care for people.

You can see our judgements on the front page of this report.

People we spoke to told us that they feel secure at Loreto cottage. One person told us they feel 'very safe here.' People told us they enjoy a range of opportunities to engage in recreational and learning activities. One person told us about the range of college courses they have taken. Another person told us that they 'like to go to the club in the minibus with (the manager).'

A relative of a person who uses the service spoke highly of the quality of care and the welcoming attitude of Loreto cottage staff. They described the care provided as respectful and focused on the individual. They told us they feel 'very fortunate' that their relative lives at Loreto Cottage and advised us that the staff 'try to involve people as much as possible' in care planning and delivery.