We carried out this unannounced inspected on 23 and 24 April 2018. The service was last inspected in January 2016 when the service was rated as ‘Good’. At this inspection we have rated the service as ‘Requires Improvement.’ This was because we had concerns about the robustness of the quality assurance systems, staff understanding of the Mental Capacity Act and the maintenance of the premises.Treseder House is a ‘care home’ that provides care for a maximum of eight adults with learning and/or physical disabilities. The service is owned and operated by the Royal Mencap Society. 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. The service is owned and operated by the Royal Mencap Society and can accommodate a maximum of eight people.
At the time of the inspection there were seven people living at the service. The service is set in a detached house on two floors with access to the upper floors via stairs. One room had en-suite facilities; other rooms shared three additional bathrooms, one of which was specially adapted with a hoist to support people with limited mobility. Shared living areas included a lounge, a dining room, a garden with decking area and patio seating area.
The service had undergone a number of management changes in recent months including a new service manager and an interim Area Operations manager.
The service is required to have a registered manager in post to hold responsibility for the day-to-day running of the service. 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 and associated Regulations about how the service is run. The registered manager had given CQC notice of a period of absence from their position.
Most people living in the service had limited verbal communication and were not able to tell us in depth their views about the care and support they received. However, we observed people were relaxed and comfortable with staff, and they received care and support in a way that kept them safe. People's behaviour and body language showed that they felt cared for and that they mattered. Some people were able to tell us their views and said they felt safe and happy living at Treseder House. It was clear people were comfortable with staff and moved freely around their home.
Support was provided by a consistent staff team who knew people well and understood their needs. Staff were positive about the people they supported and demonstrated a good knowledge of people’s support needs. We saw that staff had good relationships with people and displayed empathy and warmth in their care. Staff comments included, "I believe people have a good life here. We try our best to make them happy" and "The staff seem to be happy and the people we support are happy."
People were encouraged to be individuals and do what they wanted to do to provide them with a fulfilling life. For example, people who could, went out regularly to local community activities, such as day placements. People also left the service for trips supported by staff. There were a range of personalised and appropriate risk assessments in place to help keep people safe.
There were enough staff to meet people’s changing needs and wishes. Staff said they felt supported by managers and received regular individual supervision. There were also regular staff meetings which gave staff the chance to meet together as a staff team to discuss people’s needs and new developments for the service.
The atmosphere at the service was calm and happy. During the inspection we saw people were well supported and took part in their planned activities for the day. This included attending various community activities and day placements. People told us they enjoyed these activities.
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Relatives were positive in their feedback about the service. We were told people were welcome to visit and the service was, “very caring.” Comments from relatives included, “My [relative] has been at Treseder House for many years. The staff I've found very considerate for the needs of [person’s name], the place has an air of serenity which [person’s name] needs. When I've visited, it’s been easy to talk to the staff. I'm in e-mail contact with the manager. I am contacted if there is a problem."
People were supported to maintain good health, have access to healthcare services and received continuing healthcare support. Staff supported people to eat and drink enough and maintain a balanced diet. People who required it had specialist speech and language assessments and risk management plans in place.
Medicines management systems demonstrated generally safe practice. However, we saw incidents where handwritten additions to people’s medicine administration records (MAR) had not been double signed. This is good practice as it acts as a check to ensure accurate transcription of additional medicines onto medicine recording systems. Management confirmed this was an oversight and the need to ensure this was completed would be highlighted to staff.
The premises were generally well maintained and provided a bright and inviting environment. However, there were some required maintenance issues at the service. For example we saw a kitchen cupboard and plinth were missing in the kitchen. A piece of furniture had been moved from the top of the stairs leaving the wall behind it a different colour from the remaining wall. A bathroom and an upstairs toilet had a strong malodour and a ceiling mounted ventilation extraction unit was unhygienic.
We spoke with the service management about this and were told they were aware of the required maintenance issues. Following the inspection we were sent evidence demonstrating that maintenance requests had been recorded. This demonstrated that the service had made maintenance requests over six months ago including work required in the kitchen which had not been undertaken.
The service had satisfactory safeguarding policies and procedures. Staff were trained to recognise abuse, and what to do if they suspected abuse was occurring. Suitable risk assessment procedures were in place, and risk assessments were regularly reviewed.
The service operated safe recruitment checks for new staff including Disclosure and Barring Service checks (DBS) and reference checks. However, we found the service policy to renew staff DBS checks every three years in line with the local authority requirements had not been consistently completed. When this was drawn to the attention of management a required DBS renewal was begun immediately.
Care records were clear, informative to the reader and were up to date. Records were regularly reviewed, and accurately reflected people’s care and support needs. Details of how people wished to be supported were recorded in their care plans and were personal to them and provided clear information to allow staff to give appropriate and effective support. Any identified risks to people’s care and support were appropriately managed.
Care records demonstrated staff shared information effectively with healthcare professionals and involved them appropriately. Healthcare professionals told us, “Communication is good. They keep us well informed of things we need to know” and “If there have been any concerns about the service user, the staff will contact our service for advice.”
Consent to people’s support arrangements was not consistently recorded in care records. This meant it was not clear from documentary evidence if people had been asked and had agreed to their current support arrangements.
We reviewed service arrangements for ensuring that where people did not have the capacity to make certain decisions that the service acted in line with legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. We found the service had met the legal requirements to make a Deprivation of Liberty (DoLS) application where it was clear that a person was subject to a specific deprivation of their liberty, such as use of monitoring equipment due to a health condition.
The service had not carried out mental capacity assessments for three people, who management confirmed, were not free to leave the service without supervision. This was because the people had been assessed by another agency as having capacity to understand and consent to their care plan. However, we found no evidence of discussions with people about this, consent to the arrangements or of review having taken place about the on-going supervision.
People and their families were given information about how to complain. Relatives told us when they had brought an issue to the attention of management in the past, it had been managed quickly. People had confidence that they were listened to and their views mattered.
Quality assurance processes were not sufficient to adequately pick up and address shortfalls in service provision. For example, we found identified maintenance issues had not been addressed in a timely way.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.