56 Sycamore Grove is a care home for three people with learning disabilities. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.This is the first time this service has been given an overall rating of Requires Improvement. At the previous inspection dated November 2015 we rated the key question Safe as Require Improvement. We found that risk assessments were devised over significant periods of time which the registered manager had signed annually as ongoing. Action to improve this key question from Requires Improvement to at least Good is now required.
This inspection took place on the 28 February 2018 and was unannounced.
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. Registering the Right Support CQC policy
A registered manager was in post. 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.
Quality Assurance systems were in place, but areas identified as requiring action had not been prioritised or completed. The registered manager had self-assessed how set outcomes were being met. We saw the registered manager had indicated that all standards were met in the self-assessment, dated December 2017. Action plans were devised and included “re-formatting” care plans, having keyworker meetings, assessing staff competency with medicines and developing questionnaires to relatives. The area manager had conducted an assessment of the set outcomes in January 2017 and had recorded “plan to review and re-write care plans”. While we acknowledge the staff and people went through a period of instability, no action was taken in relation to “re-formatting” care
Although people’s records were securely stored, they were not complete or up-to-date. Risks assessments were devised over a significant period of time, which the registered manager signed and dated to indicate they were reviewed annually. At the inspection of November 2015, we said “where risk assessments were in place they had been devised over a significant period of time” and were not updated in that period. While the risks identified may be ongoing, there was little consideration given to changes of legislation and good practice that have occurred in the meantime. This meant no action had been taken to improve the guidance to staff on how to minimise risks.
The staff we spoke to were knowledgeable about people’s individual risks and the actions needed to minimise the risks. Individual risks to people included self-harm risk of malnutrition and mobility impairments. Some risk assessments lacked detail and were inconsistent with information held in care plans. For example, the risk assessment for one person with a mattress monitor was missing.
There were people who expressed their anxiety and frustration using aggression. Staff told us and training records confirmed that staff had attended positive behaviour management training. For one person there were a number of behaviour management strategies which had been devised over ten years and had been reviewed annually as current. Risk assessments were not reviewed although the person had continued to express their anxiety and frustration. Strategies were not reviewed to assess that appropriate action was being taken to minimise the risk of self-harm to the person.
Care plans did not fully reflect people’s physical, mental, emotional and social needs. The agreed outcomes specified within social workers comprehensive care plans were not used to develop care plans with the person. Where care plans were in place, they lacked people’s preferences on how their care was to be delivered. For some people, care plans were developed over a significant period of time which the registered manager had reviewed annually as current.
People’s life stories were not part of their care plans, which meant there was little information about people and their family, education, hobbies and interests.
Incidents and accidents were reported, however there was no overarching view of patterns and trends. The registered manager said copies of these reports were analysed by the provider. They said action was taken where further action was advised from senior manager. The registered manager said the reports were then filed in care records.
The safety of communal and personal spaces and the living environment were regularly checked to support people to stay safe.
Steps were taken to ensure medicine systems were safe. People told us staff administered their medicines. Staff told us and training records confirmed staff’s competency to administer medicines was assessed. Medicine administration records (MAR) charts were signed by staff to indicate the medicines administered. Where “as required” also known as (PRN) medicines were prescribed, protocols were devised on the administration of these medicines. Some protocols lacked detail on the signs and symptoms that indicated PRN medicines were needed. This meant that the PRN protocols did not guide staff on how to recognise when people might need these medicines.
People told us the types of day to day decisions they were able to make. The staff told us and training records confirmed they had attended Mental Capacity Act (MCA) training. The staff we spoke with were knowledgeable about the day to day decisions people made. These staff also confirmed that people were accompanied in the community.
Mental capacity assessments had not been completed for care and treatment which meant the applications for Deprivation of Liberty Safeguards (DoLS) were not within the principles of the MCA. There were inconsistencies with the assessments of capacity for specific decisions. For example, a mental capacity assessment was in place to reduce calorie intake for one person but when the same person refused to follow specific diets for their medical condition a capacity assessment of this complex decision was not taken. The registered manager told us urgent DoLS applications for continuous supervision were made some time ago. However, copies of the application were held at the provider’s office and not held at the home.
The safeguarding processes in place ensured people at the service were protected from abuse. Members of staff told us and training records showed safeguarding of abuse training was attended. The people we spoke with said they felt safe and the staff gave them a sense of safety.
Staffing rotas were designed for two staff during the day and one member of staff lone working from 5pm onwards. The member of staff lone working also slept in the premises. People told us they received assistance from the staff as required.
The staff were supported to develop the appropriate skills and knowledge needed to meet the needs of people accommodated. The training records reviewed showed that staff had attended training which the provider had set as mandatory. One to one meetings with the registered manager were regular to discuss performance, personal development needs and concerns.
People participated in menu planning. There was a range of fruit, vegetables as well as tinned and dried produce.
People were aware care records were held. They said there was one to one time with their keyworker. People’s views about the service were gathered. We saw “your views” forms that were in picture and word formats were used to gather people’s feedback about their meals, places to visits, staff and activities.
There were opportunities for people to participate in community activities. People with religious beliefs were supported to visit places of worship and to join clubs, activities and trips organised by Christian groups.
The staff were knowledgeable about the aims of the organisation. They knew how these values were embedded into practice. Staff told us the team was stable and they worked well together. They told us the registered manager was approachable. Staff received feedback through regular team meetings where discussions about people, information were shared and roles and responsibilities discussed.
Staff supported people when they became distressed and responded to requests for support and assistance. Staff knew people’s preferences and how to approach people in a sensitive manner.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report.