Archived: United Response - 4 Burnham Avenue

The service is a residential care home, which provides care and support for up to five people with a learning disability. At the time of our inspection there were five people living at the home. The service is a detached three-storey building, with an open plan lounge and dining room, which leads into a small conservatory. On the ground floor are a kitchen and two utility rooms leading out to a well-kept garden. There is a downstairs toilet and a bathroom on the first and second floor. The service had a cat named Smudger, which people told us they liked having around.

At the last inspection on 16 and 18 August 2016, we identified seven breaches of Regulations associated with assessing the risks to the health and safety of people, systems and processes around safeguarding people from abuse and improper treatment, staff supervision and training, personalised care, how the provider received and acted on complaints and effective good governance. The provider had also failed to notify the Commission of two incidents of alleged abuse. As a result, the service was rated 'Inadequate' overall and the provider was placed into Special Measures by CQC. We met with the provider to discuss our concerns and issued two Warning Notices, which required the provider to take immediate action in relation to assessing the risks to the health and safety of people and the effective governance of the service.

We recommended the provider ensured consistency in the caring approach of staff to ensure people's dignity and well-being are promoted. We also recommended staff training in Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Following the last inspection, the provider wrote to us to confirm that they had addressed these issues.

Since our last inspection, the provider has continued to engage with the Commission. We required the provider to submit regular action plans that updated us about the steps they had taken to improve the service. At this inspection, we found that the actions had been completed and the provider had now met all the legal requirements. Since our last inspection, the service had experienced a period of considerable change. Although significant improvements had been made to address previous shortfalls raised in our last visit, the service is on an improvement journey and these improvements were yet to be embedded and sustained.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service did not have a registered manager in post at the time of our visit. Following our last inspection, the newly appointed manager left the service in December 2016. The provider appointed another manager in March 2017; however, they have not yet commenced employment. The service has been without a registered manager since August 2016. 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. An interim manager who had been in post for three weeks was managing the service day to day.

The recent focus had been on changing the culture of the service. Other areas of improvement had been identified, but not wholly implemented. For example, at the last inspection some people told us they did not feel safe because of the behaviours some people who used the service displayed. We identified that safety incidences were not always analysed and responded to effectively. This meant the risk of further incidents were not always reduced, which could have put people at risk. At this inspection, we found that incidences were still not being fully documented which meant we could not identify how people’s needs were being responded to. Whilst the management team had appointed a Practice Development Advisor to review people’s behaviour care plans and support the staff in preventing and responding to people’s behaviours, people told us they still did not feel entirely safe. This area requires further improvement.

At the last inspection, the provider's systems and processes designed to monitor the quality of the service were not always followed. Internal audits and checks did not identify issues, which were affecting people's safety and wellbeing. At this inspection, we found systems for monitoring quality and auditing the service had improved and were being used to continually develop the service. However, not all systems and processes designed to monitor the quality of the service had been fully embedded. This area requires further improvement.

People were protected against the risk of abuse; staff had a good understanding of how to recognise abuse and what action they should take if they suspected it had taken place. Staff were provided with training relevant to their role and felt well supported by management.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed safely.

Safe staff recruitment procedures ensured only those staff suitable to work in a care setting were employed. Sufficient numbers of care staff were deployed to meet people's needs. We saw that staff recruited had the right values, and skills to work with people who used the service.

At the last inspection, we observed the premises were not always clean or properly maintained. At this inspection, we found noticeable improvements had been made to the home environment which had been service user led. The home was clean and tidy throughout, routinely maintained and monitored by the provider.

People's capacity to consent to care was considered and the home worked in accordance with current legislation relating to the Mental Capacity Act 2005 and the Deprivation of Liberties Safeguards. This included training for all staff on both subjects, which was a recommendation at our previous inspection.

Care plans reflected information relevant to each individual and their abilities, including people's communication and health needs. Staff were vigilant to changes in people's health needs and their support was reviewed when required. The service had good links with health care professionals to ensure people kept healthy and well.

People were provided with a variety of meals and the menu catered for any specialist dietary needs or preferences. Mealtimes were often viewed as a social occasion, but equally any choice to dine alone was fully respected.

People looked happy and were relaxed and comfortable with staff. They were supported by staff that understood their needs and abilities and knew them well. Staff were kind and caring towards people and upheld their privacy and dignity at all times. People were involved as much as possible in planning their care. Staff were flexible and responsive to people's individual preferences and ensured people were supported in accordance with their needs and abilities. People were encouraged to maintain their independence and to participate in activities that interested them.

The service placed a strong emphasis on meeting people's emotional well-being through the provision of meaningful social activities and opportunities. People were offered a wide range of individual activities, which met their needs and preferences. There were processes in place for people to express their views and opinions about the service provided. The feedback from people and their representatives in their most recent customer satisfaction survey was positive. The complaints procedure was displayed and people said they knew what to do if they were not satisfied with the service. Complaints were logged and records showed the provider looked into complaints and responded to complainants.

As a result of improvements made to the quality and safety of Burnham Avenue, the overall rating of the service had improved from 'Inadequate' to 'Requires Improvement'.

The service is a residential care home, which provides care and support for up to five people with a learning disability. At the time of our inspection there were five people living at the home.

The service is a detached three-storey building, with an open plan lounge and dining room, which leads into a small conservatory. On the ground floor are a kitchen and two utility rooms leading out to a well-kept garden. There is a downstairs toilet and a bathroom on the first and second floor. The service had a cat, which people told us they liked having around.

The registered manager had officially left the service in August 2016 but had been absent from managing the service in the four months prior to this. The provider had notified us of the registered manager’s absence. 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. At the time of our inspection, a new manager was on their second day of employment. The provider told us it was their intention to support the new manager to register with the Care Quality Commission without delay. Since July 2016, a new area manager was overseeing the service. The new manager and area manager were present for both days of the inspection.

There was a systemic failure in areas of the service, which led to people being in receipt of poor quality care. The provider had a lack of insight into the previous registered manager's and area manager’s failure to follow their processes. This meant that all aspects of the service were failing and people were not always receiving their planned care.

The provider's systems and processes designed to monitor the quality of the service were not always followed. Internal audits and checks did not identify issues, which were affecting people's safety and wellbeing. The response by the provider to any issues that were identified was inadequate and did not improve the service.

At this inspection, we identified a number of Regulatory Breaches. The overall rating for this service is 'Inadequate' and the service has therefore been placed into 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection, we found that the provider did not have effective systems in place to assess, monitor and improve the quality of care. This meant that poor care was not being identified and rectified by the provider.

Risks to people's health, safety and wellbeing were not consistently identified, managed and reviewed and people did not always receive their planned care.

Medicines were not managed safely. There was no system for checking, the stock of medicines or to monitor the competency of staff responsible for administering medicines. Changes had been made to the prescribing instructions without evidence this was supported by an appropriate healthcare practitioner. The dates of when creams had been opened were not being recorded, this presented a risk because after the expiry date, prescription creams may not be safe or they may lose their effectiveness.

The service did not have appropriate systems in place to protect people from harm. Although most staff had received safeguarding training, this had not been embedded into the culture of the service. This meant staff were unsure of how to report issues of concern.

We found that the service was not clean. There was evidence of poor cleanliness throughout the building. There were no cleaning schedules in place or hand soap to promote infection control and cleanliness. We shared our concerns with Environmental Health.

Safety incidents were not always analysed and responded to effectively, which meant the risk of further incidents was not always reduced.

Staff had a good understanding of the Mental Capacity Act 2005 (MCA); however, this was not always demonstrated when making best interest decisions for people who were deemed to lack capacity. We made a recommendation to refer to the MCA and its codes of practice. Staff demonstrated a good understanding of the Deprivation of Liberty Safeguards (DoLS) and how to put this into practice.

We found staff did not always have the knowledge and skills required to meet people's individual care needs and keep people safe. The staff were not in receipt of appropriate support from the provider to enable them to carry out their duties they were employed to perform.

Prompt referrals to health and social care professionals were not always made in response to changes in people's needs or behaviours.

People spoke fondly about the staff and at times, we observed some positive interactions between staff and people. However, we found that people's dignity and independence was not always promoted.

There were gaps in some people's care plans, which meant staff, did not always have the information they needed to provide safe and consistent care. People and their relatives were not always involved in planning and reviewing their care. This meant we could not be assured that people's care preferences were being regularly identified and met.

People did not receive person centred care as the care records did not give adequate information required for individualised care. There was a programme of social and leisure based activities on offer to people. However, there was no evidence in how those activities had been chosen and how people had been consulted.

People were reluctant to complain about their care and effective systems were not in place to promptly manage complaints to improve people's care.

The provider did not always notify us of reportable incidents and events as required.

Food was produced using fresh ingredients to a high standard and offered good choice. People could choose to eat in the dining room or other areas of the home. Drinks were provided at regular intervals and on request.

During this inspection, we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

Is the service safe?

Since our last inspection people's medical and health records had been reviewed. We found that a new system for monitoring and recording health related records had been introduced. Everyone's medical and health records were accurate and reflected the care and support they had received. People told us that they were supported to attend health related appointments and records were in place that reflected people's comments. For example, one person told us, "I went to see the dentist and I haven't got to go back until December".

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with four of the five people who lived at the home, the registered manager and three staff who supported them. We also reviewed records relating to the management of the home which included, three people's care and health records, three staff recruitment records, policies and procedures and audit reports. All of the people who lived at the home had a learning disability and required differing levels of support.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. On the day of our inspection the manager told us that no one who lived at the home was subject to a DoLS. However, appropriate policies and procedures were in place. Relevant staff had been trained to understand when an application should be made to deprive someone of their liberty and how to submit one.

The manager was clearly passionate about the health and wellbeing of people who lived at the home. However, the manager had not taken sufficient steps to meet a compliance action that was set at our previous inspection in relation to records. We are following this up to make sure that records which relate to people's health care and treatment ensure they are not placed at risk of inappropriate care or treatment.

Is the service effective?

Since our last inspection a new care planning system had been implemented. This was person centred and gave good information to ensure people received the care and support that they needed. People told us that they were happy with the care that had been delivered and their needs had been met. One person told us, "I am doing house work and going to the bank later with X (referring to a member of staff)". Another person told us they were very happy when we asked them. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. Feedback was sought from relatives in February 2014. All praised the staff. For example, one person wrote, 'I always receive a telephone call if X (referring to their family member) has a problem. X is supported by staff to make the call'. Another person wrote, 'All the staff are excellent and very friendly and are constantly aware of X's needs'.

Is the service responsive?

People benefited from meaningful activities and engagement with staff. We observed people going out throughout the day on different one to one activities of their choosing. For example, one person told us that they were due to go and visit their family. We saw that they were supported by a member of staff to go to a train station to collect tickets for the visit.

Is the service well-led?

We noted that feedback from relatives of people who lived at the home had been obtained in relation to the manager. This asked for their views on the manager's leadership, support and the impact on the service that people who lived at the home received. All people who completed a form praised the manager. Comments included, 'Staff very rarely leave. This demonstrates the level of support and leadership she provides'.

We saw there were systems for monitoring the quality of services provided and for obtaining the views of people. These included representatives of the provider who visited the home on a regular basis to audits the service provided to people.

People told us they were "quite happy" with the care and support they received from the provider. We found that the provider used person centred tools to help people identify their needs and plan their care and support. People were engaged in a range of activities to meet their needs and people told us about the activities they enjoyed. We found that the provider cooperated with other service to meet people's needs safely and appropriately. A person's relative told us "they (the person) likes how it is there, they feel they are treated as an adult"

We found that people were supported by staff who were appropriately trained and supported in their role. A staff member told us "it's pretty good here, I have been here ten years and I enjoy working with the guys".

The provider had a complaints policy and procedure in place and this was available to people and their relatives in an accessible format to meet people's communication needs. People told us that staff 'listened' to them and they could tell them if they had any problems. We have asked the provider to make some improvements to ensure that people's care and treatment records are accurate.

Evidence gained from this inspection demonstrated that the provider had taken steps to achieve compliance with regard to infection control and record keeping. Although we spoke to three people who lived at the service their comments did not relate to record keeping.