The Laurels

The Laurels is a residential care home providing a regulated activity to up to seven people. The service provides personal care support to adults with learning disabilities and/or autism. At the time of our inspection there were seven people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: People were supported to make choices using their preferred communication methods and were listened to by staff. People were able to choose what they did when and if they didn’t want to do something or changed their minds they were listened to.

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.

Right Care: The registered manager and staff team were passionate about promoting person centred care and we saw this demonstrated throughout the inspection. We observed people being supported by staff who knew them well using a person-centred approach. Staff were relaxed, confident and engaged with people consistently. People’s privacy and dignity was fully supported, and the provider’s policies and processes supported this.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

People were kept safe from avoidable harm and we observed people being supported by staff who knew them well. There were appropriate policies and systems in place to protect people from abuse. Staff knew how to recognise abuse and protect people. Managers maintained people’s safety and investigated incidents. Lessons learned were shared with the whole team and the wider organisation.

There was a culture of positive risk taking within the service led by the registered manager. Staff demonstrated their knowledge and understanding of people’s needs and we observed staff spent time confirming with people their choices and that they had fully understood what the person had chosen.

People confirmed there were enough staff to support them and that they were staff who they knew and were comfortable being supported by. We observed safe staffing levels during the inspection and staff had time to spend with people and people were supported with activities of their choice. People confirmed to us they didn’t feel rushed by staff. Staff had the information and time they needed to provide safe and effective care.

At the last inspection we had identified concerns in relation to outstanding maintenance works and medicines. At this inspection we found there was an effective process in place for maintenance management and that the provider had robust medicines management, administration and storage processes in place.

Since the last inspection there had been changes to the environment. People seemed happy with the changes and the changes had been made with the involvement and consideration of the people living at the service.

The provider worked with a variety of health and social care workers. The registered manager had developed close working relationships which supported positive outcomes for people.

People, and those important to them, worked with managers and staff to develop and improve the service. The provider sought feedback from people and those important to them and used the feedback to develop the service. People and staff confirmed they felt listened to and were able to make suggestions. Staff told us they felt supported, valued and appreciated.

There were a number of systems and processes in place for monitoring the quality of care and used to plan improvements. Where issues were identified remedial action was taken. Staff had access to policies and procedures which encouraged an open and transparent approach.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 6 October 2021) and there was a breach in regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 22, 24 and 25 June 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Laurels on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

The service could show how they met the principles of Right support, right care, right culture. People lead confident, inclusive and empowered lives where they were in control and could make meaningful choices. The ethos, values, attitudes and behaviours of the management and staff provided personalised support for each person.

The needs and quality of life of people formed the basis of the culture at the service. Staff understood their role in making sure that people were always put first. They provided care that was genuinely person centred.

The leadership of the service had worked hard to create a learning culture. Staff felt valued and empowered to suggest improvements and question poor practice. There was a transparent and open and honest culture between people, those important to them, staff and leaders. They all felt confident to raise concerns and complaints.

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.¿

• People’s medicines were reviewed to monitor the effects of medicines on their health and wellbeing. However, we found some concerns in the storage and management of medicines.

• People’s care and support was provided in a mostly safe, clean, well equipped, well-furnished and well-maintained environment which mostly met people's sensory and physical needs. We observed that there were some outstanding maintenance works that had not been completed.

• People were protected from abuse and poor care. The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

• People were supported to be independent and had control over their own lives. Their human rights were upheld.

• People received kind and compassionate care from staff who protected and respected their privacy and dignity and understood each person’s individual needs.

• People had their communication needs met and information was shared in a way that could be understood.

• People’s risks were assessed regularly in a person-centred way, people had opportunities for positive risk taking. People were involved in managing their own risks whenever possible.

• People who had behaviours that could challenge themselves or others had proactive plans in place to reduce the need for restrictive practices. Systems were in place to report and learn from any incidents where restrictive practices were used.

• People made choices and took part in meaningful activities which were part of their planned care and support. Staff supported them to maintain independence and promote choice.

• People’s care, treatment and support plans mostly reflected their sensory, cognitive and functioning needs.

• People received support that met their needs and preferences. Support focused on people’s quality of life and followed best practice. Staff regularly evaluated the quality of support given, involving the person, their families and other professionals as appropriate.

• People received care, support and treatment from trained staff and specialists able to meet their needs and wishes. Managers ensured that staff had relevant training, regular supervision and appraisal.

• People and those important to them, including advocates, were actively involved in planning their care. Where needed a multidisciplinary team worked well together to provide the planned care.

• Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.

• People were supported by staff who understood best practice in relation to learning disability and/or autism. Governance systems mostly ensured people were kept safe and received a high quality of care and support in line with their personal needs. People and those important to them, worked with leaders to develop and improve the service.

Our last inspection found a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities). This inspection found not enough improvement had been made at this inspection and the provider was still in breach of regulation 17. Governance processes were not always effective in helping to keep people safe, protect their human rights and provide good quality care and support.

Our last inspection found a breach of regulation 11 (Need for Consent). This inspection found people that the service assessed as lacking mental capacity for certain decisions, had clearly recorded assessments and any best interest decisions. Staff understood the Mental Capacity Act 2005, including Deprivation of Liberty Standards.

Why we inspected

This was a planned inspection based on the previous rating.

We undertook this inspection to provide assurance that the service is applying the principles of Right support right care right culture.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have identified a breach in relation to governance; governance and quality assurance systems were not fully effective at monitoring the quality and safety of the service. This placed people at risk of harm. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People in care homes receive accommodation and their care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection. This inspection took place on 7 and 9 January 2019 when there were seven people using the service.

The service had a registered manager. 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 Laurels had been developed and designed in line with the values that underpin

Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities using the service lived as ordinary a life as any citizen. People were given choices and their independence and participation within the local community was being encouraged and enabled.

At our last inspection we rated the service as overall good. At this inspection, we found some areas where improvements were needed and one breach of the fundamental standards. We have now rated the service as requires improvement.

The provider’s governance and quality assurance systems were not being fully effective at monitoring the quality and safety of the service. We found a number of areas where records relating to people’s care, and to the management of the service, were not complete, accurate and up to date.

Where people were unable to make more complex decisions about their care and support, staff had not always demonstrated how they were acting in accordance with the MCA 2005.

Whilst staff knew how to support people in a way that minimised identified risks, records relating to this were not always accurate. Similar concerns were found in relation to medicines records. We were concerned this could impact on people’s safety.

Overall, the design and layout of the premises met people’s needs, but further action was needed to ensure that all aspects of the premises were well maintained and in a good state of repair.

There were sufficient numbers of staff to meet people’s needs.

Staff followed infection control guidance and the home was visibly clean.

Incidents and accidents were investigated and remedial actions taken in response.

Health and safety checks were carried out to ensure the safety of the building and equipment within it, but we have made a recommendation about window restrictors.

Staff had received training in safeguarding adults, and had a good understanding of the signs of abuse and neglect.

Staff understood their responsibility to raise concerns and report on incidents and accidents.

Staff received the training and support they required to meet people's individual needs. Staff worked well with external health care professionals and people were supported to access health services when required.

People were treated with dignity and respect and staff were kind and caring in their interactions with people. People received care that was centred on them as an individual.

People were supported to follow their interests and take part in social activities both within the home and within the community.

Relatives were confident they could raise concerns or complaints and these would be dealt with.

We have made a recommendation about developing end of life support planning for people using the service.

Relatives and staff expressed confidence in the registered manager and their ability to manage the home well. Everyone continued to speak positively about the friendly and homely culture within the home.

We found two breaches 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 this report.

Dolphin Homes, the provider, is a specialist care provider delivering care and support for adults with learning difficulties, behaviour which challenges others, physical disabilities and complex health needs, autism and Asperger's syndrome. The Laurels provides care and support for up to seven people with a learning disability and / or a physical disability. People’s rooms were arranged over two floors with both stairs and a lift available to access the first floor. Each room had its own ensuite wet room. There was a bathroom, but this was not in use. Where necessary people’s room were fitted with overhead hoists to assist with moving and handling tasks. In addition the home had a lounge and conservatory, a kitchen and separate dining room, a laundry and a staff office. The home had a large garden to the rear and parking to the front.

The service had a registered manager. 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.

Although the people living at The Laurels were unable to communicate with us, we observed that they appeared relaxed and comfortable in the presence of the staff that were supporting them.

Care records included guidance for staff to safely support people. People had risk assessments and risk reduction measures were in place although we did note that body maps could be more effectively used to document and plan for how skin damage was responded to.

Arrangements were in place to help manage people’s medicines safely, although we noted that medicines audits could be more effectively used to help identify administration errors and allow mitigating actions to be taken to prevent further errors.

Staff were trained in how to recognise and respond to abuse and understood their responsibility to report any concerns to their management team.

Safe recruitment practices were followed and appropriate checks had been undertaken which made sure only suitable staff were employed to care for people in the home. There were sufficient numbers of experienced staff to meet people’s needs.

Staff received a suitable induction which involved learning about the needs of people using the service and key policies and procedures. Staff were supported to provide appropriate care to people because they were trained, supervised and appraised.

The provider and registered manager understood their responsibilities with regards to the Mental Capacity Act (MCA) 2005 and improvements were underway which when embedded will ensure that mental capacity assessments are fully documented.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people’s liberty or freedoms were at risk of being restricted, the proper authorisations were either in place or had been applied for.

People were supported to have enough to eat and drink and their care plans included information about their dietary needs and risks in relation to nutrition and hydration.

Staff had a good knowledge and understanding of the people they were supporting. Staff were able to give us detailed examples of people’s likes and dislikes which demonstrated they knew them well.

People were supported to take part in a range of activities and make choices about how they spent their time.

Relatives and staff spoke positively about the registered manager. There was an open and transparent culture within the service and the engagement and involvement of people and staff was encouraged and their feedback was used to drive improvements. There were systems in place to assess and monitor the quality and safety of the service and to ensure people were receiving the best possible support.

On the day of our inspection one person was away on holiday and one person was admitted to hospital due to illness. We saw how staff supported the individual by arranging for the GP to visit and liaise with ambulance services. The manager arranged staff to support the person for their admission into hospital.

The people who we saw on the day of our inspection communicated non-verbally and by gestures and signs. Staff were aware of the common signs they used to say yes or no. This way of giving consent was clearly recorded in people's care records.

People's care needs had been assessed and care plans showed how those needs were being supported. Where necessary risk assessments were in place to ensure the safety and welfare of the person.

We looked at how medicines were administered and stored. We found the service used a pharmacy supplied system which all staff had been trained to use. One member of staff said: "I like using the medicines system as I know exactly what tablets to give and at what time. We have all received training and the manager checks our competency every year."

The manager talked with us about their recruitment process. We found all staff were checked appropriately before commencing work in the service.

The provider carried out a quality monitoring audit every three months. We found this covered a wide range of areas and gave the manager a number of actions they could follow to improve the service.

We observed that staff asked people about how and when they wanted their care and support. This indicated that people were involved in planning their care on a daily basis.

People chose how to occupy themselves in the service. We observed that people were spending time in the communal areas watching television and interacting with each other in the sensory room. During our inspection we observed people spending time in their bedrooms listening to their choice of music and watching DVDs. We also saw people being involved with cooking in the kitchen with staff members.

Throughout the day we observed staff maintaining the security of the building and people looked relaxed and comfortable with the staff supporting them.

During the inspection we observed staff spending the majority of their time with people who used the service. They frequently checked on them to ensure they were alright when spending time on their own.