Archived: The Maples

The Maples is a care home without nursing for up to 15 people aged 18-65 years of age living with a range of complex conditions, including autism with associated sensory and communication difficulties, and complex behavioural needs. There were 13 people being supported in three different bungalows on one site at the time of the inspection.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

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

The service could not show how they met the principles of Right support, right care, right culture.

Right support:

¿ The model of care and setting did not maximise people’s choice, control and independence. The remote rural location of the campus meant people had to use a car or public transport to access local amenities. Due to vehicle sharing and 13 staff out of 76 who were authorised to drive, people could not always enjoy unplanned outings unless they utilised public transport. We received feedback that some staff did not feel confident to support people in the community, which also limited the use of public transport as an option for some people. One person told us, “We have no activity room now as they have turned it into a meeting room.”. The provider told us there were plans to build a bespoke activity centre on site this year.

Right care:

¿ The care people received was not always person-centred and did not always promote people’s dignity, privacy and human rights. People were not always supported by trained, skilled staff who were familiar with people’s needs and agreed care plans. Agency staff, who were frequently allocated as people’s one to one support, had not always received training such as, epilepsy or certified restrictive practice training. The provider had not reviewed the compatibility of people using the service or the impact of people’s needs upon others’ rights. A person told us they were frightened by one of the people they shared a house with.

Right culture:

¿ During our inspection the management team were open about the need to make improvements and had started to invest to develop the service. However, at the time of our inspection, this had not made enough impact to enable people to live full, inclusive or empowered lives. Staff told us they felt there was a lack of visible leadership, and management failed to act on known issues. For example, alarm technology to manage risk was not being implemented by staff due to lost equipment. The management team had not acted to replace equipment or seek suitable alternatives.

People¿were not¿supported to have maximum choice and control of their lives and staff did not always support¿them in the least restrictive way possible¿and in their best interests; the policies and systems in the service¿did not¿support¿this practice.¿

¿ People’s care and support was not provided in a safe, clean, well equipped, well-furnished and well-maintained environment which met people's sensory and physical needs. People’s homes were in a state of disrepair and did not provide a good standard of comfort or therapeutic surroundings for people with different sensory needs. We were not assured that the provider had consistently implemented effective infection control systems to ensure people and others were protected from the risks associated with COVID-19.

¿ People were not protected from abuse and poor care. Staff were not always able to recognise or respond appropriately to abuse. For example, staff did not recognise the unauthorised use of restrictive physical interventions were a potential form of abuse. The service relied on a significant amount of agency staff which impacted on people's care. Care staff, both permanent and temporary, had not always been provided with training or had their competency assessed to ensure they had the skills to safely manage behaviours that could challenge the person and others.

¿ People did not receive care, support and treatment from trained staff and specialists able to meet their needs and wishes. The provider had not ensured that staff had relevant training, regular supervision and appraisal.

¿ People were not always supported to be independent and have control over their own lives. Their human rights were not always upheld. The provider had not ensured all 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 did not always have care from staff that protected and respected their privacy and dignity and understood each person’s individual needs. People’s communication needs were not always met, and information shared in a way that could be understood.

¿ People’s risks were not always assessed regularly in a person-centred way. People were not involved with 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. However, there was limited evidence of this guidance being followed by staff. Systems in place to report and learn from incidents where restrictive practices were used were not effective.

¿ People did not always make choices and take part in meaningful activities which were part of their planned care and support. People’s aspirations and goals were not fully explored so staff could support them to achieve these. Support did not focus on people’s quality of life and follow best practice.

¿ People’s care, treatment and support plans, did not fully reflect all of their sensory, cognitive and functioning needs. People and those important to them, were not actively involved in planning their care. Care plans were not always reviewed to ensure they were up to date and accurate.

¿ Systems were not fully embedded to ensure the safe management of medicines. The provider was working to their own medicines improvement plan. However, this had not identified or mitigated all the concerns we found during the inspection.

¿ Referrals to appropriate health professionals had not always taken place, and when they had, not all had been followed up to ensure actions were taken to improve people’s health and wellbeing.

¿ People were not always supported by staff who understand best practice in relation to learning disabilities and autism. The provider was aware of the shortfalls in staff knowledge and training and was taking steps to improve staff training and support in these areas. Governance systems did not ensure 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, were not fully involved with leaders to develop and improve the service.

¿ Where people were supported by staff who knew them well, and understood the support they required, people experienced caring and positive relationships with staff.

The provider recognised improvements were required and had reacted with an action plan. However, there was not a clear understanding of risk-based priorities or vision shared by the whole team to drive improvements. We asked the provider for reassurance that they would take urgent action in response to our findings on the first day of the inspection. We checked that this had taken place on our second visit.

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 4 September 2019).

Why we inspected

The inspection was prompted in part due to concerns received about safe management of medicines. A decision was made to undertake a comprehensive 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.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We identified eight breaches at this inspection in relation to person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse, premises and equipment, receiving and acting on complaints and good governance and staffing.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the relevant local authorities to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Maples is a residential care home that was providing care to 14 people living with learning disabilities at the time of the inspection. The service provides accommodation and support in three separate bungalows on one site for up to 15 people who have autism and accompanying learning disabilities.

We inspected this service within the principles of Registering the Right Support (RRS) and other best practice guidance. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes.

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

Not all people living at The Maples were able to verbally give us their views. Therefore, we observed their care and support throughout the inspection to help us understand the experience of people who could not talk with us.

Outcomes for people did not fully reflect the principles and values of RRS for the following reasons. There was limited information seen that staff were consistently providing support and care that met people’s needs in line with strategies to reduce behaviour that challenged. People's care plans described what interests and activities may help in reducing behaviour that challenged. However, people’s daily records showed limited evidence of these taking place. RRS principles state that social isolation should be reduced by accessing the wider community and other relevant resources.

We have made a recommendation that the provider refer to best practice guidance, on delivering care and support to meet people’s assessed needs to achieve meaningful outcomes.

People told us they took part in activities they enjoyed and were supported to follow their interests. People, and where applicable their relatives, were provided with opportunities by management to review their support needs on a regular basis. Accessible information was provided to help people make an informed choice. Complaints were handled and responded to in line with the provider's complaints policy.

People were supported by staff that knew them well and were kind and caring. There was a calm, friendly and warm approach by staff when supporting people. People's views were requested and acted on and staff communicated effectively with people. Staff treated people with respect and dignity. People's records were handled appropriately and in line with data protection legislation.

People were protected from the risk of avoidable harm and abuse and staff understood how to act on any concerns. There were sufficient numbers of staff in place and they understood how to provide people with safe care and support. People's medicines were managed safely and effectively. Accidents and incidents were investigated. This included clear processes for investigation and support for staff to learn from mistakes.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. Staff were well trained and received regular supervision to enable them to carry out their roles effectively. People were supported effectively to eat and drink healthily and had access to support from external health and social care agencies.

There was a committed management team in place and there were effective systems to monitor and improve the quality of the service. The service had identified areas of improvement and produced an action plan to ensure these actions were completed. The provider and managers undertook regulation quality assurance checks to maintain an overview of the service. People, relatives and staff told us they liked the management team and felt supported. The provider and managers encouraged people, relatives and external stakeholders to give their views about how the home could be improved and developed.

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 13 January 2017).

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up

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.

The Maples is a residential care home registered to provide accommodation for persons who require nursing (without) or personal care. They support up to 15 people who have autism and accompanying learning disabilities. The service was supporting 14 people at the time of inspection.

There was not a registered manager 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. The service was being managed by a manager who had applied for registration with the Care Quality Commission.

At an inspection in September 2015 we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the inspection the provider sent us details of how they would meet their legal requirements relating to the three breaches.

At this inspection we found improvements had been made. People felt safe and were supported by staff that had the skills and knowledge to meet their needs. The service was continuing to work on recruiting to vacant posts and in the meantime took measures to ensure temporary staff were of a good standard. The service had robust recruitment procedures and conducted background checks to ensure staff were suitable for their roles.

Relatives felt people were safe. Staff had a clear understanding on how to safeguard people and protect their health and well-being. People received their medicines as prescribed. There were systems in place to manage safe administration and storage of medicines.

People had a range of individualised risk assessments in place to keep them safe and to help them maintain their independence. Where risks to people had been identified, risk assessments were in place and action had been taken to manage the risks. These were regularly reviewed and updated when needed. Staff were aware of people’s needs and followed guidance to keep them safe.

People were supported by competent staff that benefitted from regular supervision (one to one meetings with their line manager). Staff received adequate training and support to carry out their roles effectively.

The manager and staff had a good understanding of the Mental Capacity Act (MCA) 2005 and applied its principles in their work. Where people were thought to lack capacity to make certain decisions, assessments had been completed in line with the principles of MCA.

People were supported to maintain their health and were referred for specialist advice as required.

People and relatives were involved in decisions about people’s support needs. People had care plans which detailed the support they required and how the support would be provided. Care plans were regularly reviewed and updated. Staff knew the people they cared for and what was important to them. Staff supported and encouraged people to engage with a variety of social activities of their choice in the community.

The service looked for ways to continually improve the quality of the service. Feedback was sought from people and their relatives and used to improve the care. People knew how to make a complaint and complaints were managed in accordance with the provider’s complaints policy.

The manager informed us of all notifiable incidents. The manager had applied to become a registered manager and had a clear plan to develop and further improve the service. Staff spoke positively about the support and leadership they received from the management team.

During our last visit, we identified concerns about people's care and welfare needs not being met. At this inspection we found the provider had taken appropriate action to ensure people who use the service experienced care, treatment and support that met their needs.

At our last inspection we found the provider did not operate effective recruitment procedures. At this inspection we found the provider had taken appropriate action to ensure people were cared for, or supported by, suitably qualified, skilled and experienced staff.

During our last inspection we found the provider did not take appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff. At this inspection we found the provider had taken appropriate action to ensure there were enough qualified, skilled and experienced staff to meet people's needs.

At our last inspection we found the provider did not have suitable arrangements in place in order to ensure that staff were appropriately supported with training, supervision and appraisal. At this inspection we found the provider had taken appropriate action to ensure people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff had been properly trained and supervised.

We previously identified concerns about the way the provider assessed and monitored the quality of service they provided. This was because they did not have an effective system in place to regularly assess and monitor the quality of service, or identify, assess and manage risks to the health, safety and welfare of people who use the service and others. At this inspection we found the provider had taken appropriate action to ensure they had an effective system to regularly assess and monitor the quality of service that people receive, and to assess and manage risk.

At our last inspection we identified concerns about the way the provider protected people from the risks of unsafe or inappropriate care and treatment because they did not maintain accurate and appropriate records. At this inspection we found the provider had taken appropriate action to ensure people's personal records were accurate. Records required to protect people's safety and wellbeing were being maintained. Other records in relation to people employed by the service were also accurate.

When we reviewed people's care plans we found evidence of some service users' involvement in making decisions about their care was absent. Relatives told us they were involved in annual reviews of care for their family members. However, one relative told us they were not involved in this year's review, because the date had been changed at short notice and they were unable to attend the new date offered. Although we observed occasions where staff treated people with respect, and involved people who use services, we also observed occasions where they did not.

One person who uses the service we spoke with said 'I can assure you, the quality of care is very good'. One relative told us 'staff are caring' and another told us their family member was 'well looked after and cared for'. When we spoke with staff, they were able to describe how they would support people who use the service to meet their needs. However, we found one person had not seen the dentist or optician for two and a half years. We saw some risk assessments were in place, but others were out of date or had not been completed at all. Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

The provider did not have effective recruitment and selection procedures in place. Not all of the relevant checks had been completed before staff began work.

The provider did not take appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff on duty. There was a risk they would not be able to safeguard the health, safety and welfare of people who use the service.

When we spoke with staff they told us they felt well supported by managers and they had enough training to enable them to meet the needs of the people they supported. However, when we looked at staff training records we found the provider did not ensure that staff were properly trained and supported to provide care and support to people who use the service. There was risk that staff would not be enabled to carry out their role effectively.

The provider did not regularly assess and monitor the quality of the services they provided. They did not identify risks relating to the welfare and safety of people who use the service. The provider did not have regard to the comments made, and views expressed, by people who use the service, and those acting on their behalf. The provider did not ensure that people's personal records were accurate. Records required to protect people's safety and wellbeing were not being maintained. Other records in relation to people employed by the service were not accurate.

We have made a referral to the local authority safeguarding adults team, due to the concerns raised from this inspection.

We spoke with the person managing the service on the day of our inspection. Throughout this report, we have referred to this person as the acting manager. The location did not have a registered manager at the time of our inspection.

We spoke with relatives of people who live in the home. One relative said,

'Our son cannot make many decisions, but where possible staff support him to do that'. 'In general I feel the service provides good quality care' we were notified of the building changes, the name change of the home and the new management changes'. Another relative said, 'Compared to the past history everything is now very positive. When I saw his own flat over the weekend I couldn't believe when I said how nice the colour was that our son had chosen it all himself'.

Staff were knowledgeable of people's specific health and personal care needs and how they wanted those needs to be met. We looked at people's care plans and supporting documents. We found peoples care plans detailed their needs, and how to meet those needs whilst minimising identified risks.

The provider had ensured staff received appropriate professional development and support to deliver care and support to the people who live in the home.

We found people and their relatives had opportunities to contribute their views about the quality of the service. The provider had systems for monitoring services provided.