Archived: St Erme

St Erme Campus is a care home providing personal care for up to twenty people with autism. At the time of the inspection 13 people were living at the service.

Accommodation is on a campus style development and is based in three separate houses known as The Lodge, The House and St Michaels. There is also a small office building on the campus. Campuses' are group homes clustered together on the same site. They may share staff and some facilities. The service is part of Spectrum (Devon and Cornwall Autistic Community Trust) which has several services in Cornwall providing care and support for autistic people and/or people with a learning disability.

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

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.

The service was not able to demonstrate how they were meeting the underpinning 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.

People did not have fulfilling and meaningful everyday lives. There were limited opportunities to leave the service and a lack of variation in available activities.

The environment and facilities did not promote independence and autonomy.

Right care:

There were not enough suitably skilled staff to meet people’s needs and keep them safe.

Where people had identified goals and aspirations, they had not been supported to achieve these.

Right culture:

We identified a poor culture where there were low expectations for people and an acceptance of situations and quality of life which would not be acceptable for most people. People were not supported to live full and meaningful lives or develop their own routines.

At our last inspection we identified staffing shortages, the use of agency staff was introduced and this impacted positively on staffing numbers. However, staffing levels remain a concern and St Erme Campus is frequently working to ‘contingency’ levels which are set by the provider as the lowest number of staff required to keep people safe. The risk of running the service at, or near to, ‘safe’ levels was highlighted when three agency staff, all working 14-hour shifts, (70 hrs each per week) tested positive for Covid-19. This left the service understaffed with limited further staffing resources to draw from. Contrary to legal requirements for people to self-isolate following positive tests Spectrum allowed staff who had tested positive for Covid-19 staff to continue working at the service in a ‘bubble’ arrangement with people using the service who had also tested positive.

People were not supported to have maximum choice and control of their lives and staff did not 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. Deprivation of Liberty (DoLS) conditions were not met. Despite frequent reminders from the Cornwall Council DoLS team the manager had not supplied DoLS reports to them in line with conditions for three people.

The provider had failed to ensure monitoring, governance and business continuity systems were established and operating effectively to ensure compliance with the regulations. There was a lack of supportive leadership in place. There were indicators of a closed culture developing.

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 inadequate and there were breaches of the regulations (published 17 August 2021). We imposed conditions on the registration for the service which required the provider to send us monthly reports.

At this inspection not enough improvement had been made and the provider was still in breach of regulations. The service remains rated inadequate. This means the service has been rated inadequate or requires improvement for four consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Erme Campus 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 will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person-centred care, dignity and respect, safe care and treatment, safeguarding, staffing levels and deployment, and governance.

We took legal steps to remove the service from the providers registration. The service has now closed.

About the service

St Erme is a care home providing personal care for up to twenty autistic people. At the time of the inspection 12 people were living at the service.

Accommodation is across three separate houses all within the grounds. The houses are known as The Lodge, The House and St Michaels. There is also a small office building on site. The service is part of Spectrum (Devon and Cornwall Autistic Community Trust) which has 15 active services in Cornwall providing care and support for autistic adults and/or adults with a learning disability.

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

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Staff and relatives told us there had been a high turnover of staff and recruitment drives to recruit permanent staff had not been successful. The provider relied on agency staff to increase staffing levels. These agency staff routinely worked very long hours. Some agency staff were committed to the service and hoped to move to the area and become permanent members of the team. However, there remained concerns about the stability of the team and new staff not knowing people well or having a good understanding of their needs in order to provide good outcomes for people.

Inadequate staffing levels impacted on many aspects of the service. This included providing support in line with commissioned hours, developing trusting relationships with people and supporting people to take part in activities outside of the service. This was compounded by a lack of drivers working at St Erme to support people to go out and do things.

People were not supported to have maximum choice and control of their lives and staff did not 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.

There had been a high turnover of managers at the service. The last registered manager deregistered in August 2021. Two external consultants were working at the service as manager and deputy manager. The manager had applied for registration until a more permanent manager could be appointed. Neither of the consultants lived locally and were not at the service at the weekend. They were particularly focused on The House and a service manager had day to day oversight of The Lodge and St Michael’s. Staff, relatives and professionals told us the management situation had improved although there remained concerns about the temporary arrangements for managing the service.

Right Support

The service is based in a campus style setting. People had exclusive possession of their own rooms, in shared accommodation. The environment was not well maintained, and people’s sensory needs had not been considered when designing the service.

People were not consistently supported in the least restrictive way. At certain times of the day people were unable to move around communal areas freely. Cupboards and doors were routinely locked and some people were not able to access drinks or snacks when they wanted. The new manager was working to reduce some of the restrictions in place.

Staff recorded any incidents, including when people had been restricted. There was limited learning from incident records which meant the risks of similar incidents reoccurring were not reduced.

Staff supported people to receive their medicines safely and in the privacy of their own rooms. People did not always have access to homely remedies and we have made a recommendation about this in the report.

Staff enabled people to access health and social care support in the community.

Right Care

The service did not have enough appropriately skilled staff to meet people’s needs and preferences. This placed further restrictions on people as they were not able to go out when they wanted.

People’s access to activities was limited, both in and out of the service. There were few opportunities to try new experiences. People generally went on local walks or shopping trips.

People’s care plans did not always accurately reflect their needs. Staff were unaware of some of the information which described how to support people when they were sad or anxious.

Right Culture

People were not leading inclusive and empowered lives because the provider and staff had low expectations for them. There was a culture of presuming people were unable to progress, gain skills or set goals in order to live full and rich lives.

Staff turnover was high; recruitment practices did not focus on quality. People were not receiving consistent care from people who knew them well and were committed to delivering a high-quality service.

People’s rights were not respected. The provider had failed to make reasonable adjustments for people to manage their sensory sensitivities.

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 inadequate and there were breaches of the regulations (published 14 December 2021).

At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

We undertook this inspection to assess whether the service was applying the principles of Right support right care right culture and to check if improvements had been made following our last inspection.

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 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 will continue to monitor the service and will take further action if needed.

We have identified seven breaches in relation to the provision of person-centred care, dignity and respect, safety and risk management, safeguarding people from abuse, the maintenance of the premises, staffing levels and management of the service. Six of these were repeat breaches.

We took legal steps to remove the service from the providers registration. The service is now closed.

St Erme Campus is a care home providing personal care for people with autism. At the time of the inspection 14 people were living at the service. The service can support up to 20 people.

Accommodation is on a campus style development and is based in three separate houses known as The Lodge, The House and St Michaels. There is also a small office building on the campus. Campuses' are group homes clustered together on the same site. They may share staff and some facilities. The service is part of Spectrum (Devon and Cornwall Autistic Community Trust) which has several services in Cornwall providing care and support for autistic people and/or people with a learning disability.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability with the choices, dignity, 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 providing support to people with a learning disability and/or autistic people.

This service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

The service was not maximising people’s choices, control or independence. People’s lives were being restricted because of low staffing levels.

Right care:

There was a lack of person-centred care and people’s human rights were not always upheld. Staff told us that due to the low staffing levels, they did not feel they or people were always safe during incidents of behaviour that challenged. The way people were able to use their home was sometimes restricted to try to reduce the risk of such incidents.

Right culture:

Lack of action by leaders to ensure the service was well staffed meant people did not lead inclusive or empowered lives. Staff told us people regularly asked to go out but could not because of insufficient staffing levels.

The provider had not ensured staffing levels at The House and The Lodge were always safe or sufficient to meet people’s needs. Staffing levels in The Lodge had frequently fallen below what the provider had deemed acceptable only in an ‘extreme emergency’. The Lodge had been operating on this level of staffing for some time and future rotas showed it would continue to operate at the same levels. Staffing levels at The House were below what was needed for people to live full and active lives.

As a result of the low staffing levels, people’s lives were restricted, and they were not able to live meaningful lives that included control, choice, and independence. One staff member told us, “People are effectively under house arrest.”

The low staffing levels not only impacted on people’s lives, but also on the day to day running of the service and on staff morale.

The lack of oversight of staffing levels and related risks had placed people and staff at risk. The provider had not taken enough action to ensure there were sufficient staff at the service.

Staff told us they did not think the situation was safe and did not always feel safe supporting people. Staff told us that because people could not easily go out, they became frustrated and were more likely to experience incidents of behaviour that challenged the service. During incidents of behaviour that challenged, people sometimes required support from more staff. Due to the low staffing levels this could mean other people were left without staff support.

Staff did not always wear PPE correctly. When asked, the provider did not provide evidence they had checked staff were completing the required number of COVID tests per week.

The risks of a closed culture developing within the service and organisation had not been mitigated by the provider.

Insufficient learning had taken place to ensure people were not exposed to the risk of unsafe, poor quality care. The commission had previously found breaches for staffing at this service and had found breaches for staffing at four other services belonging to the provider, in the last year. The commission found a breach for staffing again at this inspection.

Staff told us they had raised concerns about the staffing levels but did not feel listened to or that action had been taken as a result.

The provider had not been open and honest with the local authority or the commission about the risks the ongoing low staffing levels were creating in the service.

Following the inspection, we raised safeguarding alerts with the local authority. The local authority asked the provider to continue sharing information on staffing levels, so they could check they were safe.

The provider shared rotas for the week following the inspection showing staffing levels at the service would be safe. The local authority continued to seek daily assurances from the provider that the service was operating above minimum safe staffing levels.

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 requires improvement (published December 2020).

Why we inspected

We received concerns in relation to low staffing and the impact this was having on safety and on the quality of care people received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Erme Campus 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 will continue to monitor the service.

We have identified breaches in relation to staffing, how risks were mitigated, safeguarding from abuse; and how the provider monitored the quality of the service and implemented learning to improve the service.

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

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 request an updated 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.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

St Erme Campus is a care home providing personal and nursing care for up to twenty autistic people. At the time of the inspection 14 people were living at the service.

Accommodation is on a campus style development and is based in three separate houses known as The Lodge, The House and St Michaels. There is also a small office building on the campus. Campuses’ are group homes clustered together on the same site. They may share staff and some facilities. The service is part of Spectrum (Devon and Cornwall Autistic Community Trust) which has several services in Cornwall providing care and support for autistic people and/or people with a learning disability.

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

During the inspection we observed staff wearing masks the majority of the time. We saw a member of staff had pulled their mask down. They explained this was because one person had become agitated and removing their mask temporarily was known to help calm the person. Another person found it difficult to cope with staff wearing masks. A risk assessment had been to develop to inform staff of when they were able to remove masks and how to encourage the person to tolerate masks. The provider had ordered specialised masks which they hoped the person would find less confusing.

Staff were aware of the need to be extra vigilant in respect of infection control. One commented; “We have to be a lot more thorough with the cleaning and we do it three times a day, antibac’ all the surfaces, sweeping, mopping and all that jazz.” They told us they were not required to move between the three houses but were based in one setting.

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 guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Staffing levels were sufficient to keep people safe. In one of the three houses we identified times when there were not enough staff to support people in line with their preferences. This meant people’s choices and independence were not maximised and we have made a recommendation about this in the report.

There were plans in place to further develop the service in line with Right Support, Right Care, Right Culture guidelines. The plans involved creating clear divisions between the three settings to support individualised and person-centred care.

Care planning was person-centred and staff promoted people’s dignity, privacy and human rights. Staff demonstrated a set of shared values which was in line with the organisational ethos.

Staff understood how to protect people from the risk of harm or possible abuse. Accidents and incidents were recorded and analysed to identify areas of learning and mitigate further risk. Medicines were managed safely.

Staff told us they were well supported. They had regular meetings with management, and these were an opportunity to discuss individuals support, organisational practices and raise any concerns.

The senior management team carried out thorough audits and identified areas for improvement. They had effective oversight of the service and were planning how to develop St Erme Campus in line with good practice guidance.

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 requires improvement (published 28 April 2020).

The provider completed an action plan after that inspection to show what they would do and by when to improve.

This was a focused inspection and we only looked at the previous breaches of Regulations 13, 18 and 17.

Why we inspected

We received concerns in relation to the use of PPE, staffing levels and management support. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 coronavirus and other infection outbreaks effectively. We found no evidence during this inspection that people were at risk of harm from this concern.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

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.

St Erme Campus is a care home providing personal and nursing care for up to twenty people with autism. At the time of the inspection 14 people were living at the service. Accommodation is in three separate houses known as The Lodge, The House and St Michaels. St Erme campus is part of Spectrum which has several services in Cornwall providing care and support for people with autism.

The service was established before the introduction of Registering the Right Support. The principles of this guidance reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. Following the introduction of the guidance in 2017 some work had been completed to develop the service in line with the principles and values that underpin Registering the Right Support and other best practice guidance. Structural changes had been made to buildings to give people more privacy. However, this initial response had not been sustained and other aspects of the service were not in line with the guidance. People’s opportunities to exercise choice and control and live a full and meaningful life were limited. Parts of the premises were in need of updating and did not contribute to people’s emotional well-being.

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

The service didn’t always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons. People did not experience community inclusion and were not supported to live full and meaningful lives. There were restricted opportunities to go out and the opportunities which were provided were limited. People lived in a group setting and staff needed to carefully manage shared areas to ensure people’s safety when they were together because of distressed behaviours. This had resulted in a situation when one person was regularly taken, or prompted to go outside, to separate them from others.

Staffing levels identified as necessary to ensure people had opportunities to take part in meaningful activities and access the community were not consistently maintained. Rotas were complex with shifts overlapping. This meant the periods when staffing levels were high were are often short lived further impacting on people’s opportunities to engage in meaningful pastimes.

Staff supported people to take their medicines safely and as prescribed. We identified some areas for improvement in the management of medicines and have made a recommendation about this in the report.

Staff were committed to their roles and were keen to support people to the best of their ability. They voiced frustration at the constraints placed upon them by staffing levels. Staff, the registered manager and regional manager all acknowledged recruitment was difficult. While recruitment was an ongoing process staff retention had been a problem. Spectrum were exploring ways to counteract this and had recently started a reward scheme to encourage staff to introduce potential recruits to the organisation.

Parts of the service needed redecorating and updating. The kitchen in The House was dated and units were damaged. The cupboards were grubby and the lid on a kitchen bin was broken and had not been replaced. Some people had their own flatlets and these were pleasant and reflected people’s tastes. Adaptations had been made to make them safe for people and accommodate their needs. However, shared corridors and a lounge were reminiscent of a hostel and did not provide a homely or comfortable space for people.

Care plans were comprehensive and focused on people’s individual needs. Any dietary needs were well documented and known to staff. Some people struggled to manage their emotions which could lead them to behave in a way which put themselves and others at risk. Staff were aware of potential triggers and knew how to support people when they were distressed. We were concerned that one person was not always supported appropriately.

People were not supported to have maximum choice and control of their lives and staff did not consistently support them in the least restrictive way possible and in their best interests; this was largely due to the restrictions associated with low staffing levels.

DoLS applications were made appropriately. Some people had authorisations in place with conditions attached, these were mainly in respect of recording when people were provided with 1:1 or 2:1 support and enabled to take part in activities. Reports were completed in line with these conditions.

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 30 March 2018).

Why we inspected

The inspection was prompted due to concerns received about staffing. A decision was made for us to bring forward our planned inspection and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to staffing levels, supporting people in line with their preferences, keeping people safe from abuse and the governance of the service. 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 from 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.

At this inspection we found improvements had been made to meet the relevant requirements. Agency staff were used to help ensure staffing levels were consistently met. All staff had received training to help them carry out their roles and responsibilities. Daily records were completed and contained information about people’s emotional well-being. Information in daily records and other documentation was consistent and, where appropriate, staff were directed to other records for more detailed information about any event or incident. There is more detail in the full report about our findings.

St Erme Campus is a ‘care home’. 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.

St Erme Campus provides care and accommodation for up to twenty people who have autistic spectrum disorders. At the time of the inspection 14 people were living at the service. St Erme Campus is part of the Spectrum group who run similar services throughout Cornwall. The service is made up of three separate houses known as The Lodge, The House and St Michael’s.

The service is required to have a registered manager and there was one in post at the time of the inspection. 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 care service was established 35 years ago and was designed to provide group living for people with autism. Work had been done, and was continuing, to develop the service in line with the values that underpin the CQC policy, 'Registering the Right Support' and other current best practice guidance. This guidance includes the promotion of values including choice, independence and inclusion. The service was working with people with learning disabilities and autism that used the service to support them to live as ordinary a life as any citizen. For example, structural changes were being made to the buildings to enable people to have more privacy and personal space within the service.

Staff understood how to support people to be independent while protecting them from risk of harm. They were aware of their responsibilities to raise concerns and record any untoward incidents. There were systems in place to help protect people in the event of an emergency. Medicines were managed safely and people were supported to take their medicines as prescribed.

The staff team knew people well and were provided with training to enable them to support people according to their individual needs. Recruitment processes and a thorough induction helped ensure new staff were suitable for the role and able to support people well. Staff received regular supervision and attended staff meetings. This meant they had opportunities to raise any concerns and discuss working practices.

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 supported this practice. Staff were aware of people's individual capacity to make decisions and supported them to make day to day choices. Where people were unable to make certain decisions the staff ensured that best interest decisions were made in accordance with legislation.

Staff were respectful in their approach to people. Information was recorded which enabled them to develop a thorough knowledge of people’s personalities, characteristics and individual needs. Relatives told us their family members were liked and well cared for. Staff worked closely with families and ensured they were kept informed about people’s health and well-being.

People were supported to try new activities and take part in pastimes they enjoyed. The registered manager was keen to develop links with the local community.

Staff had a clear understanding of their roles and responsibilities and this was guided by the registered manager who empowered them to take responsibility and develop their skills. The registered manager and provider understood their legal responsibilities and kept up to date with relevant changes in the care sector. There were systems in place to monitor the quality of the service to enable the registered manager and provider to drive improvement.

The service is required to have a registered manager and there was one in post at the time of the inspection. 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.

There were not sufficient staff on duty at all times to meet people’s individual needs. Staffing levels identified as necessary for the service were not consistently met in any of the three houses. Recruitment practices helped ensure staff working in the service were fit and appropriate to work in the care sector.

Staff received training when they first started work at Spectrum in a wide range of areas including supporting people whose behaviour could challenge staff and others. Training in some areas had not been regularly refreshed.

People were protected from the risk of abuse including financial abuse. The service kept people’s personal monies for them and records of all expenditures. Staff received training in safeguarding adults and were confident about reporting procedures.

Records of how people spent their days were in place. These often lacked detail and did not consistently correspond with other records such as health monitoring charts and incident records.

People were assessed in line with the Deprivation of Liberty Safeguards (DoLS) as set out in the Mental Capacity Act 2005 (MCA). DoLS provide legal protection for vulnerable people who are, or may become deprived of their liberty. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals when appropriate. Records showed applications for DoLS were being made appropriately and some people had DoLS authorisations in place.

One person was under constant supervision in order to keep them safe. The decision for this had been taken appropriately and in consultation with the relevant professionals.

Staff were enthusiastic on the subject of their jobs and spoke positively about people. People were relaxed with staff and approached them for reassurance and support when they needed to. Staff responded quickly and with humour and empathy. They demonstrated an understanding of people’s needs including their preferences, likes and dislikes and communication styles.

There were clear lines of responsibility in place. The three homes were all managed on a day to day basis by a deputy manager with the support of a development support worker (DSW). DSW’s served as a link between the service and Spectrum’s behavioural team. The registered manager had oversight of the service and staff told us she was approachable and had a good understanding of the service. There was a key worker system in place. Key workers are members of staff with responsibility for the care planning for a named individual.

We were not able to speak to the people who used the service due to thier complex health and care needs. Therefore we undertook observations of staff interacting with people who used the service. We saw staff respond and approach people in a kind and calm manner. We saw that staff showed, through their actions, conversations and during discussions with us empathy and understanding towards the people they cared for. We saw that people's privacy and dignity was respected by the way that staff assisted people.

We found that people who used the service were involved in making day to day decisions and participated in tasks at home, such as cooking, cleaning and doing their laundry.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We found there were enough qualified, skilled and experienced staff to meet people's needs.

We found that incidents of challenging behaviour were recorded, but that what was learnt from these incidents did not always influence the people's plans of care.

The buildings are currently being redeveloped so that most people at St Erme can have their own flats. This means that the service and the people that are using it are experiencing a period of considerable change. Staff were well trained however staff told us that they felt that communication with senior management in the organisation needed to be improved. We recognised that there were a number of systems for monitoring the quality of the service being delivered, but that these systems sometimes missed basic things, such as an incorrectly filled out medication record.