The Pastures

The Pastures is a residential care home providing care for up to 13 people. There were 12 people living at the service at the time of the inspection. The service accommodates people with a learning disability and autistic people who also have sensory and medical and health care needs. Accommodation is over 3 bungalows which were personalised, and people had the equipment they needed. 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.

People's experience of using this service and what we found.

Right Support:

Although staffing levels were maintained in line with people's assessed needs and agreed funding levels there was a high staff vacancy which impacted on people's care and support. Not all temporary staff had the same level of training as permanent staff and 30 staff had started in the last year. This meant a lot of staff were inexperienced and did not have a good insight into people's needs. The number of incidents is a good indicator that people experienced distress and had a lack of control over their environment and the staff that supported them.

The model of care did not always support people to make choices and have some control over their daily lives. Most people living at the service were supported by a core team of staff but not all. Staff allocation was completed on the day of the shift and considered the skill mix, training and whether staff were drivers. People could be supported by multiple staff across the day and changes to staffing was not well planned for. This led to frustration as people were not always supported in line with their communication and sensory needs.

We had concerns about the admission process and if this always considered the scope of the service and skill mix of staff. The support needs of people already living at the service were not considered when decisions were made about new people moving into the service.

Records showed a high level of incidents and medicine related incidents which were reducing month on month. However, any incidents could significantly increase the risk of avoidable harm. Oversight of staff practice and people's clinical care was the responsibility of the registered nurse, who was overseeing 3 bungalows and had high numbers of temporary staff to deploy across the shift and provide supervision for.

Staff did not always support people in the least restrictive way possible and in their best interests. Policies and systems were in place but variations in staff and a lack of clear guidance when supporting people new

to the service led to variations in care.

Right Care:

We found care was not always person-centred and did not always promote people's rights. During our inspection we identified some good interactions with people, but this was limited to some staff. Staff did not always speak with people on a regular basis to help reduce the risk of social isolation. We also noted some staff were not able to use sign language and were supporting people with sensory impairments and limited communication.

People's needs were clearly documented, kept under review and where changing needs were identified these were followed up with relevant professionals. There were close working relationships with family and the community. Safeguarding concerns were being identified and acted upon as appropriate.

Right Culture:

The provider was not ensuring that the culture of the service always enhanced peoples experiences and safety. Staff received training to enable them to meet people's care needs and training was updated as required. Staff spoken with stated the training provided was of the highest standard, but we found the care and support people received was variable depending on who was supporting them. A number of recent safeguarding concerns had been raised about poor staff conduct. The registered manager was addressing this. There was a lack of person-centred activities and care was not always planned in the right way to meet a person's needs and empower them. A range of audits were completed but did not sufficiently focus on peoples experiences and safety.

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 the service under this provider was good (published on 11 November 2022).

Why we inspected

We received concerns in relation to safeguarding concerns. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. This inspection was prompted by a review of the information we held about this service. The overall rating for the service has changed from good to inadequate. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Enforcement

We have identified breaches in relation to people's safety, staffing, governance, and oversight of the service and person-centred care in line with Right support, right care, right culture. 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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

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 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.

The Pastures is a residential care home providing personal and nursing care and is registered for up to 13 people. On the day of our inspection visit it was providing care to 11 people with learning, physical and sensory disabilities.

The care home provides accommodation across three adapted bungalows. The service was undergoing a programme of renovation such as new floors, a new activities room and a new sensory room.

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

Right Support: Model of Care and setting that maximises people’s choice, control and independence

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: Care is person-centred and promotes people’s dignity, privacy and human rights

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

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. Staff supported people according to this guidance.

People received safe care from staff who knew them well and understood risks to their health and safety. People received their medicines as prescribed and staff reported and acted upon any errors appropriately.

There were enough staff to keep people safe and they were trained in areas relevant to people’s care. Where agency staff were used, they received appropriate information and training in relation to people’s care.

Staff followed protocols to limit the risk of a spread of infection within the home such as using personal protective equipment (PPE). Some areas of the home required more thorough cleaning.

We have made a recommendation relating to the cleanliness of some areas of the home.

The service manager was visible around the home and led by example, working closely with staff and relatives. Relatives were involved with people’s care and could speak with staff or management if they wished to raise anything.

There were checks in place to show how the service manager oversaw the quality of the service and they put action plans for improvements in place where required.

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 home was rated Good at the last inspection (report published May 2019).

At this inspection we found the service remained Good.

Why we inspected

The inspection was prompted in part due to concerns received about staffing and risk management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We found no evidence during this inspection that people were at risk of harm from these concerns.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The pastures 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.

This care service supported people in line with the values that underpin the Registering the Right Support and other best practice guidelines. These values include choice, promotion of independence and inclusion. People with learning disabilities using the service can live as ordinary a life as any citizen.

Audits and quality checks by the management team did not always result in improvements. Deficiencies identified in care plans by management audits had not been addressed in a timely way. Some staff and visiting professionals spoke of discontent in the staff team and differences in the care provided by different shifts in the service. Staff also spoke of concerns as to how work was allocated to care staff. The registered manager was aware of these concerns but on the day of our inspection visit action plans had not resulted in improvements.

Staff understood their responsibilities to protect people from abuse and discrimination. They knew to report any concerns and ensure action was taken. The registered manager worked with the local authority safeguarding adults’ team to protect people.

Staff were supported in their roles and received an effective level of training. We observed them supporting people in a caring and competent manner. Safe recruitment of staff ensured people were supported by staff of good character.

Staff promoted people's dignity and privacy. Staff provided person-centred support by listening to people and engaging them. People using the service appeared comfortable in the presence of staff.

The premises provided suitable accommodation for people with communal areas and bedrooms which were personalised to people's individual interests.

Support plans were detailed and supported staff to meet people’s assessed care needs. Staff worked with and took advice from health care professionals. People's health care needs were met.

People had a variety of activities which they enjoyed on a regular basis.

Formal supervision meetings were carried out with staff. They told us they were supported and clear about what was expected of them.

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.

More information about the inspection is in the full report.

Rating at last inspection: The home was rated Good at the last inspection (report published in October 2016).

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will continue to monitor the service through the information we receive and inspect in line with CQC guidance.

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

The inspection took place on the 19 October 2016 and was unannounced.

The Pastures provides care for up to thirteen people, on the day of our visit nine people were living at the home. The Pastures is a nursing home which supports people who have complex health needs. People had a range of learning and physical disabilities. The home was purpose built offering accommodation in the form of three large bungalows.

There was a registered manager in place and a deputy manager who was a qualified nurse. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Throughout this report the registered manager will be referred to as the manager. When we state ‘management team’ this refers to the manager and the deputy manager.

People benefitted from being supported by staff who had been safely recruited and trained. Staff worked in a collaborative way with their colleagues and the management team. Staff felt supported by the management team. There was consistently enough staff to safely meet people’s individual needs.

Staff understood how to protect people from the risk of abuse and knew the procedures for reporting any concerns. Medicines were administered safely and adherence to best practice was applied. People received their medicines safely and in the manner the prescriber intended. The service regularly audited the administration of medicines. Medicines were stored securely.

Staff knew and understood the needs of people living at The Pastures. Staff made real efforts to get to know the people who lived at the home. People received care which was person centred.

The management team observed staff’s care practice and was involved in the daily running of the service. Staff had not received supervisions for some time but the manager was addressing this. Staff received training; however the manager needed to improve their overview of this.

Staff told us they were happy working at The Pastures. Staff were committed and dedicated to the service. They assisted people with compassion and in a professional way. People’s dignity and privacy was maintained and respected. People were treated as individuals. People’s wishes and what was important to them was promoted by staff and the management team.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service was depriving some people of their liberty in order to provide necessary care and to keep them safe. The service had made applications for authorisation to the local authority DoLS team. The service was working within the principles of the MCA. The manager and the staff had a good knowledge of the MCA and DoLS.

People’s care plans contained important, relevant, detailed information to assist staff in meeting people’s individual needs. People’s needs were regularly reviewed.

Staff promoted people’s emotional wellbeing. The service responded proactively to changes in people’s health and social care needs.

The service encouraged people to maintain relationships with people who were important to them. Relatives felt involved and welcomed to the home. There were planned group and individual activities daily, people also went on trips and day experiences. People were encouraged to develop and maintain their interests.

There was a positive, open culture at The Pastures. The service was welcoming and had a friendly atmosphere. There were also systems in place to monitor the quality of the service and the management team were developing these further.

We were not able to speak with people who used the service because of their complex needs. People's relatives were not available to speak with. We spoke with the deputy manager, one registered nurse and five care staff. The registered manager was not available to speak with us on the day of our inspection. We reviewed three people's care records. We also reviewed a selection of other records that included the provider's policies and procedures, staff files, training records and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA), 2005, and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The MCA provides a framework to empower and protect people who may make key decisions about their care and support. The DoLS are used if extra restrictions or restraints are needed which may deprive a person of their liberty. We saw evidence that the provider had acted in accordance with the law in relation to the MCA and DoLS. People who used the service had received appropriate mental capacity assessments and a number of 'best interest' decisions were recorded. At the time of this inspection no person living in The Pastures had a DoLS authorisation.

Staff felt that there were generally enough staff on duty to meet the needs of people. However, there was a consensus of opinion that one person should receive 24-hour one to one care due to their complex needs. We highlighted this to the deputy manager. They told us that they agreed with staff and that they were in the process of submitting a proposal for 24-hour one to one care for the person.

People's medicines were appropriately managed to help ensure that they received them safely. We saw the training records for staff who administered medicines. We observed staff administering medicines and saw that this was done in accordance with the provider's medication policy.

We reviewed staff files and saw that the appropriate checks had been undertaken before staff commenced employment. These included Disclosure and Baring Service (DBS) checks.

We saw evidence that the provider's audit schedule was effective. This included regular auditing of the quality of the service, as well as accidents and incidents and environmental risks.

The provider had effective arrangements in place to manage foreseeable emergencies. These included fire and loss of utilities.

Is the service effective?

People's needs were assessed, and care and treatment was planned and delivered in order to meet their needs. Care plans were person-centred. People had complex needs with limited verbal communication. Staff showed a thorough understanding of people's communication needs and demonstrated different communication techniques to help people understand what was being said.

People had effective risk assessments in place to help maintain their safety and welfare. A nationally recognised screening tool had been used to help identify people at risk of pressure ulcers.

The provider worked collaboratively with other health and social care professionals. These included physiotherapists, dieticians and psychologists. This helped to ensure all of people's needs were being met. We saw that the guidance and information provided by specialists was followed by staff. This included the correct positioning of people to help prevent muscle spasms.

During our inspection we observed staff manage two medical emergencies with competence. Care workers sought the assistance from the registered nurse in a timely manner, and the situations were dealt with calmly and in accordance with people's care plans.

Is the service caring?

We could not speak with people about the care and treatment they received because of their complex needs. We did however observe staff interact positively with people at all times. We saw that people enjoyed the interaction and were seen to be smiling and laughing. People's care plans explained the meaning behind the different gestures and vocal sounds they made. It was evident that staff knew the meanings exceptionally well. They responded to people's needs in a compassionate and respectful manner at all times.

The care we observed staff delivering to people was outstanding throughout our inspection. People were included in group activities as well as one to one time. Staff displayed kindness and spoke with people about the different things that they enjoyed. Staff explained about the importance of ensuring people were involved in the community and the 'community spirit.' We saw that people were regularly assisted to participate in different activities in the community and that these were designed to meet people's preferences and interests.

Is the service responsive?

People's care plans responded to, and reflected their physical and mental health needs as well as their social and emotional needs. The registered nurse and care staff responded to people's complex needs in a timely and appropriate manner. We saw that people's individual rooms, the bathrooms and the communal areas were all designed and equipped to assist and support people safely.

Some people could not eat or drink because of the complexity of their needs. They therefore required 'Enteral Nutrition.' This meant that their food and drink was given to them through tubes into their stomach. Staff responded to this by ensuring the correct procedure was followed to help avoid any complications. Staff also followed the speech and language therapist's instruction in relation to people being given a small amount of appropriate 'taster' food so that they could still enjoy the taste of different foods.

The care and support people received reflected and responded to their personal interests and hobbies. One person enjoyed trains and technical items. Staff therefore took them to the railway station so that they could observe the trains and experience the environment of the station. Another person enjoyed different bright colours. The staff therefore used a sensory light that projected different colours on to the wall.

The service had not received any complaints. Staff we spoke with could tell us what they would do if a person wished to make a complaint.

Is the service well-led?

All of the staff we spoke with told us that they felt well supported by the management team. The care staff also said that they felt well supported by the registered nurses.

Staff told us that there were staff meetings and that they were encouraged to raise any concerns or issues. They told us that they always felt listened to by the management team. They said that if they suggested something that could improve the quality of the service then this was usually acted on.

Staff told us that they felt there was 'great team' work within the service. We saw evidence of this during our inspection. Care staff we spoke with understood their roles and responsibilities and knew when they needed to 'escalate' an issue or concern to the registered nurse or the management team. We noted that there was an on-call service. This meant that staff could seek the advice of a senior person or manager during any time of the day.

Quality assurance processes were in place. These included regular audits of all aspects of the service. Accidents and incidents were audited on a monthly basis by the provider's health and safety team. We saw evidence that there was learning from accidents and incidents to help prevent reoccurrences. This included information being shared with staff as appropriate.

We found that people who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. There was a safeguarding policy and a whistle-blowing policy in place and staff knew where to access them. Staff were able to describe the process they would take if they had a concern, and this matched what was documented in the safeguarding policy.

We found that there were enough staff to meet the needs of those using the service. People were engaged throughout the day in positive interaction or in activities. Most people using the service had care delivered on a one to one basis, but otherwise, there was one carer for two people using the service.

We found that the records kept at The Pastures for people using the service and staff were accurate and fit for purpose. Care records for those using the service reflected their current needs and information in care documents matched that specified in other care documents. There were sufficient records kept for staff, including training, supervision and appraisal records.

After that inspection we asked for copies of the audits and checks that were carried out by the line manager to ensure that improvements were made. These were provided to us each month. They showed the areas that had been checked and audited and the improvements that the new management team were making. For example, there had been checks on staff training, health and safety issues, the management of people's finances and medicines. There had also been checks on compliance with a sample of the essential standards the Care Quality Commission reviews and enforces.

Although it was initially not easy to see evidence which identified that shortfalls had been followed up, the provider responded to our requests for updates and additional information. These showed that improvements had been made in all areas. This meant that there was evidence that learning from events took place and appropriate changes were implemented.