Archived: Peterhouse

Peterhouse provides accommodation and personal care for nine people who have a learning disability or autistic spectrum disorder. The service can support up to 11 people. Since our last inspection, the supported living settings have been registered separately and are not included within this report.

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This guidance ensures people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them and did not always have choice and control over what they could do.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 11 people. Nine people were using the service. This is larger than current best practice guidance. However. the size of the service fitted into the residential area and the other large domestic homes of a similar size. There were no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home.

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

Measures were not always in place to ensure people and the environment they lived in was safe and some risks to individuals had not been identified or addressed. Staffing levels had not been reviewed and there were not always enough staff to support people to access to the community. Medicines were not always managed safely. People were protected by the prevention and control of infection and staff received training in infection control. The environment continued to require refurbishment. Some parts of the grounds of Peterhouse were not suitable for people with mobility issues.

People were not always supported to have maximum choice and control of their lives. 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 always support this practice. The service didn’t always consistently apply the principles and values of Registering the Right Support and other best practice guidance. Although the management team were aware of the Registering the Right Support guidance, the outcomes for people did not fully reflect the principles and values of Registering the Right Support. People did not always have choice or control about what they wanted to do due to inadequate staffing levels and this did not demonstrate a caring service.

People were not always able to take part in community activities due to a lack of staffing and people were not always supported to engage in meaningful activity. We made a recommendation that the provider reviews the provision of activities and meaningful engagement to ensure that it meets the individual interests of those living at Peterhouse. Where feedback was received from people using the service, this was not always acted on to ensure positive outcomes. There was a lack of easy read information available to aid people’s understanding in line with the Accessible Information Standard (AIS). We made a recommendation that the provider consults a reputable source and further develops the use of easy read and pictorial information to ensure that they meet the AIS.

People were supported by staff who knew them well. Staff were kind and supported people with dignity and respect although their independence could be further promoted. Staff received training, support and supervision to enable them to carry out their roles. The service worked in partnership with other health and social care professionals and these relationships had supported people to have good outcomes. End of life planning required further development. We made a recommendation that the provider consults a reputable source to further develop end of life planning.

The registered manager did not manage the service day to day. Auditing systems were ineffective and had failed to address key concerns identified at this inspection. Some recommendations made at the previous inspection had not been implemented. The oversight and governance of the service required review to ensure any issues were identified and rectified to ensure the service continuously improved.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 17 July 2018).

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

The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We identified four breaches in relation to risk assessment, staffing and managerial oversight and governance at this inspection. The provider took some action to mitigate the risks after the first day of inspection, however further improvement was still required.

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

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 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.

Peter House provides residential accommodation and personal care for up to 11 people who have a learning disability or autistic spectrum disorder and mental health needs. Accommodation is provided in one single dwelling as well as care and support provided to people living in nine supported living settings across Essex. This is so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living. Other than the inspection of the care home where we did look at the safety of the premises, for the supported living settings, this inspection looked at people’s personal care and support. At the time of our inspection there were nine people living in the residential care home and 20 people supported in the community including supported living units.

The supported living settings had been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy.

A registered manager was in post who was also the provider of this and other services but did not have day to day oversight of the service. 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.

At our last inspection in December 2016 the rating for this service was requires improvement. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safe care and treatment of people, a lack of action to lawfully obtain consent and ineffective governance and oversight of the service. We also found staff had not been provided with the training and skills required to meet the complex needs of people who used the service.

Following the last inspection, we asked the provider to complete an improvement action plan to show us what they would do and by when to improve the key questions; Is the service safe?, Is the service effective?, Is the service responsive? And Is the service well-led? to at least good.

At this inspection we found some improvements had been made to meet the relevant requirements, however there were still some areas which required further work. Action was taken by the registered provider during our inspection to rectify the potential risk of scalding from unprotected radiators and the risk of falling of un-restricted windows. However, whilst we acknowledge the registered provider has responded to rectify these shortfalls, these risks to people’s safety had not been previously identified and mitigated prior to our bringing these to the attention of the registered provider.

We recommended that risk assessments in place contain a date scheduled for review to ensure the current arrangements in place continued to meet people’s health, welfare and safety needs.

Not everyone had an up to date care plan which reflected their health, welfare and safety needs. This meant that the current arrangements for identifying people current care needs including risks to people’s welfare and safety were not as robust as they should be and improvements were required.

There were systems in place to monitor people’s level of dependency and to assess the number of staff needed to provide people’s care. However, when cover for staff absences was required there were not always sufficient staff available. This sometimes impacted on people’s ability to access community activities.

Any restrictive practice used to keep people and others safe had been appropriately assessed in people’s best interests. There was improved training provided to staff in the use of de-escalation techniques when people became distressed and presented with behaviour that put themselves and others at risk. Appropriate assessments had been carried out with detailed guidance for staff as to the least restrictive option, which upheld people’s rights to having their dignity respected.

Staff understood and had a good knowledge of the key requirements of the Mental Capacity Act [2005]. Where Deprivation of Liberty Safeguards (DoLS) applications to restrict people’s freedom of movement in their best interest had been authorised, we found timescales for review had not all been actioned and so the authorisation was no longer legally valid.

People’s medicines were managed safely and they were supported to received them as prescribed.

Staff had received training in safeguarding people from abuse and understood their responsibilities to report concerns to the management team and outside agencies. There were arrangements in place to help protect people from the risk of financial abuse. However, we recommended the provider implement a system to maintain personal inventories to differentiate people’s personal belongings apart from those which belonged to the registered provider.

The service had a recruitment process in place which ensured that staff were recruited safely and an induction programme to support new members of staff when they joined the service. We recommended that the provider looked at ensuring sufficient staff are available at all times to provide support for people with their chose preference of daily activities and outings.

A choice of food and drink was available that reflected people’s nutritional needs, and took into account their preferences and any health requirements. People were supported to maintain their health and had access to wide range of health and social care professionals.

We last inspected this service on 05 April 2016 where a number of breaches were found. These related to a lack of oversight by the provider to ensure the service delivered was of good quality and safe. People's safety and welfare was compromised because effective quality assurance monitoring processes to identify issues that presented a potential risk to people were not in place. Necessary maintenance work to the environment, staffing numbers, cleanliness and measures to limit the risk of cross infection also required attention. Staff training was also insufficient to ensure staff could care for people with complex needs. At the previous inspection in April we had found five breaches of legal requirements in relation to Regulation 12, 15, 16, 17 and 18 of the Health and Social Care Act 2008. We issued a warning notice for regulation 12 which was to be met by 04 July 2016.

Following the inspection in April 2016, we received an action plan which set out what actions were to be taken to achieve compliance. A subsequent inspection on 09 August 2016 was then undertaken to follow up on the progress the provider had made in meeting the warning notice. At this time we noted that the provider had met the requirements of the warning notice and only the domain of safe was inspected in relation to the physical environment of the service which posed risks to people's health and safety. The inspection at this time did not change the current rating of the service. The overall rating and judgement from the inspection in April 2016 was inadequate and the service was therefore placed in special measures. Three domains of ‘Safe’, ‘Effective and ‘Well Led’ were rated as Inadequate at that time with two further domains of ‘Caring’ and ‘Responsive’ being rated as Requires Improvement.

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

At this inspection we found further improvements had been made to meet the relevant requirements, however there were still some areas which required improvement. The service still required further time to ensure improvements implemented were embedded fully and would be sustained.

Whilst we are clear improvements were evident at this inspection we found breaches in relation to regulation 11 with regard to consent and a few continued breaches in relation to regulation 12 with regard to health and safety, and infection control, regulation 17 and regard to continued sustainably, provider oversight of the service and effective auditing, and regulation 18 with regard to effectively trained staff.

The service had a registered manager in post who was also the provider. Since the last inspection the provider had appointed a new manager, who was to take over the day to day management of the service and had been in post since July 2016. We were told an application for registration was to be submitted and the provider was in the process of doing this. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Systems were in place to reduce the risk of abuse and to assess and monitor potential risks to people. The service still had some areas where the monitoring had not identified risk to people.. This was with particular reference to areas relating to infection control, food safety and the environment. Risks to people were being managed but the service was not always proactive in identifying and assessing the risk.

Recruitment processes were safe and we saw on the two days of this inspection there were sufficient staff on duty to meet people's care needs. Staff numbers had been increased since the last inspection.

The provider had appropriate arrangements to make sure people received their medications safely, Staff responsible for administering medicines had received training and were subject to competency assessments to ensure people’s medicines were administered, stored and disposed of correctly.

Training had been delivered to staff, however not all staff had received sufficient training in dealing with people’s behaviour which could place others at risk. Training was still not fully of a sufficient standard and detail which would ensure staff felt competent in their role and supported in relation to their responsibilities, to enable them to deliver care and treatment to people safely. We also found the manager’s formal supervision programme was not yet fully embedded.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) . Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals and appropriate referrals had been made by the service. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. However care plans did not evidence fully how people made their decisions and a few staff we spoke with were not aware of how the mental capacity act related to the people in the service. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals.

People's capacity to make decisions was identified, but there was limited information available to show how people made decisions in relation to their care.

People's privacy and dignity was upheld when staff were carrying out care tasks. Care plans had all been reviewed and were written in such a way as to ensure that good care was supported effectively. Where people's health needs changed, external healthcare professionals were consulted and prompt medical attention was sought as required.

There was no comprehensive scheduled programme of activities for people. Activities were provided but this was not at a level which would meet everyone’s needs all of the time.

Whilst we acknowledge that improvements had been made with infection control practices these were still not fully in place at the time we inspected and some further work to be completed was noted at this inspection.

Thorough systems for auditing the service were not yet fully effective to ensure that people received care which was safe and of a good quality. Systems and processes implemented required further time to fully embed and show as consistent approach to improving the service delivery. Improvements had been made but there were still a few areas where a lack of oversight did not fully ensure the service delivered was of good quality, safe and continued to improve. Monitoring addressed concerns identified at inspection but was not yet sufficiently embedded to identify further areas of improvement.

You can see what action we told the provider to take at the back of the full version of the report summary.

Peterhouse is a residential care home that provides care and support for up to eleven people who have a learning disability or autistic spectrum disorder. At the time of our inspection there were nine people using the service.

The service had a registered manager in post but they did not manage the service on a day to day basis. The registered manager was also a director of the company that provided the service. 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.

We carried out an unannounced comprehensive inspection of Peterhouse on 5 April 2016 and we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the service was given an overall judgement rating of ‘inadequate’ and is therefore in Special Measures.

Services in Special Measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

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

Following the comprehensive inspection on 5 April 2016 we served a warning notice on the provider in relation to the physical environment of the service which posed risks to people’s health and safety. The warning notice included a timescale by when compliance with the legal requirements must be achieved.

We undertook this focused inspection to check that the provider had made improvements to meet the legal requirements in the warning notice, within the given timescale. This report only covers our findings in relation to the warning notice and those requirements. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Peterhouse on our website at www.cqc.org.uk.

Measures had been put in place to reduce the risk of fire in the laundry and the risk of the spread of fire from the laundry. The laundry facilities had been refurbished which included fire safety precautions.

Actions had been taken to ensure the means of escape from the premises in the event of an emergency could be safely and effectively used. These included a secure ramp for people who use a wheelchair, new emergency lighting and the removal of rust and moss from the fire escape steps to minimise a slip and fall hazard.

The laundry facilities were fully refurbished and equipped to enable effective cleaning and minimise the risk of cross infection to protect people using the service, and staff, from harm.

Wardrobes and radiators were securely fixed to the wall to protect people from risk of injury and where required protective covering had been placed over radiators to protect people from risk of burns.

Further improvement was required to ensure the issues with the stair carpet coming away and fraying do not reoccur and pose a trip hazard.

Health, safety and fire risk assessments had been carried out. We will monitor to check the provider regularly reviews the assessments to identify risks to people using the service and necessary precautions to be taken within the service, and ensure compliance is sustained.

Other issues identified in the April inspection under the domain Safe were not followed up at this inspection. We will review our rating for Safe at the next comprehensive inspection. To improve the rating to 'Good' would require a longer term track record of sustainability.

Peterhouse is a residential care home that provides care and support for up to eleven people who have a learning disability or autistic spectrum disorder. At the time of our inspection there were nine people using the service.

The service had a registered manager in post but they did not manage the service on a day to day basis. The registered manager was also a director of the company that provided the service. 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 had appointed a new manager who commenced in post in January 2016 to take over the day to day management but they were not yet registered with the Care Quality Commission to manage this service. They have been employed to manage Peterhouse and another service.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special Measures'. Services in Special Measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

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

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

There had been a lack of oversight by the provider to ensure the service delivered was of good quality, safe and continued to improve. People’s safety and welfare were compromised because they did not have in place robust and effective quality and assurance monitoring processes to identify issues that presented a potential risk to people. Thorough risk assessments had not been carried out routinely to identify risks in relation to people's health care needs, the physical environment and fire safety; necessary maintenance work and health and safety precautions had not been taken to protect people from risk of harm. Cleanliness and measures to limit the risk of cross infection had been neglected.

A system was not in place to ensure there were sufficient numbers of staff on duty to support people to follow interests and take part in social and therapeutic activity. There were not enough staff to enable people to go out and to support those who remained at home. People were not supported to participate in meaningful activities and the service did not provide people with opportunities and support to access the community on a regular basis. The two staff members on shift had additional responsibilities that included cleaning and preparing and cooking meals.

The service did not have a pro-active approach to staff member’s learning and development needs in line with the provider's stated purpose and the needs of people using the service. Staff training was not developed to sufficient depth for staff caring for people with complex needs. They did not have the opportunity to develop the skills to carry out their role and ensure their practice was relevant and up to date.

Despite these shortfalls staff had developed good relationships with people living at the service. They knew their individual care and support needs well and people were supported, where able, to express their views and choices. Staff had a clear understanding of how to safeguard people and knew what steps they should take if they suspected abuse.

The service had applied the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) however this was compromised by not having enough staff to enable people to go out and about with support and supervision.

There was an effective recruitment and selection process to check that potential new staff were suitable to work with people who used the service. This was followed and helped to ensure that only suitable staff were employed.

Medication was managed and stored safely and administered correctly to people. People were supported to maintain good health. They received continuing specialist help pertinent to their healthcare needs. They had prompt access to a range of healthcare professionals for routine follow up and when they became unwell.

Relatives who completed surveys as part of the home's quality monitoring process were complimentary about the care provided at Peterhouse. One relative said: 'We have always found the service very good.' Another relative said: 'Fantastic. Really improved and person centred.'

Staff knew people well and we saw that there were respectful and caring interactions between members of staff and people living in the home. We saw that staff listened to people and treated them with consideration.

People received care and support that met their needs and took into account their individual preferences. Staff were able to demonstrate that they understood people's specific needs and they provided care in a person-centred manner.

Staff understood their responsibilities to safeguard people and ensured they received their prescribed medication safely.

There were robust systems in place to recruit staff safely and provide training to ensure they had the skills and knowledge to support people safely.

Peterhouse was well managed and there were effective processes to monitor the quality of the service. They consulted with people and took their views into account to make improvements.

People living at Peterhouse had complex needs and some were not able to speak with us. We saw that people smiled and appeared relaxed and comfortable with staff and others living in the home. One person was able to communicate with us and used some signing to show us what they liked. Another person spoke with us generally and they were looking forward to Christmas and visiting relatives. We could see that they were confident and happy.

During our inspection we saw that people received good care and that staff treated them with respect.