Sapphire House

Sapphire House is a residential care home for up to seven people who may be living with a learning disability, autistic spectrum disorder and a mental health condition or complex needs. The property is a detached house on a residential street which has been converted to self-contained flats and bedrooms with communal areas. There were five people living in the home when we visited. People using the service received support with their personal care. This is help with tasks related to personal hygiene and eating.

The service 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 could live as ordinary a life as any citizen. These values were seen in practice at the home. For example, the building was like any other on the road with no signs to show it was a care home. Staff did not wear uniforms and people lived their lives in the ways they wanted.

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

Some people were diagnosed with new mental health conditions just before the restrictions put in place due to the Covid-19 pandemic. They did not receive the required support from outside specialist services, due to the restrictions. This led to a decline in the quality of support they received from specialist health professionals; this was reflected in adverse behaviours and a decline in mental health.

People had positive behaviour support plans (PBS) which enabled staff to support people consistently and were regularly reviewed. However, staff had to develop these for some people without the usual support from specialist healthcare professionals.

Staff felt supported by the registered manager and provider, although staff supervision had not always taken place in line with the provider’s policy. An action plan was in place to address this.

Where people presented specific risks to themselves or others, risk assessments were in place to minimise the risk and occurrence. People were involved in review meetings about their support and aspirations. They were involved in setting goals and targets and were supported by staff to achieve these.

Support plans detailed people’s preferred routines, wishes and preferences. They detailed what people were able to do for themselves and what support was required from staff to aid their independence wherever possible.

The service applied 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 using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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.

Staff recognised that most people had the capacity to make day to day choices and supported them to do so. People were encouraged and supported to be independent. People were engaging in the community, for example utilising their local community to use ordinary community resources, shops, access day services and activities. However, some restrictions had been in place to meet with national Corona Virus guidance.

The registered manager and staff demonstrated a detailed knowledge of the people they supported. Over time they had developed trusting relationships, so that people felt safe receiving support. People were able to have privacy and independence with staff accessible nearby if support was needed.

Staff had a detailed understanding of people's support needs and training was in place to help staff to meet them. Staff were encouraged to continuously learn and develop by completing qualifications and additional learning.

People had positive relationships with staff who knew them well. There were enough staff available to meet people's needs and give individual care and support. There was a strong emphasis on person-centred care. People were supported to plan their support where possible and they received a service that was based on their individual needs and wishes. The service was flexible and responded to changes in people's needs.

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 18 February 2019).

Why we inspected

The inspection was prompted due to concerns received about ligature risks, safeguarding and support for people experiencing mental health crisis. A decision was made for us to inspect using our targeted methodology developed during the Covid19 pandemic to examine those specific risks and ensure people were safe.

We undertook this targeted inspection to check on specific concerns we had. The overall rating for the service has not changed following this targeted inspection and remains Good.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

At our last inspection on 27 and 29 January 2016 we rated the service good. At this inspection on 12 and 13 December 2018 we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service remained Good.

There were good systems in place to protect people from abuse and avoidable harm. All risks to people were assessed individually and there was detailed guidance available for staff. There were enough suitably trained and safely recruited staff to meet people’s needs. Medicines were received, stored, administered and disposed of correctly. Staff understood how to prevent and control infection and all the necessary health and safety checks were completed to ensure a safe environment. Accidents and incidents were recorded, analysed and reviewed to identify any trends and to prevent future reoccurrence.

People’s needs had been assessed before they moved into the home and people received personalised care which was responsive to their needs. Support plans were person centred and focused on outcomes for people and the support they needed to meet these outcomes. People had enough to eat and drink, were supported with their dietary needs and were offered choice around their food. People had access to the healthcare they needed. 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.

People were supported by caring staff who respected them and promoted their independence. People’s needs around their communication were met and people were encouraged to be involved with all aspects of their day to day support. Staff protected people’s privacy and dignity and supported them to keep in contact with their families who could visit whenever they wanted.

The service 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 could live as ordinary a life as any citizen. These values were seen in practice at the home. For example, the building was like any other on the road with no signs to show it was a care home. Staff did not wear uniforms and people lived their lives in the ways they wanted.

People and relatives told us they could raise any complaints they had with the registered manager. The complaints procedure was available and the provider actively sought feedback from people and their relatives. The registered manager reviewed any complaints to ensure the appropriate action had been taken and any learning identified.

People and staff told us the home was well managed and all our observations and evidenced gathered during our inspection supported this. Staff understood the vision and values of the home and felt supported by the management team. The managers promoted a positive, person centred and professional culture, had good oversight of the quality of the home and managed any risks. There was good record keeping and monitoring to ensure people received the support they needed. The provider promoted continuous learning by reviewing all audits, feedback and accidents and incidents.

Further information is in the detailed findings below.

Sapphire House provides accommodation for up to a maximum of eight young adults who may have a learning disability, autistic spectrum disorder, sensory impairment or physical disability. Some may also present with some challenging behaviour. The accommodation is set over two floors with a communal living room and kitchen. There are also two flats in a self-contained area of the building. Outside there is a good sized garden that people can use and enjoy.

A previous inspection had taken place on 4 August 2014 and we found the provider was in breach of Regulations 13 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. We asked the provider to make improvements to protect people against the risks associated with the unsafe use and management of medicines. We asked the provider to make improvements in relation to the records kept around people’s care. At this inspection we found the provider had made improvements and was meeting the requirements of the regulations.

At the time of inspection, the home had a manager in place who was still going through the process of becoming the registered manager. The home had been without a registered manager for some months and the area manager and a peripatetic manager were looking after the service. The manager told us that they felt supported by the provider and senior management and were enjoying their role. 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.

People told us that they felt safe at the home. There were safeguarding policies and procedures in place that were being followed and staff were aware of their responsibilities.

There was a recruitment policy in place which was being followed by the management team. References had been sought along with DBS checks and gaps in employment history had been explored.

Staffing levels were worked out on a one to one basis and staffing rotas evidenced that there were enough staff for the level of dependency. However, there was a heavy reliance on the use of agency staff due to difficulties recruiting to the service.. The manager told us that the recruitment of staff was a priority.

People and their families had been involved in planning for their care needs. Care plans provided information and guidance for staff on how to support people to meet their needs. These included behaviour and sensory support plans. Risk assessments clearly identified risks and what to do to mitigate those risks.

There were environmental risk assessments in place and people had personal evacuation plans in the event of an emergency. There were a high number of accidents and incidents but these were recorded and responded to appropriately.

There was a medication policy in place but this was not always being adhered to. Audits from a local pharmacy had identified this resulting in the booking of more training for staff and the checking of competencies.

Staff had been through an induction process and had received regular training that was appropriate for the needs of the people living in the service. Staff received regular supervision and appraisals and were being supported in their role.

Staff had completed training in the Mental Capacity Act 2005 and this training had been embedded in every day practice of caring for people. Staff had received training in Deprivation of Liberty Safeguards (DoLS).

People were encouraged to maintain a healthy diet and were able to eat their preferred choices. People were involved in food shopping and encouraged and supported to cook and make drinks. There was access to snacks and drinks throughout the day.

People were supported to access health services and their health care needs were being appropriately met.

People told us that they liked the staff and that they were caring. We saw staff interact with people in a kind and compassionate way. Relatives were regular visitors to the home and were actively involved in the planning of support for their relatives.

Care plans were detailed and individualised in how to provide support to people. These included functional assessments detailing people’s diagnosis as well as sensory and behavioural support plans. Plans had been regularly reviewed with people and their relatives.

People and staff records were kept confidential and only those authorised had access to them. Staff were aware of ensuring conversations and records were kept private.

People’s changing needs were identified and they were supported by referrals to appropriate health care professionals. Behavioural support plans showed there had been significant input from a Positive Behaviour Practitioner

A lack of meaningful activities had been identified. This was being addressed by the home who had implemented weekly activity planners, which had been drawn up with people and their relatives. People told us that they enjoyed activities of their choice.

There was an easy read complaints policy in place and the provider had carried out a service user survey, the results of which were positive.

People were actively involved in the running of the home and some people represented the home at forums for the group of homes the provider ran. .

Staff told us that they found the new manager very approachable and were positive about the impact they had made in the seven weeks they had been in post. Staff meetings were taking place but did not take into account views and opinions of the staff. However, the manager planned to address this in the future.

The area manager had systems and processes in place for auditing and monitoring the quality of the home. However, the information from these audits were not being acted upon. We have made a recommendation about this.

The home were not carrying out relatives and other stakeholder survey’s. We have made a recommendation about this.

Below is a summary of what we found.

Is the service caring?

The atmosphere at the service was busy and friendly. People appeared relaxed in the company of staff. We saw that staff spent time dancing to music with one person and how this person appeared to enjoy this. Another staff member told us that this person enjoyed using a particular aspect of public transport. We saw that the person displayed behaviour that showed they were happy when staff told them they were going on this mode of transport that day. Two people we spoke with told us that the staff knew how to meet their needs. One person added that the staff looked after them well, the staff were nice and they were polite and respectful towards them.

We spoke with a relative who told us that they were 'Very pleased with the way they are looking after [their relative]'. They were happy that their relative was taken out to the cinema and to a library. Their relative added that the staff were 'Quite nice' and provided them with feedback about their relative's progress.

Is the service responsive?

People's needs were assessed before they moved into the service. We saw examples of assessments of people's needs. This meant that there was a process in place to ensure people's needs could be met by the service before people moved in.

People had their health needs met. For example, the regional manager told us about a health matter that occurred the previous day for one person. We saw records that showed that this matter was being monitored and followed up with relevant health professionals.

The service sought support from relevant professionals to meet people's needs. We saw a record that showed that an appointment had been made for a mental health professional to visit the service in the near future and review people's support plans and medication needs.

Is the service safe?

There were systems in place to ensure staff were competent in being able to meet people's needs safely and effectively. We saw that new staff received an induction to the service.

However, at the time of our inspection, there was no written guidance for staff to follow for one person to show what steps should be taken before giving them medication to manage their challenging behaviour. The chart used to record when this medication was given showed it had been given nine times between the end of July and early August 2014. Records showed one occasion when the person was given this medication after they had become calm. The regional manager confirmed that such medication should not be given to this person once they were calm. This meant that this person was given a medication unnecessarily by staff.

Following the inspection we were provided with a document that set out what steps staff should take before giving this person this specific medication.

There were systems in place to monitor health and safety within the service. These checks included water temperature checks and fire safety checks. There were arrangements in place to deal with foreseeable emergencies.

Is the service effective?

People were involved in making day to day decisions about their care. We saw one person chose a specific staff member to support them to wash their hair that morning.

The service had taken steps to address the staff shortages. The regional manager told us that staff covered vacancies between themselves. Records showed that recruitment was underway and interviews had been scheduled for several applicants. This meant that people's needs were met because there were arrangements in place to cover staff vacancies.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Records showed that risk assessments had been completed to promote people's independence and minimise risks to their safety.

People's health needs were met and staff recorded health information on people's records. We saw that people's appointments with health professionals were recorded.

Is the service well led?

The service had been open for approximately three months at the time of our inspection. Management cover was in place whilst the permanent manager was no longer in post. A new manager had been recruited and was due to start in the near future.

Overall, staff told us they were supported in their role. One staff member told us that they 'Definitely' felt supported in their role. Another staff member told us that 'The staff are all supportive' and 'The managers are easy to approach'.

There were systems in place to monitor the quality of service delivery. We saw that one person had been involved in making changes to a plan about a specific aspect of their care. We saw an example of a record of a telephone discussion with one person's relative discussing their relative moving into the service.

There were systems in place for staff to be given the opportunity to provide feedback about the service. We saw that staff attended staff meetings held at the service.

There was a process in place for managing complaints. There was one complaint currently being investigated.

We saw records that showed staff documented incidents that took place at the service. The regional manager told us these incidents had led to a referral to a mental health professional to review people's needs.

However, not all records could be located promptly when needed. We saw one example where written guidance in place was not up to date to reflect the care that staff provided to meet one person's needs. There was no written guidance in place for staff to follow about supporting one person who may display inappropriate behaviour towards staff. Following the inspection we were provided with a document that showed guidance was now in place for staff to be able to respond to such behaviours consistently.