Highdowns Residential Home

About the service

Highdowns Residential Home is a residential care home providing personal care for up to 14 people with learning disabilities or autistic people. At the time of the inspection 14 people were living at the service. The accommodation is spread across several buildings and situated on farmland. At the time of the inspection 5 people were living in the main house, 4 people lived in an adjoining cottage and the remaining 5 people all had their own separate accommodation.

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

Right Support

Staff supported people to have choice and control and be independent.

People were supported by staff to pursue their interests.

Areas of the service were in need of updating to help ensure people’s surroundings were pleasant and supported their comfort and well-being. There were plans to make the necessary improvements in the near future.

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

Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcome.

The policies and systems in the service had not consistently ensured staff supported people in the least restrictive way possible and in their best interests. Staff had not consistently recorded when restrictions had been put in place to keep people safe. This meant opportunities to learn from those incidents and how they might be impacting on everyone living at the service were lost.

Right Care

Staff promoted equality and diversity in their support for people. They understood people’s diverse needs and provided appropriate support.

Staff had training on how to recognise and report abuse and they knew how to apply it.

The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

Staff and people cooperated to assess risks people might face. Where appropriate, staff encouraged and enabled people to take positive risks.

Right Culture

People led meaningful lives because of the ethos, values, attitudes and behaviours of the management and staff.

Training for staff to help ensure they were able to provide good quality care and support had not been refreshed regularly in line with the organisations policies.

The management team were supportive and knew people well.

Staff evaluated the quality of support provided to people, involving the person, their families and other professionals as appropriate.

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

Rating at last inspection

The last rating for this service was good (published 4 October 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 and Recommendations

We have identified breaches in relation to restrictive practices and staff training. Please see the action we have told the provider to take at the end of this report.

We have made recommendations about recording information in relation to risks and support for management when new systems are introduced.

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.

We found the following examples of good practice.

The service was appropriately staffed. Although there were currently issues with the recruitment and retention of staff throughout the sector, Highdowns had been able to meet people’s support needs.

The service currently had six full time staff vacancies. Through a combination of the use of agency staff, bank staff and staff completing additional shifts, the manager had ensured that staffing levels were safe. In addition, the service’s manager, two deputy managers, maintenance person and farm operative were supernumerary and trained as support staff. This meant these staff where available to provide care and support as short notice when necessary.

Personal protective equipment (PPE) was readily available and used appropriately by staff and visitors. Staff and people living at the service were regularly tested for COVID-19. All visitors completed lateral flow testing before entering the services premises. Relatives told us, “Staff always have worn masks. They are good with all that” and “You do a lateral flow test before visits, show results. They had a separate door to go to and wait. The staff were wearing masks”.

Additional cleaning protocols were in place to ensure all high touch points were regularly sanitised. Changes had been made to how staff were deployed to limit transmission risks between individual households.

The service was following current guidance in relation to visiting care homes during outbreaks of COVID-19. Essential care givers and visits to people in receipt of end of life care were possible. However, the service was currently closed to other visitors in accordance with national guidance. The need for these restrictions had been explained to people and their relatives. Staff had maintained regular communication with relatives and supported and encouraged people to keep in touch with their relatives while visiting was restricted.

People told us they were happy and enjoyed living at Highdowns. One person took pride in showing us their livestock. Relatives were complimentary of the service and its staff team. Their comments included, “[Highdowns] is brilliant I am really happy”, “I think it is fantastic, the staff are wonderful” and “I don’t have anything negative to say, I think they have managed a very very challenging situation very well”.

Highdowns Residential Home is a residential care home providing personal care for up to 14 people with learning disabilities and/ or autistic spectrum needs primarily under aged 65 years of age. At the time of the inspection three people were living at the service. The service is made up of six separate buildings, three of which are single occupancy.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that 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 receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was bigger than most domestic style properties and was registered for the support of up to 14 people. 14 people were using the service. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the service having six separate buildings. At the time of the inspection six people were living in the main building and there was a plan to reduce this to four in December 2019. The other five buildings were designed for smaller numbers with one being for four people, one for two people and three single occupancy. The site deliberately had no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

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 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/ did not support this practice. Any restrictive practices were regularly reviewed to ensure they remained the least restrictive option and were proportionate and necessary.

People and their relatives told us they felt safe living at the service and staff treated them in a caring and respectful manner. People were observed to have good relationships with the staff team.

Staff involved people in decisions about how and where they spent their days. They were knowledgeable about people’s needs and skilled in communicating with them, which meant staff could support people to make meaningful choices. Staff actively encouraged people to maintain links with the local community, their friends and family.

Staff and relatives told us the staff team worked well together and communicated effectively. Records of people’s care were regularly reviewed and updated and were an accurate reflection of their needs. When changes to how care was delivered were necessary, this was carried out effectively and in partnership with other professionals.

Staff helped people to plan meals and shop as well as preparing and cooking meals. Staff encouraged people to eat a well-balanced diet and make healthy eating choices.

Staff were recruited safely and there were sufficient numbers to ensure people’s care and social needs were met. Staff received induction, training and supervision to assist them to carry out their work.

There was a clearly defined management structure and regular oversight and input from senior management. Staff were positive about the management of the service and told us the registered and deputy managers were supportive and approachable. There were systems in place to continually drive improvement. This included gathering the views of all stakeholders and regular audits of all aspects of the service.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. The service used positive behaviour support principles to support people in the least restrictive way. The service used some restrictive intervention practices as a last resort, in a person-centred way, in line with positive behaviour support principles.

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 (report published 15 March 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Highdowns provides care and accommodation for up to 14 people who have autistic spectrum disorders. At the time of the inspection 13 people were living at the service. Highdowns is part of the Regard group. The service is made up of five separate buildings, three of which are single occupancy.

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 sufficient staff on duty at all times to meet people’s individual needs. Staffing levels identified as necessary for the service were consistently met in all of the five 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 Highdowns in a wide range of areas including supporting people whose behaviour could challenge staff and others. Training specific to people’s health needs had 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.

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. For people recorded as not having capacity to agree to staff supporting them with their medication, formal mental capacity assessments had not been conducted. This applied to two people who lived at Highdowns. This issue had also been highlighted during a recent internal quality assurance audit.

Staff were positive about their jobs and spoke highly about people they supported. 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 service was managed on a day to day basis by a registered manager supported by a deputy manager and a team of support staff. 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.

Highdowns provides care and accommodation for up to 13 people. At the time of the inspection thirteen people were living at the service. There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Highdowns is part of the Regard Partnership group which provides services to people living with a learning disability. The service is made up of five properties on the same site located on the outskirts of Camborne.

Overall the premises were well maintained and, pleasant. However, we saw that cleaning schedules in the main house had not been consistently followed or reviewed to ensure standards of cleanliness remained high; this was also the case in communal bathrooms where we found overflowing bins. We saw a number of pieces of old furniture had been stacked at the back of the property. The registered manager arranged for this to be removed.

The service had a main house (which accommodated six people), a cottage (which accommodated four people) and three separate independent units. Two people agreed for us to see their living areas in the independent units. These units comprised of a bedroom, lounge/kitchen and private bathroom area. We saw that their living areas were decorated to reflect people’s personal tastes.

Recruitment practices helped ensure staff working in the service were fit and appropriate to work in the care sector. Staff had received training in how to recognise and report abuse. They were clear about how to report any concerns and were confident that any allegations made would be appropriately investigated to help ensure people were protected. There were sufficient numbers of suitably qualified staff to meet people's needs and keep them safe.

Staff monitored people's behaviour and routines in order to help ensure people's needs were not negatively impacting on others. Families and other professionals were involved in regular discussions about how best to support people. The registered manager told us they were continually assessing people's needs to check these were still being met.

People's individual abilities and strengths were recognised and respected. People received as much support as they needed but were encouraged to be independent wherever possible. There was a key worker system in place. Key workers had oversight of each individual's plan of care. Staff took a flexible approach to support, according to the needs of the individual. People approached staff for assistance and reassurance as they needed it and staff responded with understanding and good humour.

The registered manager had a clear understanding of the Mental Capacity Act 2005, and how to make sure people who did not have the mental capacity to make decisions for themselves, had their legal rights protected. However, the legal requirement to inform CQC about the granting of a Deprivation of Liberty application for a person, by completion of a notification, had not been sent.

Information was presented in easy to read formats to aid people's understanding. Support plans contained one page profiles and simple text was supplemented with pictures. Communication tools were available and staff supported people to use these to plan their days.

The registered manager took an active role within the service. However, we found that lines of accountability and responsibility within the management structure were not clear. For example, cleaning tasks that had been delegated to help ensure the smooth and efficient running of the service had not been completed or reviewed.

We identified a breach of the regulations. You can see what action we have told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with seven people who used the service, a relative, the staff supporting them and from looking at records.

If you want to see the evidence support our summary please read the full report.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic.

Care plans were individualised and contained information that directed and informed staff to provide appropriate care and support. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies.

People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard people they supported. Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped to continually improve the service. Highdowns had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). We saw that they were using these protections appropriately.

Staff knew about risk management plans and showed us examples where they had followed them. People were not put at unnecessary risk, but also had access to choice and remained in control of decisions about their care and lives.

The registered manager set the staff rotas and took people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were met.

Is the service effective?

People's health and care needs were assessed with them, or their representative, and where possible people, or their representatives, were involved in writing their plans of care. People told us that their care needs were met, and relatives told us they felt staff met their family members care needs 'as best they can'. People's preferences, interests, aspirations and different needs had been recorded and care and support had been provided in accordance with people's wishes.

We found all people who used the service had a care plan and found the information was up to date and had been reviewed regularly.

We observed how staff interacted with people and saw there was a relaxed atmosphere in the home. We saw different methods of communication being used with each person who lived at the home. Some people were able to verbalise clearly what they wanted to do, whereas other people, whilst able to understand staff verbal communication, were not able to respond in the same manner. Therefore staff used different methods of communication for example a communication board.

From quality assurance surveys, discussions with staff and management team plus a tour of the home, it was acknowledged that some parts of the environment in the home needed to be updated in the main house. In addition, Highdowns had built a new self-independent unit and this was overall to a good standard. This unit is not presently used. We expressed concern regarding installation of CCTV and the position of the door handle in this unit and therefore the potential impact on the privacy and dignity of a future user of this unit. We noted the room lacked natural ventilation and natural light. We requested that the provider inform us when they proposed to use this bedroom and how they would address these issues before the unit began to be used.

Is the service caring?

We spoke with people being supported by the service and a relative. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example, 'The staff are brilliant', 'They listen to me' and 'I love it here'.

People were treated with respect and dignity by the staff. We saw how people who used the service interacted with staff and saw that people approached staff without hesitation. We observed staff interacting with people who used the service 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.

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. The findings of the surveys were positive in all aspects of care delivered.

Is the service responsive?

We found that people who used the service were involved in making day to day decisions and participated in tasks at home, such as cleaning and doing their laundry. During the inspection we noted that people attended a variety of activities this meant they had opportunities to pursue their interests.

People knew how to make a complaint if they were unhappy. We saw records where people had raised concerns and saw their concern had been investigated and the findings where explained to the person. I If further actions to improve the service had been identified these were shared with the individual and put in place. We saw that concerns raised had been completed in line with the service's complaints policy. The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

The service had a quality assurance system, and records showed problems and opportunities to change things for the better were addressed promptly. As a result the quality of the service was continuously improving. Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We saw 'house meeting' minutes. This was an opportunity for people who used the service to meet and express their views on the service provided and to be involved in how the service continued to be developed.

We saw minutes of regular meetings held with the staff and management team. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

Staff told us they were offered relevant and useful training on a regular basis. Staff also told us they felt supported by the registered manager and could approach them at any time if they had a concern.

People told us they felt safe living at Highdowns and would talk to their key worker if they had any concerns. Staff reported they were able to raise concerns to management and appropriate external agencies if the need arose.

We observed there were enough qualified and experienced staff on shift at all times to ensure the care and welfare of people who used the service. Staff were supported by training and supervision processes to carry out their work and ensure the welfare of people who lived at Highdowns.