Disability Supported Accommodation Service North Network

MLDP North provides support for 48 people living in their own homes. Some people lived in their own bungalow in a complex of several bungalows together and received a range of support each day. Other people lived in shared houses with staff support 24 hours per day. Each house or group of bungalows had a designated staff team. The staff teams were managed by a care co-ordinator. There were seven care co-ordinators in total.

People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

The service had a registered manager who had been in place since May 2016. 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 2008 and associated Regulations about how the service is run.

The care service has 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.

At this inspection we found that the improvements seen at our last inspection in November 2016 had been sustained and built on.

Risks had been identified for each person and risk assessments were in place to mitigate these risks. All risk assessments we saw were current. Risk assessments detailed why any restrictions were in place, although one required further clarity which was evidenced as being completed straight after our inspection. Staff were aware of the reasons any restrictions were in place.

Behavioural support plans were in place and current for those people who may display behaviours that challenge staff. Person centred care plans were in place, had been reviewed and were up to date.

Quality assurance systems were in place. Trackers were used to monitor that care plans, risk assessments, staff training, staff supervisions and service audits were being completed. Incidents and accidents were reviewed by the care co-ordinators and any action taken recorded. These were logged onto a tracker so an overview of all incidents across the service could be reviewed for trends or patterns.

The registered manager had completed audits for each of the properties. A schedule of audits of MLDP North were to be undertaken by care co-ordinators form MLDP North’s sister services in the south and central areas of the city was in place. However, due to reasons outside of the registered manager’s control these audits had not been completed as planned in 2017. Action plans were produced following the audits and were signed off as the actions were completed.

The number of incidents had reduced across the service, linked to having more stable staff teams and a reduction in unfamiliar agency supporting people. People’s needs had been re-assessed by social services as part of the procedures of applying to the court of protection under the Mental Capacity Act (2005) when people had constant staff supervision or had restrictions in place. This had led to an increase in support hours for several people which had enabled people to participate in additional activities.

A system was in place to recruit staff who were suitable to work with vulnerable people. Staff training had been identified and had increased. More training had been booked for the forthcoming months. The registered manager was now able to identify and specify the training their staff required and book courses just for MLDP North staff. Previously the service had been offered places on courses booked by the central Manchester City Council human resources department.

Relatives we spoke with were very complimentary about the staff teams and care co-ordinators. We observed positive interactions between the staff and the people they were supporting. Information about people’s likes, dislikes and preferences was recorded meaning staff were able to form meaningful relationships with the people they supported.

People were supported to maintain their independence where possible, for example travelling to activities on their own.

Medicines were well managed by the service. Protocols were in place for any ‘as required’ medicines.

Staff said they felt well supported and that morale had improved. Care co-ordinators were more visible in the properties, staff had supervisions with their line manager and regular team meetings were held. Staff focus days had been held where staff discussed what was working well and where improvements were needed.

An out of hours on call system was in place so staff were able to speak with a manager outside of office hours. Staff told us this system worked well; however a care co-ordinator said there had been some occasions when the on call manager had not responded to a call in a timely manner which had affected the administration of an ‘as required’ medicine. The registered manager told us the ‘as required’ medicine policy was being re-written so that senior staff were able to make the decision as to when an ‘as required’ medicine was needed.

Capacity assessments had been completed and applications to the court of protection made through the relevant social service department where people had been assessed as not having the capacity to consent to their support. Where people lacked capacity and did not have any family members involved in their care advocates were used to ensure that people’s best interests were taken into account. We have made a recommendation to follow best practice guidelines to record where people are assessed as having the capacity to consent to their support.

People were supported to maintain their health. Health action plans were in place to record the support each person required with their health needs. People were supported with their nutritional needs.

MLDP North provides support for 55 people living in their own homes. Some people lived in their own bungalow in a complex of several bungalows together. People received a range of support each day. Other people lived in shared houses with staff support 24 hours per day. Each house or group of bungalows had a designated staff team. The staff teams were managed by a care co-ordinator, who managed two teams. There were seven care co-ordinators in total.

The service had a registered manager who had been in place since May 2016. 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 2008 and associated Regulations about how the service is run

The previous inspection took place in March 2016 where five breaches of the Health and Social Care Act 2008 were identified. The provider was placed into special measures by CQC. We took enforcement action and issued three warning notices to the provider. The provider appointed a new experienced Nominated Individual (the service manager for the independent living services) to oversee the service. A Nominated Individual is a person employed as a director, manager or secretary of an organisation with responsibility for supervising the management of the regulated activity.

An interim improvement manager was also appointed and an improvement plan developed. Manchester City Council has two similar services in the South and Central areas of the city. The development plan covered all three services. Since the last inspection the Nominated Individual and interim improvement manager have met regularly with CQC to update us on the improvement plan and the progress they were making.

This inspection was carried out to check what improvements had been implemented since our last inspection. We found that improvements had been made throughout the service and these were sufficient for CQC to be able to take the service out of special measures.

People and their relatives told us they felt safe supported by MLDP North staff. Staff had undertaken training in safeguarding vulnerable adults and were able to describe the different types of abuse and how they would report any concerns. The registered manager monitored all safeguarding referrals. An escalation policy had been introduced so any referrals to other professionals about a safeguarding concern were followed up. We saw multi-disciplinary meetings had been held where appropriate.

Care plans, risk assessments, moving and handling guidelines and behaviour management plans had been reviewed and updated. These gave guidance for staff about the support people required. However we found some staff teams continued to be risk averse and restricted people, for example from going into the kitchen. The risk assessments did not support this and the reasons for the restriction were not evident.

A new positive risk assessment tool was being introduced which would assess what a person wanted to do and looking at how this could be achieved safely.

People’s personal care files had been standardised across the service and old information removed. This meant staff were able to access the information in the files more easily. The care co-ordinators used a standard method for saving electronic files. This meant other care co-ordinators in the service were able to access the information if required.

The staff teams were now stable and the use of agency staff had greatly reduced. New staff had been recruited. This meant people were supported by staff that new them well. The number of incidents occurring had reduced due to people being supported by familiar staff. However we saw that people were not always able to access the local community when they wanted to due to the level of staffing available or because agency staff, whilst able to support people in their home, were not able to support them in the community. We saw one person had missed three appointments due to staff not being available to support them.

Robust recruitment procedures were in place. A safe system of administering medicines was used. Staff had received training in the administration of medicines and were observed annually by the care co-ordinators to check their competency.

Staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards in Domestic Settings. They were able to describe how people may have the capacity to make some decisions and not others. People were encouraged to make choices and we saw some communication aids had been developed to assist this.

Staff said training courses had recommenced after a break at the start of the year. A database was being populated by the care co-ordinators so the training each staff member had attended and what they required was easily accessible. We will check at our next inspection to see that this has been completed.

Care plans were written in a person centred way. Details of people’s likes, dislikes and life history were noted. People’s support had been reviewed internally. Reviews had also been held by the local authority care management teams for some people to re-assess their needs and the support they required. However not everyone had goals they wanted to achieve in place for 2016.

We spoke with staff who had supported people at the end of their lives. They were positive about the support they had been able to provide to the person and the support they had received from their care co-ordinators and the registered manager. Best interest meetings had been held and the care co-ordinated with the medical professionals, district nurses and MacMillan nurses.

All the staff and care co-ordinators we spoke with said that staff morale had improved and were positive about the changes made at the service since our last inspection. Staff felt well supported, with the care co-ordinators visiting the properties more often and staff supervisions being regularly completed. Staff meetings were held in for each team. The care co-ordinators had a weekly meeting to discuss progress on the improvement plan.

We saw one property required maintenance work to be completed. The care co-ordinator and registered manager were aware of this and had arranged to meet with the social landlord to agree the work to be undertaken and the timescales for completion.

We were told the registered manager, interim improvement manager and the service manager for the independent living services were approachable and supportive.

A new system of weekly spot checks and quarterly audits had been introduced. These looked at the environment, people’s personal files and staff knowledge, supervision and training. Care co-ordinators did not audit the properties they managed. We did not see that action plans had been written from the audits, the registered manager told us they were going to develop these. We will check that the system of audits has been embedded and is used to drive improvements in the service at our next inspection.

During this inspection we found one breach of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Following the inspection in October 2014 the provider wrote to us to tell us the action they intended to take to ensure they met all the relevant regulations. Part of this inspection was undertaken to check whether the required improvements had been made. We found that people’s nutritional needs were assessed and monitored and medicines were safely administered. However we found that the service was not acting in accordance with the MCA and did not have robust quality monitoring systems in place.

MLDP North provides support for 55 people living in their own homes. Some people lived in their own bungalow in a complex of several bungalows together. People received a range of support each day. Other people lived in shared houses with staff support 24 hours per day. Each house or group of bungalows had a designated staff team. The staff teams were managed by a care co-ordinator, who managed two teams. There were seven care co-ordinators in total.

The service had a registered manager in place. 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 registered manager was not working at the time of our inspection and so the service was being managed by the Nominated Individual (NI). A Nominated Individual is a person employed as a director, manager or secretary of an organisation with responsibility for supervising the management of the regulated activity.

People we spoke with, and their relatives, said that they felt safe being supported by MLDP North. Staff told us that they had completed safeguarding training and could describe the action they would take if they witnessed or suspected abuse. We saw that referrals were made to other professionals by the care co-ordinators if relevant when concerns were raised. However these had not been followed up to ensure a prompt response from the other agencies. We were told that a new policy had been introduced to make sure any new referrals were followed up in a timely manner.

We found some risk assessments were in place to identify and mitigate risks people may face. However not all risks had been identified and they were not always up to date. Behavioural support plans were in place for people with complex needs. These gave guidance for staff to manage people’s behaviour; however they did not identify what the actual risks were.

We found agency staff were employed on temporary contracts to provide consistent support for people. However we saw that the number of incident reports increased when agency staff were used. Staff told us that some of the people they supported could not access their usual activities with agency staff due to the risk of an incident occurring when people were supported by unfamiliar staff. We were told agency staff did not always complete the necessary incident forms, meaning that a complete record of the incidents which had occurred was not kept.

We were shown the information provided to two new agency staff to support people with complex needs. The information was not sufficient to enable the agency staff to safely support the people who used the service.

We found a safe system for administering medicines was in place. Staff had received training in the administration of medicines. People we spoke with told us that they received the medicines as prescribed.

A safe system for recruiting staff suitable for working with vulnerable adults was in place.

Staff we spoke with demonstrated a limited understanding of the MCA and how this legislation was relevant to their practice. The registered manager had failed to take the necessary action to ensure the rights of people were upheld when they were unable to consent to their support.

Staff we spoke with said that they had completed training courses but we were unable to check this as training records were incomplete.

We found that people were supported to maintain their health and systems were in place to monitor people’s nutritional intake where required.

All the people we spoke with, and their relatives, were complimentary about the regular staff supporting them. We observed positive interactions between staff and people who used the service during our inspection. Staff we spoke with had a good understanding of people’s needs.

We saw care plans included people’s likes and dislikes and were written in a person centred way. However care plans had not been reviewed and updated and information was not always easily accessible.

We saw a survey was used to ask for relatives views about the service. However we did not see any evidence that these were analysed and actions taken about any points raised.

Staff said they enjoyed working at the service. However we found staff supervisions and team meetings were inconsistent across the different staff teams.

There was not a robust system of quality audits in place. Spot checks were inconsistently completed, incidents were not reviewed, training records were not complete and MCA best interest assessments had not been completed.

During this inspection we found twelve breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

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, it 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 that people were involved in planning their support and were treated with dignity. We found that general day to day support met people's needs and promoted independence. Systems were in place to deal with allegations of abuse. We found that staff needed additional first aid and other training. Although permanent staff were supported to provide a safe and effective service through supervisions and appraisal, the provider needed to take more action to ensure agency staff always received the support required.

The person we visited did not speak but was able to respond to questions. They indicated through making positive signals such as nods and smiles, that they liked receiving a service from Harpurhey MLDP Network team. This person was especially positive about the staff who provided day to day support.

We found that staff were in the main suitably qualified to carry out their role, however training needed to be updated.

We found the service had systems in place to protect the rights of people using the service. We saw that people experienced effective safe and appropriate support. We found the staffing structure and staff deployment met the needs of people using the service.