Redstone House

Redstone House is a care home providing accommodation and personal care to up to four adults. At the time of inspection there were three people living at the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Based on our review of safe and well-led the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right Support

People were encouraged to have control in their daily lives and staff ensured people were able to live as independently as possible. For example, people had been supported to learn new skills such as preparing meals and making their own hot drinks. Risks were managed well to keep people safe while promoting their independence and staff supported people to access healthcare services when they needed them.

Right Care

Staff knew people well and ensured that people received the support they needed to keep them safe and to meet their individual care needs. People's rights were promoted, and they were protected from discrimination. People were treated with dignity and their privacy was respected. Staff were kind and caring. They treated people with respect and encouraged them to make decisions about their care and support. The support staff provided was flexible to take into account people's needs and preferences.

Right Culture

There was a positive ethos at the service and a culture of empowering people to live the lives they wanted to. People were involved in planning their own care and were encouraged to give their views about the support they received. One social care professional told us, “The manager and staff make sure that [person] is heard.” People's families were also able to give their feedback about the support their family members received and their views were listened to.

We found that people’s care plans and risk assessments did not always include enough detail, the registered manager told us they were aware of this and planned to review these. The registered manager was approachable and supportive, staff enjoyed working at the service and were listened to. The registered manager and staff maintained effective working relationships with other professionals to ensure people received the care they needed.

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.

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 requires improvement (published 23 October 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We undertook this inspection to assess whether the service had made improvements following the previous inspection. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall 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.

Redstone House is registered to provide accommodation and personal care for up to four adults who have a learning disability. At the time of our inspection three people lived there. The service is delivered within a three-storey house in a residential area.

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.

The building design fitted into the residential area and the other large domestic homes of a similar size. There were deliberately 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

At our last inspection we raised several concerns about the care and support of the people who lived here. These included the way risks to people were managed, and the home not being well managed to ensure people received a good standard of care. The provider had responded to these concerns by putting in new management, employing more staff and having a clear plan on what they needed to do to improve the care people received.

During this inspection we found that significant improvements had been made and as a result people received a better standard of care, and the home was no longer in breach of the regulations. Time was now needed for the provider to demonstrate that the improvements made were embedded and could be sustained.

People were safe because there were enough staff employed to support them and meet their needs. The provider’s recruitment procedures ensured that only staff that were suitable to work with vulnerable people were employed. People were protected from the risk of abuse because staff understood their roles and responsibilities in identifying and reporting any concerns. People had their medicines when they needed them, and the storage and management of medicines was safe. The home environment was kept clean and hygienic to reduce the risk of infections.

The home environment had improved, and maintenance task were quickly addressed when they arose. Staff training and supervision had improved to ensure that they had the skills and knowledge to provide the care people needed.

People had enough to eat and drink and were now more involved in food and drink preparation to increase their independence. Staff worked with people to ensure their food intake was nutritious, and healthy options were promoted. People were supported to access health care professionals such as doctors when they needed them.

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.

People were supported by kind and caring staff that new them well. Staff treated people with dignity and respect and protected their confidentiality and privacy. Staff understood people’s communication needs and involved them in day to day decisions about their care and support.

People’s care plans were detailed and gave clear guidance to staff on preferences and support needs. Staff were able to understand the triggers that caused distressed behaviour from people, which had resulted in a reduction in these incidents. People’s access to activities that interested them and kept them from being bored had increased. This had been possible due to staff responding in a positive way to people’s behaviours.

The management of the home had improved so that the focus was on making improvements to the lives of the people who lived there. The provider had taken responsibility for the failures we highlighted at our previous inspection and tasked two managers to work with the staff in the home and make positive changes, while a permanent manager was sought. As a result, the home was now well managed and there was a clear plan in place to continue making improvements. A new manager was going through the CQC registration process.

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 carried out a survey with the manager at this inspection. This 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. No restrictive intervention practices were used.

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 Inadequate (published 7 June 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since February 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

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.

This inspection took place on 06 December 2018 and was unannounced.

Redstone House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care service had not 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 were not supported to live as ordinary a life as any citizen.

Redstone House in Redhill is registered to provide accommodation and personal care for up to four adults who have a learning disability. At the time of our inspection four people live here. The service is delivered from a two-story house in a residential area.

It is a requirement of the provider's registration that they have 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. The registered manager was present during this inspection.

This inspection had been bought forward as we had received concerning information about peoples care and support needs not being met. During the inspection we found a number of issues that needed to improve, however the care staff were seen to be kind and caring to people.

We found areas that required improvement across all five of the key questions that we ask during an inspection (Is the service safe, effective, caring responsive and well led?). In total we have identified seven breaches in the regulations.

The breaches were around managing risks to people, while minimising the impact to their independence; not having enough staff at all times to meet people’s needs; the safe management of medicines; not providing care and support that met people’s needs and preferences; not providing information in an accessible format; failing to carry out maintenance to the home environment in a timely manner; and not having quality assurance processes that promoted continuous improvement.

The provider had not ensured the home was well led. Staff were focussed on giving day to day care, however little structured and documented work had been completed to improve people’s lives. All the people who live at the home had some form of behaviour that may challenge themselves or others. This meant that they required one to one, or even two to one support at times of the day. The providers failure to promote continuous improvement meant that although these behaviours were known and documented when they happened, people had not been supported to overcome them. The records of accidents and incidents had not been reviewed to try to reduce the risk of repeat concerns arising.

The providers quality assurance processes were not effective at ensuring areas for improvement that had been identified were actioned in a timely manner. Maintenance issues such as exterior doors not being able to be locked had taken months to fix leaving people at risk as the house had not been secure.

Redstone house did not provide a consistently safe standard of care. There were risks to people’s health and safety because behaviours that may challenge had not been well managed. Although incidents had been recorded no structured approach had been taken to try to help people manage and overcome behaviours. Risk management also had an impact on people’s independence as they were restricted from doing things themselves because staff had failed to investigate less restrictive options. For example, using small jugs, and small kettles/coffee pod machines to enable people to make their own drinks in a safe way, rather than staff having to step in and help. Guidance from health care professionals had also not been consistently followed effectively, or sought to help people overcome behaviours that impacted their lives.

Levels of staffing were not always adequate to meet people’s needs. Prior to the inspection we received information that a lack of staff had impacted people’s care and support. During our inspection, we identified times where people were at risk, or their activities delayed due to the deployment of staff. For example, a staff member supported one person to go to college, however this meant the other three people had to wait for them to return if they want to go out, due to their behavioural support needs.

People were not always supported to take part in activities that interest them. Where activities had ceased, due closure of a service, or people’s behaviours meant they were excluded, alternatives had not been sought. Activities planners did not reflect the activities (or lack of) that people had access to. Care plans were basic and contained little information about the person as an individual, such as their goals and aspirations for their life. No information or guidance for staff had been obtained to ensure that peoples preferences and choices were know should they approach the end of their lives.

Peoples medicines were managed in a safe way and they received them when needed. However, staff did not always know what the medicine was for, or the possible side effects. They did know they could look in a person’s care file if they needed the information, such as should a person have an unexpected reaction after taking medicine.

Staff had the skill and training to meet people’s needs, although there were some gaps, and out of date training identified. The provider had already identified this and was taking action to give staff the training they needed.

There was a complaints process in place, however this was not in a format that would make it easy for people to understand. Everyone we spoke or interacted with was happy with the service, and no complaints had been recorded in the complaints file. There were three positive comments in the compliments file from relatives.

People were supported to have enough to eat and drink. People had access to health care professionals when the need arose, as well as for routine check-ups to keep them healthy. Where people lacked the capacity to make specific decisions, staff understood and followed the requirements of the Mental Capacity Act 2005. This ensured that decisions made for people in their best interest and any restrictions put into place to keep them safe were done in a lawful way.

Despite the issues we found during the inspection we did see that people were supported by kind, caring and friendly staff. People formed caring relationships with staff and enjoyed their company. People were supported to maintain relationships that are important to them.

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.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded

People’s experience of using this service:

¿ Staff understanding of risk management was not sufficient to ensure people were kept safe. Staff had still not recognised or reported incidents and accidents to the appropriate authorities.

¿ Staff had not understood that restricting someone’s activities in response to that person’s behaviour was a form of institutional abuse. Two instances of one person hitting another had also not been identified as potential abuse. None of these had been notified to the relevant authorities.

¿ Concerns over how people’s monies were managed had also been raised. Purchase of take away meals and payment of activities had been done with people’s monies. These costs should have been already included in the care package paid for by the commissioners of the service, and not needed people to pay for them themselves.

¿ Guidance documents for staff to keep people safe were not adequate to minimise the risk of harm. This included staff understanding of how to respond to behaviour that may challenge, and night time fire evacuation arrangements.

¿ Staffing levels had increased, however people’s activities were still impacted by a lack of staff. Staff were working long hours to cover shifts, leaving them at risk of being tired and increasing the chance of mistakes being made.

¿ Further work was needed to ensure peoples medicines were managed and administered in a safe way.

¿ The registered manager had left the home since our inspection in December 2018. The home was being managed by two registered managers from the owner’s other homes.

¿ Some improvements had been made, and further improvements were planned, however there were still many areas identified at the previous inspection that had still not been taken care of.

¿ The management structure of the service was fragmented and confusing to the staff. Key information and support were not available to staff when they needed it. For example, documents around finances were not available at or after the inspection because the person in charge of these was unavailable. No contingency was in place for other people to be able to access the information in their absence.

Rating at last inspection:

¿ At our last inspection in December 2018 (report published February 2019) we rated the service as inadequate. At this focussed inspection we saw that some improvements had been made, and the process was ongoing, the overall rating remains the same.

Why we inspected:

¿ This focussed inspection took place as we had received concerns around the care and welfare of the people who lived here.

Follow up:

¿ We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

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

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.

The inspection took place on 11 March 2016 and was unannounced. At our last inspection in 24 July 2013 we raised a concern about the people who use the service could not be confident that their human rights would be upheld. This was because decisions and restrictions were being made for people without their consent and without a formal assessment of the need for them under the Mental Capacity Act. Our previous inspection highlighted risks associated with leaving fire doors wedged open, leaving windows unrestricted without assessment and leaving electrical or chemical hazardous items accessible to people. The registered provider had also not always taken steps to provide care in a home that was suitably designed and adequately maintained by not providing sufficient toilets, and by allowing staff to use communal areas as an office and cloakroom. The Statement of Purpose was not up to date or accurate and did not accurately reflect the kinds of services provided or the current range of service users' needs that those services were intended to meet. Files containing information about people were not kept securely and confidentially.

The registered provider provided us with an action plan to ensure that our concerns would be actioned and completed by September 2013. This was confirmed to have been completed within the stated timeframe set out in the action plan by the registered provider during this inspection.

There was positive feedback about the home and caring nature of staff from people and relatives.

Some adaptations had been made for people with mobility needs, such as rails on stairs. The registered manager and staff worked well to keep the environment clean and feeling homely for people. The majority of people who live at the service were unable to communicate verbally with us. We therefore re non-verbal and were therefore observed their response to staff during the day and have used our observations in the report. One person who could verbally communicate said, “Staff are very nice.” A relative said, “The staff are great all of them we have no problems.”

A health care professional told us that “they had no concerns" over the care and welfare of the people who lived at Redstone House.

The staff were kind and caring and treated people with dignity and respect. Good interactions were seen throughout the day of our inspection, such as staff holding people’s hands and sitting and talking with them. People looked relaxed and happy with the staff. We were told by one family member that they felt “People had positive relationships with their care workers” and they also felt “Confident about the service their relative received” at Redstone House.

People could have visitors from family and friends whenever they wanted.

There was a strong emphasis on key principles of care such as compassion, respect and dignity. We observed that the people who used the service were treated with kindness and that their privacy and dignity was always respected.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

In the event of an emergency people would be protected because there were clear procedures in place to evacuate the building, in a format people could understand. Each person had a plan which detailed the support they needed to get safely out of the building in an emergency.

The service had sufficient staff on duty to meet the needs of the people who used the service. The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home. Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported.

People received their medicines when they needed them. Staff managed medicines in a safe way and were trained in the safe administration of medicines.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Staff asked people for their permission before they provided care. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

Care plans were based around the individual preferences of people as well as their medical needs. People were not always involved in their care plans due to their complex conditions so the registered manager used other ways to gain information about people and their preferences by using a keyworker system of staff who knew them well or by consulting with those close to them such as relatives.

Care plans gave a good level of detail for staff to reference if they needed to know what support was required. Feedback from a healthcare professional was positive about the actual care given to people.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. People’s health was seen to improve due to the care and support staff gave. Visiting healthcare professionals were complimentary about the care given at the home.

People had a good choice of food and drink available to them. People received support from staff where a need had been identified. People had access to activities that met their needs. Some activities were based in the local community giving people access to friends and meeting new people. The staff knew the people they cared for as individuals.

A complaint policy was available to help people and relatives know how to make a complaint if they wished. We looked at the complaints log and saw none had been made. The registered manager told us that if a complaint was raised they would take action

Quality assurance records were kept up to date to show that the provider had checked on important aspects of the management of the home. Records for checks on health and safety, infection control, and internal medicines audits were all up to date. Accident and incident records were kept, and would be analysed and used to improve the care provided to people should they happen.

People had the opportunity to be involved in how the home was managed and were supported to have some input in house meetings to give people a chance to have their say.

People told us they had enjoyed their meal and got enough. They also said the staff offered them choices of food and they could have a snack or a drink at any time.

We found people who use the service could not be confident that their human rights would always be upheld because decisions and restrictions were being made for people without their consent and without a formal assessment of the need for them under the Mental Capacity Act.

We saw people were supported to be able to eat and drink sufficient amounts to meet their needs and were protected from the risks of inadequate hydration and nutrition.

The provider was putting people at risk by leaving fire doors wedged open, leaving windows unrestricted without assessment and leaving electrical or chemical hazardous items accessible to people. The provider had also not always taken steps to provide care in a home that was suitably designed and adequately maintained by not providing sufficient toilets, and by allowing staff to use service users' communal areas as an office and cloakroom.

The Statement of Purpose was not up to date or accurate and did not accurately reflect the kinds of services provided or the current range of service users' needs that those services were intended to meet.

Files containing information about people who use the service was not kept securely and confidentially.