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The Thomas More Project - 33 Fallodon Way Good


Inspection carried out on 20 June 2017

During a routine inspection

The Thomas More Project - 33 Fallodon Way is registered to provide accommodation and personal care for up to 11 people. On the day of the visit, there were 10 people at the home.

There was a registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The staff knew how to support people in a way that respected their privacy and independence. The home had a welcoming and friendly atmosphere. Close contact with family members was actively encouraged. However a staff member spoke to a certain person in a way that did not protect their dignity. The remaining staff showed they knew how to communicate and respond in ways that treated people with dignity and respect.

New staff were recruited only after they had been through an in depth recruitment process. Risks to people were identified and kept to a minimum. This was done in a way that did not impact on people and their freedom of movement and independence. The staff knew what their responsibilities were in relation to protecting people from the risk of abuse. There were systems in place to support staff and people to stay safe.

Staff were trained and generally being supported to ensure they were aware of people's needs and how to meet them. However there had been a slippage in the frequency of staff supervision for three staff whose records we viewed. This could mean people were being care for by some staff who were not being fully supported and developed in their work.

People were supported to see a wide range of health professionals and they received the help they required to maintain optimum health. People were provided with a wide range of meals and drinks that they enjoyed.

People were supported with kindness by the staff. The team had built up close, relationships with the people they supported, their families and friends. The staff understood how to treat people as individuals and respected their lifestyle preferences, choices and wishes.

People who lived at the home were well supported to take part in a variety of activities of their choosing. People enjoyed the activities and the opportunities made available to them. There were links with the nearby community and people were well supported to be part of this if they wanted to be.

The care and service people received was regularly reviewed to find out what improvements were needed, and how the service could be further developed. There were quality checking systems in place to monitor the service to ensure people received care that was personalised to their needs. Audits had picked up some matters that required action, including the shortfall in frequency of staff supervision. The registered manager was acting on these issues. There were a range of checks and audits in place that ensured the on-going safety and quality of the service. These had been effective at providing assurance that the service remained good, and that the service was meeting people's needs and the regulations.

The team spoke positively about the management structure of the service and the organisation. They told us that the registered manager was a caring and supportive leader. The staff team told us they were well supported by the registered manager. The registered manager was also very positive about their role and the team that they managed. Staff said the registered manager and deputy manager were always there for them. They said both managers helped them whenever they needed advice, guidance and support.

Inspection carried out on 10 November 2014

During a routine inspection

33 Fallodon Way is a care home for up to 11 people. It provides care and support to people who have autism and learning disabilities. We carried out an unannounced inspection of the home on 10 November 2014.

A registered manager was in post at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirement of the law; as does the provider.

People were well supported in their living environment and felt safe and happy. People who used the service told us that they felt safe and had no concerns about their safety. Comments included;” I am happy and I like it here. “I feel safe here and when I use the call bell staff come quickly”.

There were enough staff to keep people safe and meet their needs. We looked at the staff rota which confirmed that the staffing levels were enough for the day and night and reflected the numbers and circumstances of people living at the home We saw that staff were deployed in accordance to their experience and skills.

There were systems in place in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguard (DoLS). (MCA) is legislation used to protect people who might not be able to make informed decisions on their own about the care they receive. We also saw that the Deprivation of Liberty Safeguards (DoLS) legislation was considered, when people were at risk of having their liberty restricted due to their assessed needs. The registered manager had taken steps to ensure that correct authorisation was in place.

Staff received appropriate training relevant to the people they cared for. These were in areas such as; person centred planning, autism and dementia awareness. Staff also received structured opportunities to review their practice and performance in form of supervision and appraisal meetings.

People’s privacy and dignity were respected when staff assisted them. Staff knocked on the doors and waited for an answer before going into people’s bedrooms. Bedrooms were locked by the people when not occupied to protect their privacy and independence.

People were supported by kind and caring staff. We saw that staff interacted with people in a positive and considerate manner. One person told us “The staff are alright caring and kind they treat me well”. I’m involved with my support plan with my keyworker” and “they are good to me. I feel they meet my support needs.

Each person had their own weekly activities that they enjoyed. We saw that each person had an activity plan. This told us about how people liked to spend their time during the week and how staff needed to support them. One person told us “I enjoy going to see my parents, shopping”. Another comment was “It’s great”.

People were supported to make choices around the care they received. A relative told us “they (staff) always try their best to give people choice of what they want to do within their limits”.

There was a complaints procedure in place and people were supported to make complaint. This was in easy read language to enable people who had communication needs to know how to make a complaint and their rights.

There were quality assurance systems in place to improve the service. These included audits, house checks, provider internal compliance visits and the annual support plan review.

The registered manager undertook an annual survey to find out the views of people living at the service and their relatives and staff and visitors. The most recent was in September 2014. Action was taken to address suggestions made to improve the service.

Inspection carried out on 8 December 2013

During an inspection to make sure that the improvements required had been made

At our inspection of 13 July 2013 we found that we could not be assured that people were being administered the medicines that they required for their health needs. This was because errors had been made on the medicine administration record sheets that we looked at. We had also found that the stock levels of people’s medication were incorrectly recorded. The provider wrote to us and told us that they had put in place action to address the failings that had been identified. The provider told us that they were fully compliant by 22 August 2013.

During our inspection of 8 December 2013 we found that the provider had put in place a suitable system so that people’s medicines were managed, stored and administered safely.

We spoke with two people who used the service to find out how they felt about life at the home. Both people told us that they were happy at the home. Each person told us that they liked the staff at the home. One person told us that they had a keyworker among the staff team. They said that this member of staff took them out to the pub and the shops.

Inspection carried out on 18 July 2013

During a routine inspection

We spoke with three people who lived in the home, and three members of staff. We examined records, minutes of meetings and survey results. People told us “I love it here, I like having my routine” and “the staff are very nice here, my keyworker is the best”.

The care plans we saw provided details of people's individual needs, wishes and preferences. People also told us that care was delivered in line with their preferences. We found that care plans and risk assessments had been reviewed as planned by the provider to meet people’s changing needs.

The home had safe systems in place for the storing and administering of medicines and staff received appropriate training in this area. However we found that errors had been made on the medicine administration record sheets (MARS) that we looked at, and the stock levels of people’s medication did not match the relevant MARS.

We found that pre-employment checks were undertaken before staff began work and there were effective recruitment and selection processes in place. People were also involved in the recruitment of staff for the home.

The provider had effective quality assurance systems in place to monitor the performance of the home. The views of people living there and their representatives were taken into consideration.

People were given information about the complaints procedure and any complaint was recorded and responded to in a timely manner.

Inspection carried out on 14 January 2013

During an inspection to make sure that the improvements required had been made

This was a follow up visit to monitor ongoing compliance to the Essential Standards of Quality and Safety.

We visited the home in October 2012 and found the service was non compliant with two outcomes 8 and 16. These were outcome 8 cleanliness and outcome 16 infection control and assessing and monitoring the quality of service provision.

The provider sent us an action plan in response to our visit and within the agreed timescales. This clearly set out how the provider was going to ensure ongoing compliance and the timescales for completion.

We looked at the systems for minimising the risks of infection and assurances in respect of quality auditing.

There were suitable arrangements in place to minimise the risks of infection and to audit the quality of the service. The provider had demonstrated compliance with the Essential Standards of Quality and Safety.

We did not speak with people who use the service in respect of these outcomes on this occasion. People’s views were captured during our visit in October 2012.

Inspection carried out on 17 October 2012

During a routine inspection

We spoke with four people who used the service, a relative, two members of staff and the project manager during the visit.

People experienced care and support that was tailored to their individual needs. They were involved in making decisions about how they were supported. We observed staff supporting people in an appropriate manner ensuring their privacy and dignity was maintained.

People told us that they were confident that the service listened to them and any concerns that they had would be dealt with promptly. People told us they liked the staff that supported them.

Staff were knowledgeable about the people they supported and they were provided with training appropriate to their roles.

People were encouraged to lead full and active lives including attendance at college and social activities both in the home and the community.

People could be potentially at risk of cross infection due to the lack of guidance and monitoring by the provider. This was because of the way their toiletries were stored in the communal bathrooms.

There was a lack of quality assurance monitoring to review and improve the service. This included seeking the views of the people using the service.

Inspection carried out on 16 December 2010

During a routine inspection

Individuals living in the home were positive about the care and support they received. They told us that they had sufficient staff who treated them well.

They told us they were involved in the planning of the care and that they could access their care records.

They told us that their views were sought at weekly meetings in respect of concerns, menu planning and the planning activities. People we spoke to told us that they knew how to complain and that their concerns would be responded to.

They told us that they have opportunities to go out in the local community and trips further afield. They told us that they attend college, day centres and some individuals are supported to go to work.

People receiving a service told us that they liked living in 33 Fallodon Way.