Susan Hampshire House

Susan Hampshire House accommodates 15 people who have a learning disability and/or autistic people. At the time of the inspection there were 14 people living at Susan Hampshire House. The service is located in a large house in close proximity to Yate shopping centre and other leisure facilities.

Despite being a large service, it was operated in line with some of the values that underpin the Right support, right care, right culture guidance and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autistic people using the service can live as ordinary a life as any citizen.

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

Right Support:

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 to do the things they liked to do. People, staff and professionals were involved with decision making where appropriate.

There were enough staff that were skilled to meet people’s needs safely. This was kept under review as people’s needs changed. Staff recruitment and induction training processes promoted safety.

Right Care:

Care was planned with people to ensure their goals and aspirations were being met. Staff supported people to keep in contact with relatives and friends.

Staff understood how to protect people from poor care and abuse. Risks to people had been identified and clear plans of care were in place to keep people safe.

Right Culture:

Improvements were needed to ensure the governance arrangements identified shortfalls found during our inspection. We found improvements were needed in respect of the safe domain relating to the premises, food hygiene practices and infection control. Action was taken during our inspection to address these shortfalls. However, these had not been identified in the provider’s quality checks that had been completed.

There was an open culture, where people, relatives and professionals worked together to achieve good outcomes for people. People’s views were sought to make improvements to the service and to ensure care was person centred. People were at the heart of the service.

Some areas of the home would benefit from a refurbishment, including soft furnishings in both the lounges and conservatory. The registered manager had requested an additional budget to make improvements and was waiting for the provider to approve.

The registered manager and staff understood their role in making sure people were at the centre of the care they received. They provided care that was person centred and protected and promoted their human rights.

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 good (published 25 July 2018).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding. We inspected the domains of safe and well led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Susan Hampshire House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach as the provider’s governance arrangements was not robust and had not identified the shortfalls in the safe domain found at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.

People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

A manager was 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 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. People were very much part of their local community and care was tailored to the person. The service was planning to review the block purchase of the short breaks because they recognised this could be upsetting to people who lived at Susan Hampshire House.

Improvements had been made to the service to ensure people’s care plans were current and reflected their needs. Systems were in place to monitor this.

People were safe. There were sufficient numbers of staff to meet people’s needs and to spend time socialising with them. Staffing was reviewed to ensure it was safe when people stayed at the home for short breaks. Risk assessments were carried out to enable people to receive care with minimum risk to themselves or others. People received their medicines safely.

People were protected from the risk of abuse because there were clear procedures in place to recognise and respond to abuse and staff had been trained in how to follow the procedures. Systems were in place to ensure people were safe including risk management, checks on the equipment, fire systems and safe recruitment processes.

People received effective care because staff had the skills and knowledge required to effectively support them. People's healthcare needs were monitored by the staff. Other health and social care professionals were involved in the care and support of the people living at Susan Hampshire House.

People were treated in a dignified, caring manner, which demonstrated that their rights were protected. Where people lacked the capacity to make choices and decisions, staff ensured people’s rights were protected by involving relatives or other professionals in the decision making process.

The home provided a caring service to people. People, or their representatives, were involved in decisions about the care and support they received. Staff were knowledgeable about the people they supported and very committed to providing care that was tailored to the person. People were treated with kindness and compassion. People were supported to keep in touch with friends and family.

People received a responsive service. Care and support was personalised and person led. People were supported to take part in a variety of activities and trips out based on their interests and aspirations. These were being reviewed as it was recognised people had been doing the same activities for many years. People were involved and included in the running of the home.

The home was well-led. The registered manager and provider had monitoring systems, which enabled them to identify good practices and areas of improvement.

There was a registered manager in post. They had been working in the home for the last three years. 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 last inspection was carried out in May 2016 where the service was rated ‘requires improvement’. This was because there were areas of non-compliance in relation to the lack of records to guide staff when people stayed in the service for short breaks. This had been addressed with risk assessments, personal care plans and other associated documentation being in place. We also found there was not a good response to repairs and some of the areas of the home were not clean and needed redecoration. These had been addressed with some decoration work and flooring being replaced and the home was clean and free from odour. Carpets were now being deep cleaned at regular intervals. Improvements had been noted in respect of how the provider monitors the service and how people and their relative’s views were sought. Shortly after the last inspection, the provider sent us an action plan. What they told us they would do had been completed.

Care was effective and responsive to people’s changing needs. Staff were knowledgeable about the people they supported and spoke about people as individuals. There were some gaps in the care planning process, which could mean care may not be delivered consistently. This was because the staff were following the local authority care plan. This lacked specific details in some areas and could be open to interpretation.

People were supported to maintain contact with friends and family and take part in activities in the home and the local community. Day care staff were employed to support people in this area.

People were treated in a dignified, caring manner, which demonstrated that their rights were protected. Where people lacked the capacity to make choices and decisions, staff ensured people’s rights were protected by involving relatives or other professionals in the decision making process. People had access to healthcare professionals when they became unwell or required specialist equipment.

Sufficient numbers of staff supported the people living at the service. Staff had received appropriate training to enable them to support people effectively. Staff were supported by the registered manager and they had regular one to one sessions with a senior member of staff. Team meetings were organised monthly enabling staff to keep up to date, discuss the running of the home and the welfare of the people they supported.

People were protected from the risk of abuse because there were clear procedures in place to recognise and respond to abuse and, staff had been trained in how to follow the procedures. Systems were in place to ensure people were safe including risk management, checks on the equipment, fire systems and safe recruitment processes. Suitable arrangements were in place to ensure people received their medicines safely.

Systems were in place to ensure that any complaints were responded to. People were involved in the running of Susan Hampshire House and their views sought. People were involved in the recruitment of staff and their views sought on activities, menu planning and the décor of the home. Surveys had been reintroduced since the last inspection.

The staff, the registered manager and representatives from Freeways Trust completed regular quality checks on the systems that were in operation in the home to ensure they were effective. Some improvements were needed including ensuring the provider was responsive to requests such as training. Improvements were required to the overview records for complaints and accidents and incidents so they could be monitored for any themes or trends.

There was a registered manager in post. They had been working in the home for the last two years. 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.

Some improvements were required to the environment to ensure it was safe and meeting the needs of people. Maintenance was not always responded to promptly. Some areas of the home were not clean and carpets were heavily stained.

People had access to healthcare professionals when they became unwell or required specialist equipment. Feedback from health and social care professionals was generally positive in respect of the staff’s approach to people and delivery of care. However, some professionals had told us that not all their advice and recommendations were followed or shared with the team and the necessary improvements to the whole service in respect of the culture had been slow.

People were protected from the risk of abuse because there were clear procedures in place to recognise and respond to abuse and staff had been trained in how to follow the procedures. Systems were in place to ensure people were safe including risk management, checks on the equipment, fire systems and safe recruitment processes. However, people who stayed for short breaks did not have the same documentation in place to guide staff in respect of the delivery of care and keeping them safe. This was being addressed by the registered manager and an action plan had been developed by day two of our inspection.

Sufficient numbers of staff supported the people living at the service. Staff had received sufficient training to enable them to support people effectively. Regular meetings were taken place however, other systems to support staff such as one to one meetings were not happening at regular intervals and there were no annual appraisals of staff’s performance.

People had a care plan that described how they wanted to be supported in an individualised way. These had been kept under review. Staff could improve on the recording of the care that was being delivered as this was repetitive and lacked information to enable them to monitor for any changes. Staff were not recording information consistently.

People were treated in a dignified, caring manner which demonstrated that their rights were protected. Where people lacked the capacity to make choices and decisions, staff ensured people’s rights were protected by involving relatives or other professionals in the decision making process. The registered manager had submitted applications to the appropriate authorities to ensure people were not deprived of their liberty without authorisation. However, not all staff were aware of these authorisations.

The service was not always well led; the provider was not taking an active role in monitoring the quality of the service and responding to requests in respect of the environment. We have recommended the provider seek advice and guidance from a reputable source, about the how from a provider prospective they can monitor the quality of the service involving people, their representative and other stakeholders.

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

Is the service safe?

People had been cared for in an environment that was safe. Staff had been trained to administer medicines and had their competencies checked yearly.

Is the service effective?

People told us they liked living at the home and were happy with the care they received. It was clear from what we saw and from speaking with staff that they understood people's care and support needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and encouraged the people who used the service to develop their independence. The people who used the service told us that the staff were very good and supported them very well. Our observations confirmed this.

Is the service responsive?

People's needs had been assessed . Records confirmed people's preferences, interests, aspirations and diverse needs had been considered and acted on. As an example one person wanted to spend time on their games machine, whilst another wanted to go out to work. Care had been provided to meet their needs. People had access to activities that were important to them and had been supported to maintain relationships with their family.

Is the service well-led?

Staff had a good understanding of the aims and objectives of the home and the people who used the service. The people who used the service told us that they felt comfortable approaching any member of staff if there were any problems. Staff and people who used the service were involved in day to day decisions affecting the home.

It was evident from observations we carried out that people felt relaxed in their home. We saw that people were treated with warmth and respect. When we spoke with people they told us about the activities they were involved with and the opportunities they had in being involved in the local community. Several people were out during the day, supported with activities of their choice. People showed their satisfaction with their lifestyle, the care offered, and that they liked living at Susan Hampshire House.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People had person centred care plans which recorded their care needs and preferences and included their health needs.

Staff we spoke with were trained in understanding how people should be protected from abuse and demonstrated action they would take if abuse was suspected.

New systems had been put in place to rectify recent medicines errors to help ensure people were protected from harm and staff we spoke with demonstrated their knowledge about the changes. There were methods in place to assess and monitor the quality of the service, but these had not always been effective in ensuring the administration of medicines was carried out safely.

Staff worked in person centred ways at all times. For example, being courteous, thinking from the person's point of view, knocking on doors before entering people's rooms.

Staff were knowledgable about people's support needs and treated people respectfully. They were relaxed, supportive and patient. They explained and reassured people when necessary.

People we spoke with told us that they were happy with their care and felt included in their support plans. One person told us they 'Love it here' and 'It's my family'.

Complaints and concerns were listened to and acted upon immediately.

People and their families were encouraged to be involved in how the service was run and how their support plans were developed. We saw that plans were person centred and reflected each person's needs and preferences.