Enham Trust - Care Home Services (Michael/Elizabeth & William Houses Also known as Elizabeth House

Enham Trust - Care Home Services (Michael/Elizabeth & William Houses) is a residential care home providing care for up to 60 people who may be living with a learning and/or physical disabilities.

The service was a campus setting. Campuses are group homes clustered together on the same site and usually sharing 24-hour staff. At the time of the inspection, 16 people were living in Michael House, 15 people were living in William House and 8 people were living in Elizabeth House. 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.

Campus settings for people with learning disabilities and/or autism are not in line with current best practice. The provider was reviewing their service model in accordance with the principles of ‘Right support, right care, right culture’ and with input from commissioners, people and their relatives.

Despite the service’s size we found people were supported in a way that was person-centred, and promoted choice, inclusion, control and independence.

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care and right culture.

Right support:

¿ The model of care provided people with the appropriate opportunities to maximise their choices.

Right care:

¿ Care was provided in a person-centred manner and people told us they felt supported.

Right culture:

¿ The leadership in the service created a culture of inclusion which empowered people’s lives.

Significant improvement had been made in respect of the premises, the care people received and the leadership within the organisation since the last inspection. People were supported to make choices about their future, including where they lived and who they were supported by.

Staff had received regular training in safeguarding and were aware of their safeguarding responsibilities. People told us staff responded to requests for support. Medicines were stored and administered safely, and people raised no concerns about their medicines. Staff had good knowledge of how to respond to accidents and incidents.

People's needs were assessed when they moved into the service. People were happy about the support they received. Staff had received training that was relevant to their role. People's nutritional and hydration needs were being met and they were offered a varied choice of foods.

Staff had good knowledge of people’s communication needs. The service offered activities daily to people in communal areas or in their own rooms. People were supported to maintain relationships with their loved ones. People's wishes for end-of-life care were identified by the service.

Staff had good knowledge of people’s needs. We observed staff speaking to people in a caring and empathic way. Relatives felt staff cared about their loved ones. People were actively engaged in developing the care they received. Quality assurance systems were in place which were effective in driving improvement.

People were supported to have maximum choice and control of their lives and staff 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 and update

The last rating for this service was rated inadequate (published 28 June 2022)

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 comprehensive inspection to check they had followed their action plan and to confirm they now met legal requirements.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

At the time of our inspection Enham Trust was in a process of transitioning from a registered care home to a supported living service. Enham Care Homes is a residential care home providing personal care for up to 60 people who may be living with a learning and / or physical disabilities. At the time of the inspection, 14 people were living in Michael House, 13 people were living in William House and 14 people were living in Elizabeth House. Each of the homes has accessible facilities and can accommodate up to 20 people all of whom have flat or bedsit style accommodation.

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

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care and right culture.

Right support:

¿ The model of care failed to provide people with the appropriate opportunities to maximise their choices.

Right care:

¿ Care was not always provided in a person centred manner and people told us they felt isolated.

Right culture:

¿ The leadership in the service failed to create a culture of inclusion which empowered people’s lives

The provider failed significantly to protect people from the risks associated with an unsafe premises.

The provider failed to ensure the service was consistently well led and governance systems did not protect people from possible harm.

Staff did not always follow systems and processes to administer, record and store medicines safely.

Infection control procedures were not always carried out safely. Staff failed to wear PPE appropriately which placed people at risk.

We could not be assured sufficient staff were deployed at all times to meet people’s needs. People and relatives told us the provider failed to deploy staff sufficiently across all three houses.

Requirements of the MCA were not consistently followed, and decisions made were not always properly documented. People who had capacity to make decisions were not always provided with sufficient information to help them make decisions and their care, support and accommodation.

Whilst the provider had systems in place for investigating and responding to complaints, not all complaints were appropriately dealt with in a timely manner. People were not always kept updated on progress.

People and relatives told us staff were caring and said they were compassionate in their approach.

Safe recruitment practices were followed with regular supervision and training provided.

Care plans and risk assessments contained useful information to help staff to understand people’s needs.

People told us they were supported to maintain a balanced diet and said they were assisted to access external healthcare appointments when needed.

The provider was properly registered and licensed with the Information Commissioners Office in respect of the use of surveillance.

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

Rating at the last inspection was requires improvement and the report was published on 16 May 2020.

Why we inspected

The inspection was prompted in part due to concerns received about how people were being supported to make decisions, the environment and leadership within the service. The inspection also took place because of its previous rating of requires improvement. A decision was made for us to inspect and examine those risks.

Enforcement and Recommendations

We have identified breaches in relation to the management of medicines, mental capacity, premises, infection prevention control, person centred care and governance 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. Due to the number of concerns we had regarding maintenance, we requested a maintenance plan from the provider prior to the report being published. This was to check the provider was aware of the need to prioritise making the premises safe for people. This was provided and we were given assurance repairs were being carried out.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

The service was a large home, bigger than domestic sized properties. This is larger than current best practice guidance. The homes were identifiable as care homes with intercoms, CCTV cameras and their location on a campus where the Trust head office was based alongside a supported living service and a number of other properties owned by Enham Trust. Staff did not wear uniforms to work in the care homes.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; the premises were large and did not fit with current best practice guidance and were on a campus where only people requiring support resided providing minimal access to the wider community.

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

Medicines were not safely managed, and people were at risk of harm as a result. This was a breach of regulations. Staff understood the principles of safeguarding and whistle-blowing and would not hesitate to speak with their house managers about concerns. Staff were not confident that they would be listened to by the senior leadership team. Support plans were not consistent and omitted information, lacked detail and could pose a risk to people if information was not already known by staff. Recruitment was safe and either all necessary checks were completed prior to commencement in post or a risk assessment implemented to cover staff shadowing colleagues. The houses were clean and there were no malodours. A quality team monitored incidents and distributed learning from them.

Assessments of needs were not always accurate and as with care plans, they omitted information or did not hold supporting guidelines. Latest good practice guidance for modified diets had yet to be adopted by the provider. Generally, feedback about meals was positive however the mealtime experience could be improved. Referrals were made to health and social care professionals as required and people were supported to attend appointments if staffing permitted. The premises were accessible, and people had bespoke access to their flats such as card or pressure mat controls. Maintenance was not always carried out in a timely way.

Mental Capacity Act 2005 information on support plans was confused. Additional work was needed to complete MCA assessments and best interest decisions to support current practice. We found the provider to be in breach of Regulation 11, the need for consent.

Staff completed an induction and attended regular training sessions. Staff told us they received regular supervision sessions.

Staff were caring and we received some positive feedback from people and their relatives about them. At times, people did not receive support when needed and this had a negative impact on their dignity and was not respectful of them. Most people praised staff for their care and for the respect they showed them. One person was distressed as they felt that once some staff members knew their sexuality, they treated them less favourably. People felt that due to staff being very busy they were not able to get to know them well. People could contribute to their support plans and were involved in care reviews.

People were mostly happy with the choices they could make such as when to get up however one person believed that they had missed an activity as their support was not on time. There was some information in people’s support plans about their interests which would benefit from being added to but due to the more experienced staff knowing people well there was little impact from this. The provider supported people to use a variety of communication methods however not all staff had knowledge of signing which was used by some people using the service. People told us they spent a lot of time in their rooms and there were few activities organised in the care homes. Most activities took place at Choices, an Enham day opportunity that people could pay to attend.

There was a complaints procedure and we received mixed feedback about its efficacy.

End of life care was not a focus for most people living at Enham however the manager told us that everyone had been asked if they wanted to consider starting an end of life plan.

The service was not always well-led and there was a continuing breach of regulations due to a lack of oversight of peoples support plans which, due to the lack of accuracy within them, posed a risk of harm. The associate director of care had applied to become the registered manager of the service, there had only been a registered manager for three months since January 2018. There were house managers in each of the homes responsible for the day-to-day management of each service and people told us they did not see the overall manager often.

We inspected during a consultation on the future of the services and received mixed feedback about the process. The provider issued regular quality assurance surveys however the numbers of people completing them had significantly reduced.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The service didn’t apply 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.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 2 March 2019) and there was a breach of regulation. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvements had been made but the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

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

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

• People were supported by staff who had been trained in safeguarding and who would report any concerns they had about people.

• A new call bell system had improved response times when people needed support and provided statistics which were analysed to improve the service provided.

• People who had no capacity assessment in place had applications made to deprive them of their liberty. We recommended that the provider review all records concerning capacity assessments to ensure all are in order.

• Staff participated in mandatory training which was updated annually. Staff received regular supervision with their line managers. Staff told us they felt supported.

• People told us that staff were kind and caring and supported them in ways that maintained their dignity and were respectful.

• A reduction in the physiotherapy provision meant that some people no longer received input from visiting professionals. The impact of this decision and the fast implementation had left some people unable to source alternate provision in a timely way.

• Several people did not attend activities provided in the onsite day service as they did not believe them to be relevant. There were a number of different activities on offer that people could choose to attend.

• There had been improvements in the oversight of maintenance however there had been faulty emergency lighting for almost one year and action was only taken to obtain quotes to fix the problems after our inspection. This was a continuing breach of Regulation 17 (2) (a) (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good Governance.

• The provider had introduced robust audits within each of the houses which were regularly checked by managers and the senior leadership team.

• The service met the characteristics of Good in most areas. More information on our findings is in the full report.

Rating at last inspection: Requires Improvement (Published18 July 2018)

About the service: Enham Care Home Services – William, Michael and Elizabeth are residential care homes that can accommodate up to 60 people. When we inspected it was providing accommodation and personal care to 54 people who had physical and / or learning disabilities.

Why we inspected: This was a scheduled inspection based on the providers previous rating.

Follow up: We will continue to monitor information we receive about the provider until we return as per our re-inspection programme.

The last inspection of this service took place on 4th, 5th and 6th July 2016 and at that time the service was rated as requires improvement.

Enham Trust – Care Home Services (Elizabeth / Michael and William Houses) is a ‘care home’. People in care homes receive accommodation and nursing or 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.

Elizabeth, Michael and William Houses are purpose built care homes which can accommodate up to 60 people. When we inspected there were 56 people living in the three homes. People live in self-contained ‘flats’ all of which have a kitchen area, living room, bedroom and en-suite shower and toilet. There were communal lounges, bathrooms and shower rooms and a large dining area in each of the houses.

The manager of the Care Home Services was in the process of applying to become the registered manager. 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 service was unable to ensure that call bells would be answered in a reasonable amount of time or that the care required by people could be provided when needed.

Changes to staffing had left some people reluctant to use their call bells, others waiting for extended periods for support and at times continence care was missed.

Low levels of legionella bacteria had been detected in the water system of Elizabeth House in late 2017. A risk assessment in January 2017 had identified this risk and a further risk assessment in February 2018 showed that actions had not been taken from the first assessment.

Fire safety procedures did not reflect Enham Trust’s fire safety policy. There were fewer fire drills held than the policy stated there should be.

Fire doors did not provide adequate fire protection, a fire safety report identified that doors should be replaced and current practices around evacuation should be changed immediately. A recent Fire Safety report commissioned by Enham Trust stated that doors should be replaced as soon as possible.

There was no system for people to sign in and out of the buildings this meant that in the event of a fire there was no accurate register of who was in each of the homes.

Medicines were managed safely and people, when possible, were supported to be independent with medicines.

Problems with catering had been dealt with through retaining a new catering provider.

Care plans were clear and covered relevant areas.

There was good use of assistive technologies and communication devices.

Staff were skilled in different communication techniques.

Staff received regular and effective supervisions.

We received a great deal of positive feedback about the quality of the care staff.

The service had, when necessary, supported people with planning for end of life care and will develop this in future as needed.

People accessed on-site day services if built into their care package, there were minimal additional activities provided in the 3 homes for people who did not access day services.

People knew how and to whom to see to make a complaint. Enham Trust dealt appropriately with a complaint during our inspection.

Changes to staffing numbers and structure were not communicated to people or their relatives by the homes management team. Frontline staff had to deliver the message that activities and outings could not go ahead due to having not enough staff.

Though concerns were raised a number of times about the reduction in staff, people had faith in the skills and commitment of the registered manager and head of care.

The acting manager is in the process of applying to become the registered manager. 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.

Enham provides residential care and support for up to 60 people with physical disabilities to live independent lives. The location is split into three separate buildings which include Michael House, Elizabeth House and William House.

The provider did not have robust quality assurance systems in place in order to respond effectively to maintenance requests.

The call bell system used to alert staff when people needed help did not always operate correctly and placed people at risk.

Support, supervisions and appraisals require improvement to ensure staff are provided with good opportunity to develop and to discuss their progress.

People told us that they felt safe. Staff had a good understanding about the signs of abuse and had confidence in their manager to take concerns raised seriously.

People were supported by staff that had the skills and knowledge to meet their assessed needs. Staff received a thorough induction before they started work.

The provider had employed skilled staff and took steps to make sure care was based on local and national best practice. Information regarding diagnosed conditions was documented in people’s files.

Recruitment practices were safe and relevant checks had been completed before staff commenced work. Staff worked within good practice guidelines to ensure people’s care and support promoted good quality of life.

The provider had appropriate arrangements in place to assess people’s capacity to make decisions about their care and treatment. Staff were knowledgeable about the requirements of the Mental Capacity Act 2005. One person was subject to DoLS at the time of our inspection and the acting manager was in the process of making more referrals to the local authority for DoLS assessments.

People who required assistance to eat and drink were supported effectively. Appropriate assessments had been conducted for anyone who had difficulty in swallowing their food. Interactions between staff and people during meals times were respectful and dignified.

Multi-disciplinary teams including mental health workers and occupational health were involved in reviewing and updating people’s risk management plans.

Medicines were managed safely. Any changes to people’s medicines were prescribed by the service’s GP and psychiatrist. People were involved before any intervention or changes to their care and treatment were carried out.

People had access to activities that were important and relevant to them. Records showed people’s hobbies and interests were documented and staff accurately described people’s preferred routines. There was a range of activities available within the home and community.

The provider actively sought, encouraged and supported people’s involvement in the improvement of the service. People’s care and welfare was monitored regularly to make sure their needs were met within a safe environment. The provider had systems in place to regularly assess and monitor the quality of the service provided.

People told us the staff were friendly and management were always visible and approachable. Staff were encouraged to contribute to the improvement of the service. Staff told us they would report any concerns to their manager and said the management and leadership of the service very good and very supportive.

The provider wrote and told us of the improvements they would make. This inspection took place to ensure that these had been completed.

The provider had carried out all the improvements they had identified on the action plan which they had sent to us. These included the publication of a new infection control policy and the appointment of a lead person in infection control. All staff had taken part in training in infection control. Staff we spoke with confirmed that this had been very useful although it was taking time to get used to the new procedures that had been put in place.

We looked at the care records for four people. People had signed to give consent for various aspects of their care and support. Two of the five people we spoke with confirmed that staff respected their wishes and that they could refuse care if they wanted to: 'Staff will stop if I don't want them to do anything.'

Two of the people we spoke with told us that they had a discussion with staff each month about their care and support, what they had done and if they needed to make changes to their support plan. One person told us: 'I am happy with what is in there. We have to update it every month. If I want to say something I can.'

The service had an infection control policy however this was dated 2005 which meant that some of the information it contained was no longer correct. The service was not able to provide us with copies of any infection control audits. By not auditing the infection control procedures they were unable to identify any shortfalls and take action to address these.

One member of staff told us: 'I had to wait until I had the results of my CRB before I could start work.' They went on to tell us about the induction process they went through before providing any care for people.

We were able to track a complaint made to the service. The complaint had been fully investigated drawing the complaint to a satisfactory conclusion.