Archived: Dorset Learning Disability Service - 4 Romulus Close

Dorset Learning Disability Service - 4 Romulus Close is a small residential home providing personal care to four people with learning difficulties, autism and mental health needs. At the time of the inspection there were four people living at the service.

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

People were supported by staff who knew them well and were committed to enabling them to live fulfilled lives. People received support that was relaxed and natural and we observed care and respect between everyone living and working in the home.

There were enough staff and they were deployed to meet people’s needs. Staff had received training and support to work in less restrictive ways and were positive about the impact of these changes on the lives of people they supported.

People were supported by staff who understood the risks they faced and how best to reduce these risks. They were confident that any concerns they had about a person’s welfare would be acted on.

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.

Staff contacted health professionals when required and worked closely with social care professionals to ensure good, safe care.

People lived in a home that was kept clean and infection prevention and control measures were in place to reduce the risks associated with Covid-19. Staff wore their PPE appropriately.

There had been a sustained period of management change. However, staff felt supported and understood their roles. The systems in place to monitor the quality and safety of the service were robust and action plans had been effective in improving the support people received.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

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

Right support:

• The layout of the home supported people to live independently and make decisions about their lives. Staff supported people to live lives that were fulfilling.

Right care:

• The care provided was person-centred and promoted people’s dignity, privacy and upheld their human rights.

Right culture:

• The values, attitudes and resultant behaviours of senior staff and the staff supporting people ensured people living in the home were leading more empowered lives within their communities.

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

At the last five domain inspection of the service (published January 2020) there had been a deterioration in the rating for four key questions. ‘Is the service safe?’, ‘Is the service effective?’ and ‘Is the service caring?’ had changed from good to requires improvement. The key question ‘Is the service well led?’ had deteriorated from requires improvement to inadequate.

We undertook a targeted inspection (published September 2020) in response to concerns identified through monitoring calls with the manager of the service. We found some improvements at this inspection. A targeted inspection does not provide a new rating.

At this inspection we found improvements had been made. The service was no longer in breach of regulation.

Why we inspected

We carried out a comprehensive inspection of this service in December 2019 (published January 2020). Breaches of legal requirements were found. We took enforcement action that required the provider to report to us about improvements made. We undertook this 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 until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Dorset Learning Disability Service – 4 Romulus Close (Known as Romulus Close) is a residential care home registered to provide personal care to up to 4 people. There were 3 people with learning disabilities living there, when we visited. The home is in a residential area of Dorchester.

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

People were supported by staff who cared about them and knew them well. Staffing levels had not always been sufficient during the COVID-19 restrictions. This had been addressed and we were assured it could not be repeated.

Incidents had not all been reported appropriately. This meant that they had not been reviewed to determine the impact on other people and whether any other statutory agency needed to be notified. Staff had understood the signs of abuse and felt confident any safeguarding concerns they reported were listened and responded to.

People’s risk assessments and care plans provided information for staff about how to safely care for each person. Staff were confident in their understanding of how to mitigate risks.

Quality monitoring systems were being embedded to ensure that people’s care plans and risk assessments would reflect any changes to their needs. We were assured by a representative of the provider that they were focussed on ensuring these systems were effective. They explained their work had been restructured to enable them to carry out this work effectively.

People’s views were considered, and staff felt confident in advocating on their behalf. Relatives and people’s legal representatives were consulted about care.

The provider was working to improve communication with statutory agencies and other interested parties. Professionals working directly with people in the home described positive working relationships with staff.

The service was clean and free from odours. Staff were wearing face masks and following Covid 19 government guidance to minimise risks to people.

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. (report published March 2020).

Why we inspected

This targeted inspection was prompted to review areas of concern that had been identified during discussions with the management of the service during the period of coronavirus lockdown. These issues had been monitored and communication with the provider indicated that they were being addressed. The inspection was timed to ensure the impact of the newly appointed mentors supporting staff in the service could be reviewed.

As part of CQC’s response to the coronavirus pandemic we are conducting a thematic review of infection control and prevention measures in care homes. This targeted inspection also looked at the infection control and prevention measures the provider has in place.

CQC have introduced targeted inspections to follow up on specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We found no evidence during this inspection that people had been harmed or remained at risk of harm from these concerns. Please see the Safe and Well Led sections of this full report.

Follow up: We will work alongside the provider and local authority to monitor progress. The provider will continue to provide monthly reports to CQC as outlined in the conditions imposed on their registration. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will continue to receive monthly reports from the provider outlining the improvements being made to improve the standards of quality and safety.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dorset Learning Disability Service – 4 Romulus Close on our website at www.cqc.org.uk

Dorset Learning Disability Service - 4 Romulus Close is a small residential home providing personal care to four people with learning difficulties, autism and mental health needs. At the time of the inspection there were three people living at the service.

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

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

The service didn’t always 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. We found some examples of choice and control being restricted.

At the last inspection the service was rated as requires improvement overall. The overall rating as remained as requires improvement, however there has been a deterioration in the rating for four key questions. ‘Is the service safe?’, ‘Is the service effective?’ and ‘Is the service caring?’ have changed from good to requires improvement. The key question ‘Is the service well led?’ has decreased from requires improvement to inadequate.

We found multiple breaches of regulations. This showed that the provider had been unable to make or sustain the improvements required at the service to ensure people receive safe, effective and high quality care.

People's safety had been placed at risk due to safeguarding not always being given sufficient priority, to ensure people remained safe. For example, when people experienced or were at risk of harm, action was not taken quickly to inform the relevant authorities.

The provider had not assessed and managed risk, which placed people at risk of harm. Some people's nutritional and hydration needs had not been fully assessed when risk occurred. Following one person having an episode of choking, measures had not been taken by the provider to reduce the risk with immediate effect.

There were not always enough staff on duty to meet people's needs safely. However, following our inspection, the provider increased the staffing levels at the service to ensure people’s needs could be safely met. Staff knew people well and had developed meaningful relationships with them.

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 always support this practice. There was no evidence that less restrictive options had been considered when managing people’s freedom of movement at the service.

Staff contacted health professionals when required. Staff we spoke with were knowledgeable about the support needs of people they worked with. Staff worked closely with social workers and learning disability nurses.

There was inconsistent management support and lack of governance at the service. This meant there was a risk that systems in place to monitor the quality and safety of the service were ineffective. Following their compliance audit the senior team requested a review of care for all people living at the service.

Following our last inspection, the provider had taken steps to provide information in an accessible format for people. Key policies such as complaints, and care plans were available in an accessible format. Some people using the service were able to sign. Staff informed us they had not received any training in regards sign language, although they were able to understand people well.

People were observed receiving kind and caring support. They had effective caring relationships with staff. Staff could explain how different support worked for different people.

The last rating for this service was requires improvement (published 01 January 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

We identified five breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment and good governance. We also identified a breach of Regulation 15 of the Care Quality Commission (Registration) Regulations.

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

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, caring, responsive and well led sections of this full report.

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.

People were supported by staff who knew them well, however, people did not have access to communication aids that would promote their knowledge and independence. At the time of the inspection people did not have routine and structure to their day. People had sensory impairments or were living with autism, which meant it was important for them to have structure to their day and information which informed them of the what day it was and what the events of the day were going to be.

Staff although kind in their approach to people were focused on task related activities such as cooking, cleaning and supporting people with eating their meals where this was required and personal care tasks.

People’s privacy, dignity and independence were respected and promoted by staff. Although kind in their approach to people, staff were focused on task related activities such as cooking, cleaning and supporting people with eating their meals where this was required and personal care tasks. Staff responded promptly to people’s requests for assistance and regularly checked whether people were happy and comfortable.

People received help with their medicines from staff who were trained to safely support them and who made sure they had their medicine when they needed it. When errors occurred, staff were supported to reflect and learn from their mistake.

People were supported by staff who had undergone an induction programme which gave them the basic skills to care for people effectively. Training certificates in staff files confirmed the training staff had undertaken, which included safeguarding of vulnerable adults, manual handling, infection control and the Mental Capacity Act 2005 (MCA).

The requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was being met. Where people had restriction on their choices, best interest decision making processes were in place. People were consulted on decision in regards restriction on their movements with the support of advocates, relatives or health professionals.

People's risk of abuse was reduced as the provider had a suitable recruitment processes in place. Although there were sufficient staff to meet people’s care needs, staff felt they were unable to support people in their preferred activities as much as they would like. The registered manager informed us additional funding was being sought.

People were protected by the prevention and control of infection by staff who had received the appropriate training. The service had a comprehensive range of health and safety policies and procedures to keep people safe and each person had an emergency evacuation plan in place.

To ensure the environment for people was kept safe specialist contractors were commissioned to carry out fire, gas, water and electrical safety checks.

Care staff prepared and cooked meals. Staff told us they asked people what they wished to eat and then prepared their dinners. We observed the lunch time meal, people were not involved in supporting staff to prepare their meals or setting the tables.

The service had a complaints policy and procedure which was available for people and visitors to view in the home. Although the provider had an easy read version of their complaints procedure, this was not visible for people to see around the home. People had access to external health professionals. Where people's health needs had changed, staff worked closely with other health professionals to ensure they received support to meet their needs

Quality assurance systems were in place to monitor the quality of the service and audits took place. However, these audits were not always effective in identifying some of the issues found during our inspection.

The service had a 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.

When we last inspected the service in December 2013, we had concerns that people were not protected from the risk of inappropriate care because peoples care plans had not been changed to identify peoples risks and because accurate review records were not maintained. We asked the provider to take action about these concerns and they sent us a plan detailing that they would have addressed them all by August 2014. At this inspection we found that improvements had been made.

There were enough staff at the service to keep people safe, but the home had vacancies and was sometimes running on minimum staff numbers. People were supported with a range of activities and were not impacted by the staffing levels, however it meant that unplanned activities might not have been possible on some occasions.

People were protected from avoidable harm by staff who knew them well and understood the risks they faced. Risk assessments were comprehensive and focussed on supporting people to be as independent as possible whilst supporting their behaviours and managing their individual risks. Staff were recruited following appropriate pre-employment checks and received appropriate training for their role.

People were supported to live in a safe environment because fire safety, building and equipment checks were carried out regularly and any issues were recorded and actioned.

People received their medicines as prescribed and we saw that they were stored safely and recording was accurate and regularly audited.

Staff had daily contact with the registered manager and were encouraged to speak with them whenever they needed to. More formal supervisions for staff were being scheduled but were overdue and the registered manager was aware and managing this.

People were supported to make decisions or to be involved in best interests decisions where they were unable to make decisions for themselves. Staff understood the relevant legislation around this and records were robust.

Staff understood how to offer people choice and we saw that people were involved in choices about all aspects of their support in ways they were able to understand.

People were supported by staff in a way which was kind and respectful. Rapport between people and staff was good and there was a relaxed atmosphere at the home. Staff ensured that they were mindful about how to maintain peoples privacy and dignity.

Relatives were regularly contacted to discuss any issues and were involved in reviews of their relatives care. Records were person centred and detailed, they gave histories of the people living at the home and focussed on what people liked and what their interests were.

Relatives and health professionals who visited the service felt welcomed and that staff were caring and supporting peoples needs well. They also felt that the home was well managed and had regular contact with the staff and registered manager.

There had been some corporate changes made which were not all viewed positively. Staff told us about the impacts both on people who lived at the service, and also on staff. The registered manager was aware of these and in the process of feeding them back at management level.

There was an open culture at the service and staff were clear about their roles and responsibilities. The registered manager encouraged staff to tell them about ideas and they had plans for how to further develop the service.

During our visit we spoke with one person who lives in the service. We also spoke to the relatives of two people who live in the service. We were unable to speak with other people who live in the service due to their complex needs.

People's relatives told us that they felt positive about the quality of care people received; and with their families relationships with the staff. We observed residents interacting with the staff in a relaxed way.

People's relatives told us that they were asked for their consent when making choices and decisions about their daily lives; and that people's choices and decisions were respected by the staff. A person's relative told us, 'The care is very good."

The home had procedures in place to ensure that people received their medicines as prescribed. Medicines were handled in a secure way.

We found that there were sufficient numbers of staff, with the right competencies.

People benefitted from safe care. However, the service was not consistently monitoring the management of risks to people's welfare and safety.

We found that people's personal records were not appropriately maintained.

We used a number of different methods to help us understand the experiences of people using the service. This was because the people using the service had limited speech and difficulties with communication related to their disability. We observed people in their day to day environment and spoke to some of their relatives. We gathered evidence from the care records and talking to staff.

We observed people being treated with respect and kindness by staff and that people appeared happy and relaxed. We saw that people were encouraged to participate in activities outside their home in the local community and to socialise with others. People were assisted with transportation in an adapted vehicle for sole use by the people who lived there.

The care record showed that assessments had been carried out and this information was kept in the home to assist staff in planning and delivering care.We found that staff worked as a team to deliver the service and were well supported by training and supervision. The involvement of relatives was supported and encouraged where possible.

Safeguarding procedures were in place and appropriate actions were put in place to address the concerns. There was evidence that learning from incidents took place and appropriate changes were implemented.