Walnut House

Walnut House is a residential care home providing personal care to 4 people at the time of the inspection. The service provides support to people with a learning disability and or autistic people. Walnut House is a house, with bedrooms across the ground and first floor, and shared facilities for people to use.

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.

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

Right Support: Some improvements had been made to the care environment since our last inspection, whilst other areas still required further development at the time of our visit. Following our inspection, additional works were completed to improve the living experience of those being supported. Care plans were under review prior and following our inspection, we did however identify gaps in required information which the provider was taking appropriate steps to improve.

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.

Right Care: People were observed making their own choices over both days of our inspection visits and staff listened to people’s direction and followed their wishes. We continued to identify gaps in mandatory training of staff during our inspection, which poses a risk that staff may not have the required knowledge to keep people safe and ensure all staff were consistently promoting choices. Care records offered little involvement in their implementation of people, although monthly keyworker reviews alongside the person had been newly implemented.

Right Culture: The provider was currently implementing a change of senior structure within the organisation to improve oversight and timely action taken where areas of concern are identified. These roles were still being established at the time of our inspection. Our inspection highlighted that audits that had been completed, prior to these new roles being implemented, had not led to timely changes being made within the service. Although some improvements had been made since our last inspection additional input from the provider was still required to ensure people’s needs were fully met.

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 25 January 2023).

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 some improvements had been made but the provider remained in breach of regulations.

At our last inspection we recommended that improvements were made to monitoring and reviewing people’s MCA and DoLS applications. At this inspection, we found improvements had been made in this area and the registered manager was able to explain reasons for all applications made.

The last rating for this service was inadequate (published 25 January 2023). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Exiting special measures

This service has been in Special Measures since 04 January 2023. 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

We carried out an unannounced focused inspection of this service on 29 November 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the safe care and treatment of people, staffing and good governance of the service.

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.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements and to ensure the warning notice we served in relation to regulation 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 inadequate to requires improvement. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to care records in the service not being fit for purpose at the time of inspection and timely action and meaningful audits had not been taking place 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Walnut House is a residential care home providing care and support to four people. The service provides support to people with a learning disabilities and or autistic people. At the time of our inspection the service was fully occupied. Walnut House is a house, with bedrooms across the ground and first floor, and shared facilities for people to use. Access to the service was via a side gate, attached to another location under the same provider.

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

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. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right support: The condition of the care environment was poor. This did not demonstrate value placed on the care experienced by people. Care records did not demonstrate people were involved in the development of these documents, or that their individual wishes and preferences were consistently reflected. People’s dignity, privacy and human rights were not being consistently upheld, particularly in relation to the implementation of the Mental Capacity Act (2005). 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. Gaps in staff training did not ensure staff had the necessary skills, knowledge and expertise to safely meet people’s needs.

Right care: People were not always supported to have maximum choice and control of their lives. 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. Gaps in staff training did not ensure staff had the necessary skills, knowledge and expertise to safely meet people’s needs. Care records did not demonstrate people were involved in the development of these documents, or that their individual wishes and preferences were consistently reflected.

Right culture: Members of the provider team visited the service but did not complete meaningful reviews to support ongoing improvement of the service. Inspection findings highlighted that where shortfalls were being identified, timely action was not being taken to address these and make improvements to the quality of people’s care or the condition of the care environment. The provider was unable to demonstrate their own plans for the implementation of Right Support, Right Care, Right Culture and associated specialist training into their ways of working and service provision. Overall, there has been a deterioration in the service’s rating, and breaches of the regulations were identified.

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 26 July 2019.

Why we inspected

This inspection was carried out because of concerns identified about two other locations under this provider. 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.

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

Enforcement and Recommendations

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.

Follow up

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

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.

Walnut House is a residential care home providing personal care to four people with a learning

disability and a primary diagnosis of autism. The service can support up to five people. Walnut House is located within the grounds of another care home run by the provider. The building is owned by a local housing association who have responsibility for the maintenance of the building. Bedrooms are situated on both the ground and first floor. A sleep-in room for staff is provided on the first floor and a staff office is located on the ground floor. People share two bathrooms, a kitchen and living room.

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. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

Written risk assessments did not always fully analyse identified risks, however staff identified risks in practice and worked collaboratively with others to minimise these. We identified some minor issues with the storage and recording of some medicines which were immediately rectified and did not impact on people receiving their medicines as required. Staff worked with people to keep the environment clean and tidy. Some areas of the service, such as the kitchen and bathroom, would benefit from updating. The service was acting to raise and discuss this with the organisation that owned the building. People were supported by consistent and familiar staff. There were enough staff to meet people’s needs safely.

Staff worked with the provider’s own speech and language therapist and positive behaviour support lead. This helped ensure the support provided met best practice guidance and people’s individual needs. The service specialised in supporting people with autism. Relatives told us this was reassuring and had provided better outcomes for people. Staff spoke positively of the training provided and the provider ensured staff had the support and knowledge required. People were supported to lead healthy lives through the support of staff to eat well, exercise, and access healthcare services. 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 and staff had close relationships. Staff knew people well and this helped ensure people were comfortable discussing their care. Staff were kind, caring, and respectful. They valued people’s individual uniqueness. People were supported to be independent.They worked alongside staff with day to day domestic tasks to help develop their daily living skills and self-worth.

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. Staff supported people’s ability to choose and have control over how they spent their day and the activities they wished to participate in. Activities were varied and supported each person’s individual interests and hobbies. 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. Staff supported and valued people’s relationships.

No complaints regarding the service had been made. Relatives told us they had never needed to make a complaint but would feel comfortable to do so if required. Information was presented in a manner that was individual to each person’s communication needs. No one in the service was receiving end of life care, however we have recommended that the service consider how they support people with end of life care.

People and relatives were happy with the quality of the service provided. There was a homely friendly and calm atmosphere. The service had an inclusive approach and supported people to be involved in decisions about the service, such as the staff team. Staff worked together as a team and morale was high. Systems were in place to monitor and sustain the quality of the service. The management team sought and engaged in additional opportunities for learning and developing the service through networking and participating in external training and events.

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 Good (report published 08 October 2016).

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.

Walnut House is a care home for adults with learning disabilities or autistic spectrum disorder. The home can accommodate up to five people. The home has a communal lounge and dining room and people who use the service each have their own bedroom and bathroom. At the time of our visit four people were living at the home.

The home 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.

Staff told us they worked as part of a team, that the home was a good place to work and staff were committed to providing care that was centred on people's individual needs. There was a strong caring culture in the care and support team.

Staff received the training they needed to deliver a high standard of care. They told us that they received a lot of good quality training that was relevant to their job. Everyone we spoke with including people's relatives and staff said people received individualised care in relation to all of their needs. They said the service provided good quality, specialist care for people.

There were effective systems in place to manage risks, safeguarding and medication, and this made sure people were kept safe. Where people displayed behaviour that some people may view as challenging there was training and guidance given to staff. This helped them to manage situations in a consistent and positive way, and protected people's dignity and rights.

People received care and support that was responsive to their needs. Care plans provided detailed information about people so staff knew exactly how they wished to be supported. People were at the forefront of the service and encouraged to develop and maintain their independence. People participated in a wide and varied range of activities. Regular outings were organised and people were encouraged to pursue their interests and hobbies.

The staff recruited had the right values and skills to work with people who used the service. Staffing levels remained at the levels required to make sure every person's needs were met and helped to keep people safe.

Systems were in place which continuously assessed and monitored the quality of the service, including obtaining feedback from people who used the service and their relatives. Systems for recording and managing complaints, safeguarding concerns, incidents and accidents were managed well. The management took steps to learn from such events and put measures in place. This meant that lessons were learnt and similar incidents were less likely to happen again.

Below is a summary of what we found.

If you wish to see the evidence that supports our summary please read the full report.

Is the service safe?

We saw that recruitment practice was safe and thorough. Staff told us they enjoyed their work and were appropriately trained. Staff demonstrated that they understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

We saw that Walnut House was clean and tidy and staff understood their role with regard to infection control. The provider told us that improvements would be made to their cleaning records to ensure that they could demonstrate when tasks were undertaken.

Is the service effective?

We observed good relationships between staff and people who used the service. Staff we spoke with demonstrated they understood how to meet people's individual needs. Care plans were up to date and provided detailed information on how people wished to be supported. People told us they liked living at Walnut House.

Is the service caring?

We saw that people were supported by staff who were kind and respectful. One person commented, 'The staff are very kind.' Care records contained information about people's preferences and it was clear that people had been involved in planning their care. One relative told us, 'X is incredibly happy at Walnut House. It's like home from home.'

Is the service responsive?

We saw that support was provided in a way that was intended to ensure people's safety and welfare. Risk assessments were reviewed and updated regularly to ensure that people were able to access activities of their choice. A relative told us, 'We are kept informed about doctor's appointments and medication. We attend an annual review.'

Is the service well led?

The provider had a number of systems in place to ensure that the quality of the service was regularly assessed. For example, relatives and people who used the service were regularly asked for their views. Monthly quality checks took place and covered a wide range of areas. There was evidence that the provider took action to improve the service when this was required.

We reviewed one set of individual care records. This demonstrated that individual needs were recorded and were met in line with their assessed need. This meant that people experienced care, treatment and support that met their needs and protected their rights.

People told us that they enjoyed the food provided, went food shopping each week with staff and helped with preparing meals and other kitchen tasks around this service. This demonstrated to us that people were protected from the risks of inadequate nutrition and dehydration.

The staff spoken with confirmed that they had received updated training in the management of medicines. This demonstrated to us that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Staff received induction, on-going training and supervision This showed us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The service was audited monthly and we noted that any actions arising had been addressed. This meant that the provider had an effective system to regularly assess and monitor the quality of service provided.

At that inspection, Walnut House did not have policies and procedures in relation to the medication process it had in place. We found that medication stock had not been accounted for and that no controlled drug procedures were in place.

The purpose of this inspection, carried out on 01 February 2013, was to ensure that the necessary improvements had been made. We found that they had.

We observed staff interactions during the evening and saw that staff spoke to people in a kind and respectful manner. We saw that staff gave people time to respond to questions and encouraged people to take part in activities such as the preparation of dinner.

However, when we asked to be provided with written policies and/or procedures in relation to the medication practices in the home, we could only be provided with a procedure for the administration of medication. We found no guidance available to describe the practices for stock control and management, recording, handling or disposal of medications.

We found that appropriate recruitment and selection process were in place and that staff were appropriately skilled to carry out their roles.

People's personal records including medical records were accurate and fit for purpose.