The Meadows

The Meadows is a residential care home providing personal care and support care to 10 people who have a learning disability and or mental health conditions. The service can support up to 14 people. The Meadows accommodates people in one adapted building. Accommodation is set over two floors with a lift to access the first floor. Communal space is on the ground floor. The home is set back off the road with easy access to the local village.

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

People said they enjoyed living at The Meadows and felt safe. One person said, “I feel safe here as the staff are approachable even the agency staff, feels like a family even more so since the lockdowns.” Another said, “The staff here are a lovely team, some residents say they hate living here but they don’t, they just like to moan.” Two people said they would like to move on. One person told us “I want to move on to somewhere else as I have been here long enough, it’s not that I am unsafe, but I would like to live in Taunton.” One person said they were unhappy with the restrictions placed on them and would like to move. They were being supported with an independent advocate and restrictions were part of their agreed plan and Deprivation of Liberty safeguard process.

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 this practice. Some people had previously lived in more secure settings and through careful person-centred planning were being enabling to lead less restrictive lives.

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 guidance CQC follows 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 are working towards meeting the underpinning principles of Right support, right care, right culture. Although the service is larger than recommended, the use of positive support plans and individualised activities meant people were enabled to follow their interests’ hobbies and passions as far as possible. This had been curtailed by the pandemic and lockdown restrictions. Future planning was taking place to look at development of move on flats on site and developing more communal space so people could choose to be in smaller groups. In addition, people’s needs were being reviewed and two people had moved on to other settings as a result of this. Compatibility of people living together was being reviewed as was the skill mix of staff supporting them. Staff training had been enhanced since the last inspection to enable staff to consider a more person-centred approach for each individual living at The Meadows. Investment in enhancing the environment was ongoing and people were being enabled to influence choice of decoration and how they wished to develop their garden space.

Since the last inspection we found medicines were being managed safely. Risks were being clearly identified, assessed and monitored in a more timely way.

Staff reported there had been a lot more training support and guidance available to them. The team felt positive about the new management team and the direction they were working towards to enable people to live fulfilling lives. Most staff said there had been a definite improvement in staff numbers on shift, in skills and in staff morale.

Work had commenced on improving the environment. For example the entrance hall had been refurbished and people who live at the service had chosen a calming Forrest décor. Some of this work had unfortunately been delayed due to the pandemic and lockdown, but it was clear investment and plans to improve the building and grounds were taking place.

We made one good practice recommendation in respect of medicines.

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 requires improvement (report published 7 May 2020)

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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned focussed inspection based on the previous rating. We looked at the key areas where breaches had been identified.

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 coronavirus and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 11 March 2020. 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 safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. 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 The Meadows on our website at www.cqc.org.uk.

The Meadows residential care home providing personal and support care to 12 people at the time of the inspection. The service can support up to 14 people with learning disabilities and mental health conditions.

The Meadows accommodates people in one adapted building. Accommodation is set over two floors with a lift to access the first floor. Communal space is on the ground floor. The home is set back off the road with easy access to the local village.

The service was registered to provide support to up to 14 people and there were 12 people using the service at the time of our inspection. This service had not been designed taking into account best practice guidance and the principles and values underpinning Registering the Right Support ( RRS) . This was because the service was registered prior to this guidance being issued. The service is larger than recommended by best practice guidance. The RRS 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. This was not being achieved, mainly due to staffing levels and numbers of people living in one building.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons. People were not always happy with who they were living with. Other people’s behaviours impacted significantly on people’s quality of life at times.

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

People were not always kept safe. This was because improvements were still needed in the way people’s medicines were being managed. We also found one risk assessment had not been updated following a significant incident. The registered manager said they had verbally discussed the incident and how they should support the person but their risk assessment was not yet updated but they would give this priority following our feedback.

Improvements were still needed in respect of how the provider ensured quality assurances processes. This included ensuring there was sufficient staff with the right skills for the number and needs of people living at the service. The new registered manager had with the two deputies been trying hard to ensure staff had skills and training. Despite their efforts some staff still lacked the necessary key skills to keep themselves and others safe. We were assured this would be addressed promptly.

The provider had not acted with any urgency to address the need for refurbishment of the building. Other professionals providing feedback following the inspection said the home was tired and in need of some work to ensure it was more homely. We also found some parts of the home in need of a deep clean. One professional said one person’s room was very bare and what furniture was there was of a poor quality. We fed this back to the registered manager at the inspection and they agreed to look into this.

There had been improvements to the way staff were being recruited. The recruitment process was robust and ensured only staff who were checked and seen to be fit to work with people who may be vulnerable, were employed.

People’s plans and risk assessments were being updated in line with best practice. Staff promoted people’s privacy and dignity.

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 had advocates to ensure their best interests wherever possible.

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 requires improvement (published 28 February 2019)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made/ sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We brought forward this comprehensive inspection because we had received a number of concerns from anonymous sources which indicated that there were not always sufficient staff with the right skills; that new staff had been recruited without their full checks and references being in place; people were not always getting the service they had been assessed as needed, and specifically that some people were not being supported to go out into the community. During our inspection we identified some of these concerns were founded.

The Meadows provides care for up to 14 people with a learning disability and associated conditions such as autism and mental health conditions. On the day of our inspection there were 12 people living at the service.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

We checked the service was working in line with ‘Registering the Right Support’, which makes sure services for people with a learning disability and/or autism receive services are developed in line with national policy - including the national plan, building the right support - and best practice. For example, how the service ensured care was personalised, how people’s discharge if needed, was managed and people’s independence and links with their community.

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. This was compromised when staffing levels fell due to staff leaving or staff sickness. This was because people were not always able to go out into the local community as they had been assessed as needed one to one support or two to one support to keep them safe. However the registered manager had tried hard to ensure that people did get to go out for their activity days.

We received information of concern which said there were not always enough staff with the right skills. We also received information from two healthcare professionals who said they were not assured staff always had the right training to keep themselves and people safe. This included breakaway training (safe techniques used when someone presents with challenging behaviours which places themselves and or others at risk). We found there had not always been staff in sufficient numbers and with the right skills. The service was currently dependent on agency staff to fill some gaps. Of three agency staff we spoke with on the second day, none said they had received training in breakaway techniques. We saw a new person had been admitted with high support needs. The staffing rota had not been changed since their arrival despite them being assessed as needing a significant portion of each day in a one to one staff ratio.

Some staff had not been trained in administering rescue medication for people with epilepsy. One staff member confirmed they had not been trained but did take the person out into the community without other trained staff. This placed the person at risk. We gave immediate feedback about this and the registered manager said they would ensure training was sourced as soon as possible.

We received information of concern about new staff starting work before all their references and checks had been received. We found that recruitment practices were not robust and did not fully protect people.

Staff understood about abuse and who they should report any concern to. The registered manager understood their responsibilities to work with commissioners and safeguarding teams to keep people safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare was monitored and actioned when needed. Their nutritional and hydration needs were met to ensure they had a balanced diet.

The service was clean and adapted to suit people’s needs. Some improvements were needed to ensure the environment was refurbished and this was work in progress.

The management approach was open and inclusive. There were and a range of ways used to gain the views of people, relatives and staff.

Audits and checks were established for quality monitoring of the records, the environment and care and support being delivered. However, they failed to identify the areas for improvement that we found during this inspection

We have issued four requirements on health and safety, safe recruitment, good governance and staffing levels. We have also made two recommendations about restraint practices and people being involved in activities of daily living.

Further information is in the detailed findings below.

At the last inspection in May 2015 the service was rated Good.

At this inspection we found the service remained Good.

Why the service is rated good:

The service continued to provide safe care to people. One person commented: “I feel safe here with the staff.” Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service.

People were supported to maintain a balanced diet, which they enjoyed. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

There were effective staff recruitment and selection processes in place. People received effective care and support from staff who were well trained and competent.

The service was caring and people had built strong relationships with each other and staff. People engaged in a wide variety of activities and spent time in the local community going to specific places of interest.

Staff spoke positively about communication and how the registered manager worked well with them and encouraged their professional development.

A number of methods were used to assess the quality and safety of the service people received and made continuous improvements in response to their findings.

People commented: 'I love the staff', 'I can't eat pork, so I'm given alternatives' and 'I'm really happy here.'

Staff demonstrated a good understanding of people's individual needs. Care plans reflected people's preferences and showed people were given choices.

Staff confirmed they felt they had sufficient staffing numbers to meet people's needs. We saw staffing rota's which demonstrated staff had the right knowledge, skills and experience to support people.

Staff stated they were well supported, their training needs were met. All staff felt they were competent to carry out their role.

We saw evidence that The Meadows had systems in place to monitor the quality of the service people received. They had appropriate arrangements in place to ensure it recorded and evaluated the information it gathered. This enabled The Meadows to manage risk and deliver safe and effective care.

We saw that all records were kept securely, were accurate and remained confidential.

You can see our judgements on the front page of this report.

We spoke with three people living at the home, spent time observing the care people were receiving, spoke to six members of staff, which included the unregistered manager and looked at two people's care files in detail.

People commented: 'I am happy here and the staff look after me'; 'I am going shopping this afternoon' and 'I have been able to choose my key workers and I get on well with them.'

Staff confirmed that people's needs were met in a timely manner and felt that on the whole there were sufficient staffing numbers. We observed this during our visit when people needed personal care support or wanted to participate in particular activities.

Debriefing sessions were now in place and staff supervisions were started on 7 October 2013, with these to be scheduled on a six weekly basis and appraisals to be completed on a six monthly basis. We saw evidence of debriefing sessions and supervision taking place which covered any difficulties being experienced, support needs and future training needs.

We spent time talking to people who lived at The Meadows and observing the interactions between them and staff. Comments included: 'I have been here 6 or 7 years. It is very nice' and 'I like living here. Female staff help me with personal care.'

Staff demonstrated a good understanding of what kinds of things might constitute abuse, and knew where they should go to report any suspicions they may have.

Staff informed us that they did not receive regular supervision, appraisals and debriefing sessions in order for them to feel supported in their roles and to attend to future professional development.

Our inspection raised concerns about the management and leadership of The Meadows, lack of staff support and guidance, record keeping issues and access to care files for staff to refer to. We spoke with the new manager and the provider about our concerns. They both explained that the new manager's appointment was due to recognising concerns about the running of the service. The new manager was very clear about why they had been appointed and their roles and responsibilities to assure the quality and safety of The Meadows.

People told us the staff were helpful. They told us about places they had been and things they had been doing. One person said it was too noisy in the home. Staff told us they were changing shared spaces within the home to provide a quiet room and a second television lounge.

The registered manager was not working in the home at the time of this visit and an interim manager had been appointed very recently. Health and social care professionals were involved within the home giving guidance on care planning and behaviour management and providing staff training. Staff had many ideas about activities they could introduce to enrich people's lives. We found there was a clear need for leadership, to ensure that the professional guidance and the good ideas of the staff were put into practice and supported.