Martha House

Martha House is a residential care home, providing nursing care, for adults with learning disabilities, autistic spectrum disorder and physical disability. Most people living at the service had profound conditions, complex care needs and were unable to communicate verbally.

There are two houses on site, Martha House and Frances House, both houses were included in our inspection. The site, including both of the houses are registered with CQC under one location name, Martha House.

At the time of our inspection, there were 14 people living in Martha house and eight people living in Frances house. There was a vacant room in Martha House in which people stayed for respite care. Both houses were purpose built, they provided accommodation for people on the ground floor, they were spacious, well equipped and welcoming. The site included a specialty activity suite with a hydrotherapy pool, a quieter area equipped with touchscreen televisions and specialist eye gaze equipment. Eye gaze is a system which enables some people to communicate by tracking their eye movement. There was also a communal area used for some events and social activities.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. Martha House was designed, built and registered before the guidance was published. The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 23 people and 22 people were using the service. This is larger than current best practice guidance.

However, as to the size of the service having a negative impact on people, this was mitigated by the building design fitting into the residential area and the other domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, visible industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

While the design of the service did not meet current guidance, the service had however applied the principles and values of Registering the Right Support and other best practice guidance. This ensured 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 participation within the local community was encouraged and enabled.

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

People were supported to stay safe, relatives told us they did not have any concerns about the support people received. They were, without exception, very complimentary about the service, its staff and management as well as the support people received. Relatives we spoke with told us they found the staff were, “Exceptionally caring.”

Peoples needs were assessed before they moved to the service and further assessments were completed to ensure changing needs were met. Risks to people’s health, safety and welfare were assessed, identified and regularly reviewed. Accidents and incidents were recorded, analysed and used to inform learning to reduce the risk of reoccurrence.

There were enough staff to meet people's needs. Staff had a good knowledge of people’s support and communication needs. Medicines were managed safely, all staff administering medicines were trained and competency checked to ensure mistakes were minimised. Staff understood how to recognise abuse and the processes to follow should they have any concerns.

People’s capacity to make specific decisions was assessed and, where needed, best interest decisions were made with the involvement of other relevant parties. 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.

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. This was included in people’s care plans and reflected in the service’s policies.

We observed people being encouraged and supported to make their own choices and decisions. Some people choose their own food and drink and staff knew how to support people with specific eating and drinking requirements. Staff were trained and knowledgeable about their roles. People were supported to remain well and healthy and had access to external health care professionals.

People’s privacy and dignity was respected, people were encouraged to be as independent as possible. People’s diversities were considered and respected. Staff spoke to people in a kind and considerate way, people appeared relaxed and confident in their home.

Care plans reflected people’s needs and choices, guidance was clear and followed by staff so people received support in a consistent way. Relatives were involved in people’s care and their input into the running of the service was encouraged. People took part in a wide range of activities; staff were sensitive to the fragility of some people’s conditions and facilitated outings for family members to spend quality time with people.

People’s communication needs were assessed, staff knew how to communicate with people in meaningful ways and the service was equipped with specialized equipment to facilitate this. A complaints procedure described how people could make a complaint or raise a concern, an easy read, eyegaze and screen touch version was available. Some complaints had been received since the last inspection. These were logged and responded to in line with the provider’s policy; apologies were made when needed and all complaints were reviewed to inform learning.

There was an open and inclusive culture in the service. The registered manager and provider encouraged people, relatives and staff to feedback on any areas for change, so the service could improve. Staff felt valued and well supported, performance evaluation was robust. Auditing had identified any areas of concern and action was taken in response to this.

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 13 February 2019) and there were three breaches of regulation. 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 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.

Martha House is a residential care home for up to 23 adults with a learning disability. There are two houses on the site Martha House and Frances House, both houses were included in this inspection and are registered with CQC under the name of Martha House. There were 13 people living in Martha house and 8 people in Frances house at the time of inspection. The houses were both single level. There is an activity centre on the site which included a hydrotherapy pool. Martha House is a ‘care home’. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care service had 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.

At the last inspection on 5 and 6 October 2017 the service was rated overall as requires improvement. Following this we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive, effective and well-led to at least good. At this inspection we found that the rating remained requires improvement. This is the second consecutive time the service has been rated Requires Improvement.

There was no registered manager at the service. 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. At the time of the inspection the registered manager had left the service but had not yet de-registered. The service told us that the director of operations intended to register as the manager. However, the application had not been received at the time of the inspection.

At the previous inspection we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to assess all risks and did not have sufficient guidance for staff to follow to show how risks were mitigated when managing health conditions and health and safety. Also, the provider had failed to protect people from the unsafe management and administration of medicines. At this inspection we found that risks to people had been assessed. However, where mitigations were in place these were not always monitored. Care plans were updated but the service was in the process of transitioning from paper to electronic care plans and the paper records were not always up to date but were still being used by staff. There continued to be concerns relating to the safe management of medicines. Medicines were not checked in to the service quickly and were not always available when people needed them. Further improvements were needed to be made and the service remained in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the previous inspection we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The systems in place to check the quality of the care being provided were not effective. Records were not accurate and up to date. At this inspection we found that whilst the electronic care plans were up to date the paper care plans were not and the service was still using both to provide care to people. There was a system of auditing in place, but these checks had not identified the issues we found at this inspection. For example, paper care plans were not being regularly updated and staff were not recording fluid intake in a consistent manner. Further improvements were needed to be made and the service remained in breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. The provider had failed to make sure that notifications were submitted to CQC when there was a notifiable event.

The service was in the process of improving the prevention and control of infection. An audit had been completed and the actions identified were being undertaken but had not yet been completed.

We made a recommendation about this. People were protected from risks in the environment such as the risks from fire. Staff continued to carry out regular health and safety checks of the environment to make sure it was safe. The premises were suitable for people’s needs.

When things went wrong lessons were learnt and improvements were made. Information was analysed for trends and where these were identified the service had taken action.

People were protected from abuse. Staff had undertaken safeguarding training and knew how to identify and report concerns. Where concerns were raised these were investigated and action was taken. However, safeguarding concerns were not always reported to the local authority and CQC when they needed to be.

There were enough staff to keep people safe. The service was using agency staff as there were vacancies at the service. The service was actively recruiting and interviewing new staff at the time of the inspection. Staff were recruited safely, and the necessary pre-employment checks were carried out such as checking references.

Before people moved in to the service or came for a period of respite an assessment of their needs had been completed. The information from the assessment was used to develop a care plan for the person and assess staffing levels. People’s support plans were personalised and were based on their needs and choices.

Staff had the training, skills and knowledge they needed to support people. When new staff joined the service, they completed an induction which included undertaking mandatory training and shadowing more experienced members of staff. Staff received appropriate levels of supervision, their competency was checked and there were annual appraisals. Staff told us that they felt well supported.

People were supported with eating and drinking. When people did not like the food offered they were provided with an alternative. Where people were at risk of choking they had been referred to the speech and language team (SaLT) for an assessment of their swallow so that the service had information on how people could best be supported to eat safely.

Staff worked together to support each other to deliver effective care. Where people needed access to health care this was provided. There was information for people to take to hospital with them where this was needed.

Staff worked within the principles of the Mental Capacity Act 2005 (MCA). Best interest’s meetings were held where people needed support to make decisions. People were offered day to day choices where they were able to express a preference.

Staff treated people with kindness and compassion. People were treated with dignity and their privacy was respected. Records relating to people and their needs were kept securely. The service was introducing technology to improve communication and develop ways to support people to express their views. People had access to activities and we saw that people participated in a range of activities which they enjoyed. Relatives were free to visit. There were plans in place for the end of people’s lives and these were being developed further.

When the service had received complaints, we saw that these had been analysed and acted upon and changes were made to the service.

The service had a clear vision for the future and had development plans in place to enable them to work towards this. Relatives, staff and professionals were invited to provide feedback annually via questionnaires. Where comments had been made or feedback was not always positive an action plan had been developed to make improvements. The service worked in partnership with other organisations to develop best practice and share information with others. The provider had clearly displayed their rating at the service and on their website.

During this inspection we found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. We also found one breach of the Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report. 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.

Martha House provides nursing and personal care and accommodation for up to 23 young adults with profound and multiple learning and physical disabilities. There were 20 people living at the service and one person on respite care during the inspection. There were two buildings in the service Martha House and Frances House. Both premises are arranged over one floor, containing bedrooms, communal lounges and dining areas. All of the bedrooms are spacious, with hoist systems in place. The shared toilets and bathrooms are spacious, with hoist systems in place. There is parking available on site, and there are other facilities in the complex, including a hydrotherapy pool.

There was no registered manager in post. An acting manager had been appointed recently and was leading the service. They had not yet applied to be registered with CQC. A registered manager is a person who has registered with the Care Quality Commission (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 were supported during the inspection by the manager, deputy managers- one based in each house and clerical staff.

Potential risks to people’s health and welfare had not been consistently identified. Risks that had been identified did not always have detailed guidance for staff to manage risk safely. This led to a risk of people not receiving support that was safe and effective. Accidents and incidents had been recorded and investigated to look for patterns to help prevent them from happening again.

Staff received training appropriate to their role. Checks on the environment had been completed but shortfalls had not always been identified and rectified to keep people safe.

People were not protected from the unsafe management of medicines. People did not always receive their medicines when they needed them. Medicines were not recorded or managed safely. Before the inspection, medicines errors had been identified that put people’s health and welfare at risk. The provider had taken action however, shortfalls were found at this inspection.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires, that as far as possible, people make their own decisions and are helped to do so when needed. When they lack the mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Staff sought consent from people before providing support. However, senior staff had not followed the principles of MCA when making decisions about people’s care and support. Decisions such as the use of bedrails had not been consistently recorded in line with the guidelines of MCA and not all decisions that people were unable to make on a day to day basis had been considered and recorded.

Staff had not received one to one supervisions in line with the provider’s policy. Staff told us that they felt supported by the deputy managers but there were mixed views on the overall communication within the service. Some staff and relatives felt that the communication could be better and there was not an open culture, others were very happy and felt that they were kept informed.

There were plans in place for monitoring the quality of the service. Audits completed by staff at the service were not effective and had not identified the shortfalls found at this inspection. The provider told us that they completed audits every six months but these had not been completed since May 2016.

Each person had a care plan that had information about the person’s life and preferences. The care plans did not always contain details for staff to give person centred support, were not up to date and had not been consistently reviewed. The service employed agency staff on a regular basis and there was a risk that without clear up to date care plans, people would not receive support as they preferred. Records were not all accurate and up to date.

Relatives told us that staff genuinely cared about the people they supported. People seemed to be happy and relaxed with staff and enjoyed being each other’s company.

Staff knew how to keep people safe from abuse. The management team raised safeguarding alerts when required, but there had been a delay in raising one alert. Services that provide health and social care to people are required to inform CQC of important events that happen in the service. CQC check that appropriate action had been taken. The management team had submitted notifications.

Staff were recruited safely. There were mixed views about whether there were sufficient staff on duty. Some staff told us that the need for one to one support for some people and staff sickness meant at times staffing was stretched. The manager told us that they reviewed staffing according to people’s needs. During the inspection there were sufficient staff on duty.

Before the inspection, concerns were raised that people had not been referred to health professionals as quickly as they should have been. Records showed that people had been referred to healthcare professionals promptly when needed. People were supported to eat and drink to maintain good health. People who were unable to take nutrition orally were supported by staff trained appropriately.

People were supported to attend activities. People had personalised activity plans. Relatives told us that they knew how to complain. The service had received eight complaints in the last year, the complaints procedure had not always been followed.

Surveys had been sent out to relatives, staff and stakeholders to obtain their views about the service. The results of the staff survey had been analysed. There were no results for the relatives and stakeholder survey as they had only just been completed at the time of the inspection.

Staff understood their roles and responsibilities and shared the provider’s vision of a good quality service. Relatives were invited to a relative’s forum and there were family representatives who put forward any concerns or suggestions to the provider. Staff had regular staff meetings to give their opinions and raise any concerns.

Providers are required, by law, to display their CQC rating to inform the public on how they are performing. The latest CQC rating was displayed in the service and these details were also on the provider’s website.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we have asked the provider to take at the end of this report.

Martha House provides nursing and personal care and accommodation for up to 23 young adults with profound and multiple learning and physical disabilities. There were 20 people living at the service and one person on respite care during the inspection. People were unable to communicate verbally and used body language, facial expressions and some vocal sounds to make their needs known. There are two buildings in the service, Martha House and Frances House. Both premises are arranged over one floor, containing bedrooms, communal lounges and dining areas. All of the bedrooms are spacious, with hoist systems in place. The shared toilets and bathrooms also have hoist systems in place. There is parking available on site, and there are other facilities in the complex, including a hydrotherapy pool.

A registered manager was no longer leading the service. An acting manager had been appointed and was leading the service. They had applied to CQC to be registered as the manager of the service and were awaiting the outcome of their application at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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. There were two deputy managers one based in each of the houses, together with senior staff and they assisted with the inspection process.

At the previous unannounced comprehensive inspection of this service on 6 and 7 May 2015, five breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. At the time of this inspection the provider has complied with the breaches and had met their legal requirements.

Staff had received safeguarding training to protect people and they knew the action to take in the event of any suspicion of abuse. They had a good understanding of how to keep people safe and their responsibilities for reporting any concerns. Systems were in place to ensure that people’s finances were protected.

Risks to people were identified and there were measures in place to reduce risks to keep them as safe as possible. Accidents and incidents were recorded and reviewed to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety. Plans were in place to keep people safe in an emergency.

Checks were carried out to ensure the premises were safe, such as fire safety checks, water temperatures and health and safety. Equipment to support people with their mobility, such as the ceiling hoists had been serviced to ensure that they were safe to use.

People were supported by sufficient staff with the right skills and knowledge to meet their individual needs. The needs of the people had been taken into account when deciding how many staff were required on each shift. Staff told us the training programme was on going and the manager had ensured their training and development needs had been discussed through regular supervision and their yearly appraisal.

Safe recruitment practices were followed before new staff were employed to work with people. Checks were made to ensure staff were of good character and suitable for their role.

Peoples’ medicines were managed and administered safely. However further detail was required to ensure ‘as and when’ medicines were given in line with people’s needs. This was an area for improvement.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). When people lacked the mental capacity to make decisions the staff were guided by the principles of the MCA to ensure any specific decisions were made in the person’s best interests. Some people living at the service had DoLs authorisations in place. People were supported to make decisions and choices.

People's dietary needs and preferences were documented. Staff understood people’s complex dietary needs and promoted people to eat as independently as possible. The home’s chef kept a record of people’s needs, likes and dislikes which required further detail to ensure current information was up to date. This was an area for improvement.

Personalised care plans were in place and reviewed regularly. People’s healthcare needs were monitored and appropriate advice sought from health care professionals to make sure people remained as healthy as possible. Family members supported their relatives and were involved in their care planning and all aspects of their lives.

People had the opportunity to participate in a varied activity programme. A system to receive, record, investigate complaints was in place, which showed complaints had been responded to appropriately. The service was reviewing the complaints policy with a view to implementing an easy read version. The complaints procedure was not on display to ensure that people were aware of the process. This was an area for improvement.

Staff told us that the service had improved since the previous inspection due to the new manager. They told us that they had good leadership skills and they were developing the staff to have the skills and knowledge to carry out their role. Staff told us they were supported very well by the manager.

Relatives, health care professionals and staff had the opportunity to voice their opinions through annual surveys, forums and meetings. There were quality assurance systems in place and these were being used to monitor and improve standards of care delivery.

There was a mission statement on display in the service, which outlined the visions and values of the service, such as treating everyone with dignity and respect, supporting and encouraging, and treating people with compassion. Staff were aware of these values and demonstrated their understanding of how to achieve this by offering people choice, treating them with dignity and responding to their needs. The manager was aware of, and had been submitting notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

We found that the home was clean, bright and spacious, and that staff were polite and courteous to people who used the service. We noted that staff spoke clearly to people when providing care. We found that the staff always asked before attempting personal care, and waited for a response. Staff told us that people who had limited verbal communication were represented by family and advocates where necessary, and we saw evidence to demonstrate this in care records.

We found that care plans were comprehensive, personalised and took into account the needs and abilities of the people who used the service. We saw evidence of monitoring and regular evaluations of the support that was provided, together with involvement and liaison with relatives and various health professionals, to ensure they were kept informed of changes in people's conditions when necessary.

We toured the premises and found that the equipment used at the home, including tracking hoists, motorised wheelchairs, and adapted furniture, was in working order and maintained regularly.

Staff told us that they received the training required to carry out their roles well, and that they felt well supported by the management team and other staff. We noted that the manager had implemented regular discussions of the service with staff, as well as a program of appraisal and supervision, to ensure that any issues of concern could be quickly addressed. We found that the provider had implemented ways to gather feedback on the service from people's representatives.

We observed eight people in the main lounge, who were undertaking a variety of activities and interacting positively with the staff. We noted that staff members asked people if they wanted drinks, whilst encouraging them to join in an activity.