Archived: Heatherside House Care Centre

Heatherside House Care Centre is in a secluded location which is geographically isolated. The service was a large home, bigger than most domestic style properties. It is registered for the support of up to 25 people. There were 18 people living at the service at the time of the inspection. Other people also used the service for respite care. This is larger than current best practice guidance.

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. The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons: People did not live in a service where a culture of enablement, independence, choice and inclusion enabled them to maximise their human rights and empowered them to be valued stakeholders in the service they lived in. People did not experience person centred care which was tailored to their individual needs.

People’s experience of using this service:

Information to support people with their behaviour or mood was not always available, comprising enough detail or followed by staff.

Information recorded by staff was not routinely used to learn lessons and improve the support people received and the outcomes they experienced.

Recruitment checks had been completed on new staff members. New staff had completed an induction however, staff’s induction records had not been completed fully.

People’s needs had not all been assessed. Support was not always delivered in line with best practice.

People enjoyed the food but were not routinely involved in shopping for food. People’s preferences for meals were sought each week but often people made no choice. The reasons for this were not reviewed to improve people’s ability to contribute. People were not always provided with communication tools to help express their views.

The registered manager had not ensured the service was meeting the requirements of the Mental Capacity Act 2005 (MCA). Conditions on people’s DoLS authorisations had not been met. Staff were recording people’s consent more frequently, but people had not consented to some aspects of their care.

No assessment of the environment had been completed to identify adaptations that would enable the service to better meet people’s needs or align the service more closely with the principles of registering the right support.

Staff were mostly up to date with their training but had not received training in areas relevant to the people they supported, such as learning disability or autism.

People’s health needs were supported by staff and people received their medicines as prescribed. People were not enabled to have as much control as possible over their medicines.

People were not always treated or described in a dignified way by staff.

People were not always involved in creating or reviewing their care plans. People’s care plans did not describe how people could be empowered to develop skills in the home or community or increase their independence. Staff were not routinely encouraging people to do this following an agreed plan of action.

There were not always enough staff available for people to receive person centred care. People spent most of their time in the service and there was a lack of opportunities that had been tailored to people’s individual interests and preferences, for people to engage with. Records showed people spent a lot of time in their room, sleeping, wandering or watching TV. Staff did not routinely support people to broaden their experiences to make informed choices about how they spent their time. People still did not have access to education or work opportunities, or support to develop skills within the service or community. The registered manager did not review how people spent their time, to ensure improvements and development opportunities were identified and acted upon.

The registered manager had not understood the principles of person-centred support or ensured they were embedded within the delivery of the service. The culture in the service did not reflect an aspiration to maximise people’s human rights.

Learning available from previous inspection reports, the local authority quality improvement team and a consultant engaged by the service, had not all been implemented to improve the service.

The provider and registered manager had increased their monitoring of the service, but this had not resulted in sustained improvements to the outcomes people experienced. Audits of records had not identified areas for improvement found during the inspection. Records were not routinely reviewed to identify areas for improvement. We found many of the concerns raised at previous inspections still remained.

The registered manager had not engaged with any organisations, guidance or development opportunity that focused on best practice within learning disability services, to increase their knowledge and the outcomes people experienced.

We made recommendations about medicines, risk assessments and the complaints procedure.

Enforcement:

We have identified breaches in relation to how people with behaviour that challenges were supported, how information was used to aid learning, staffing levels and staff development. We also identified breaches in relation to how people’s views were sought, understood and met, how people’s needs were met under the Mental Capacity Act 2005 (MCA) and the governance arrangements of the provider.

Rating at last inspection: Inadequate 23 May 2019

At a comprehensive inspection in March 2017, we found ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included breaches of Regulation 12 (Safe care and treatment), 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed). We asked the provider to complete an action plan to show what they would do and by when, to make improvements. We also served a warning notice on the provider and on the registered manager which required improvements to be made, so that the service met the requirements of Regulation 17 within six months.

In December 2017, we undertook a focussed inspection to check whether the service had addressed the concerns in the warning notices. At this inspection we only looked at the Well-led domain. We found that the requirements of the warning notice had not been met and there was still a breach of Regulation 17.

Following the focussed inspection, we met with the provider to discuss how they were going to meet the requirements of the warning notice and improve the service to ensure that they were good in all domains.

At our inspection in November 2018, we found the quality assurance and governance arrangements for the home were still not sufficient to ensure people received safe, effective care. We found breaches of regulation 11 (Consent), 12 (Safe care and treatment), 17 (Good governance) and 18 (Staffing). Following this inspection, the provider submitted an action plan stating how they would make the required improvements. The service was placed in ‘special measures’.

At our last inspection (May 2019) we found the provider had not made enough improvements. They had not ensured people were safe and felt safe. Consent had not always been sought from people about their care. The provider had not ensured all people’s needs were assessed or met or that people were involved in decisions about their care or how it was provided. The provider had not ensured people felt comfortable with the staff supporting them. They had not made reasonable adjustments to enable people’s needs to be met. People had not been empowered to make choices and have as much control as possible. The lack of choice and control over their daily lives meant people were not living lives as any ordinary citizen would. The provider had not ensured people’s information needs were identified, recorded or met in line with national guidance. The lack of robust quality assurance meant people were still at risk of receiving poor quality care. We found continued breaches of regulations 11 (Consent), 12 (safe care and treatment), 17 (Good governance) and a breach of regulation 9 (Person Centred Care). Following this inspection, the service stayed in special measures and we took action to remove the location from the provider’s registration.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Following this inspection, the service will remain in special measures.

Please see the action we have taken at the end of the report.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

The full details can be found on our website at www.cqc.org.uk

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 25 people. There were 20 people living at the service at the time of the inspection. Other people also used the service for respite care. This is larger than current best practice guidance. 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. The outcomes for people still did not fully reflect the principles and values of Registering the Right Support for the following reasons: lack of choice and control, limited independence and limited inclusion.

People’s experience of using this service:

People told us other’s behaviour sometimes made them feel unsafe. Recruitment checks had been completed on new staff members; but checks had not been carried out on builders working at the service of their suitability to work near vulnerable adults.

There were not always enough staff or vehicles available for people to be able to choose how they spent their day.

People did not spend their days engaged in a way that was meaningful to them which reflected their choices and preferences. People’s care records had been improved but did not contain information about how staff could provide them with person-centred care that increased their independence.

Management of medicines had improved, and people were supported to see healthcare professionals when they needed to.

People enjoyed the food but were not routinely involved in planning menus or shopping for food.

Relatives gave positive feedback about the service.

The provider and registered manager had increased their monitoring of the service, but this had not resulted in all the improvements required. We found concerns that had been raised at previous inspections still remained.

We made recommendations about how people contacted staff if they needed help, how people’s information needs are assessed, how staff levels are calculated, staff recruitment and training processes, how people’s dignity, privacy and independence are promoted and how the environment is used.

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

Rating at last inspection: Requires improvement 22 November 2018

At a comprehensive inspection in March 2017, we found ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included breaches of Regulation 12 (Safe care and treatment), 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed). We asked the provider to complete an action plan to show what they would do and by when, to make improvements. We also served a warning notice on the provider and on the registered manager which required improvements to be made, so that the service met the requirements of Regulation 17 within six months.

In December 2017, we undertook a focussed inspection to check whether the service had addressed the concerns in the warning notices. At this inspection we only looked at the Well-led domain. We found that the requirements of the warning notice had not been met and there was still a breach of Regulation 17.

Following the focussed inspection, we met with the provider to discuss how they were going to meet the requirements of the warning notice and improve the service to ensure that they were good in all domains.

At our last inspection, we found the quality assurance and governance arrangements for the home were still not sufficient to ensure people received safe, effective care. We found breaches of regulation 11 (Consent), 12 (safe care and treatment), 17 (Good governance) and 18 (Staffing). Following this inspection, the provider submitted an action plan stating how they would make the required improvements. The service was placed in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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

Enforcement: We found breaches of regulation in relation to safe care and treatment, good governance, consent and person centred care.

Please see the action we have taken at the end of the report.

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

The full details can be found on our website at www.cqc.org.uk

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 not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The service was a large, isolated setting without easy access to the local community. People lacked choice and control over their lives through their limited knowledge of opportunity and limited staffing levels in the service. The model of care was institutional and was not person centred.

Staff did not have the right skills or knowledge to provide person centred care that was based on people’s individual wishes for their preferred lifestyle. The lack of skills, knowledge and understanding of people’s needs enabled ongoing acceptance of situations, such as behaviour that challenges, that compromised people’s dignity.

The provider and registered manager did not always lead by example and had allowed a disabling, maternal culture to develop. The provider spoke disrespectfully about a person during the inspection and we made a safeguarding alert about this. Following the inspection, the provider stated they did not recall using the sentence. The safeguarding concern was closed as the safeguarding team was unable to evidence it. In addition, the provider and registered managers failure to follow current infection control guidance exposed people to risk of harm. Good practice regarding infection prevention and control was not being followed, particularly in relation to enhanced procedures required to protect people due to the pandemic.

Sufficient action had not been taken to protect people from the risks of incidents of behaviour that challenges. This impacted on the lives of people who challenged others, and those who witnessed these behaviours regularly.

Information about people’s needs and incidents that occurred was not fully recorded and investigated. This meant the service was unable to learn from incidents that occurred and exposed people to ongoing risk.

Staffing levels were too low to offer genuine choice and opportunity to people. People were allocated minimal staff time each day and this impacted on their ability to access the community and develop their skills and interests.

The provider’s recruitment procedures had not been followed to ensure new staff members were safe to work with vulnerable adults. Staff had been provided with some further training opportunities but could not describe how their practice had changed as a result. Training records showed some staff had not completed training in infection prevention and control, or safeguarding.

Clear information regarding people’s medicines was not available in all cases. There was no evidence people had been consulted in a way they would understand about taking more control of their medicines.

Risks to people had not always been assessed or defined clearly in their records. Some perceived risks were assumptions rather than based on assessment and resulted in further limitations for some individuals.

People had been asked if they were happy with the service and had made some small suggestions; however no consultation about the impact the environment had on people or the possible changes that could improve their experiences had been completed.

The registered manager and staff did not have a clear understanding of the Mental Capacity Act 2005 (MCA). People’s capacity to make specific decisions had not been appropriately assessed. People were not supported to have maximum choice and control of their lives and staff did not 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.

Information about how some people communicated was limited, which meant their needs were not fully understood. Information provided to people was not always provided in a format that was tailored to their needs.

People’s care plans did not always use respectful language and we found some examples of people’s dignity not being promoted. People did not always receive the right support to increase their independence.

The culture in the service did not value people’s differences or focus on ensuring people had equality of opportunity within the service and the community. Observations during the inspection and records of how people spent their time showed people did not live a similar life to that of any other citizen. People were given basic options and choices but were not routinely offered or encouraged to try new or different things to increase their ability to make informed choices. This meant people chose the same options that had been offered over a long period of time.

People spent most of their days in the service doing repetitive activities, which although meaningful to the person in the context of the limited opportunities available to them; did not assure us each person was living a full and meaningful life. There was no evidence people were given real opportunities to be part of their local community.

The provider and registered manager had not taken the opportunity, since the last inspection, to implement effective change to ensure the service met regulations, reflected best practice and offered improved outcomes to people. They had relied on external bodies for guidance but had not understood the reasons behind the changes they were making. As a result, the culture in the service, staff ability to implement best practice and the opportunities offered to people remained poor.

People did not raise any concerns about the service. They told us they felt safe and enjoyed the things on offer. Relatives and professionals on the whole provided positive feedback about the service, the staff and the registered manager; however, this was not reflected in the findings from our site visit or in the records we reviewed.

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 11 March 2020). Since this inspection, the registered manager has been sharing fortnightly updates of the actions taken to improve the service.

At a comprehensive inspection in March 2017, we found ongoing breaches of the Health and Social Care Act

2008 (Regulated Activities) Regulations 2014. This included breaches of Regulation 12 (Safe care and

treatment), 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed). We asked the provider to complete an action plan to show what they would do and by when, to make improvements. We

also served a warning notice on the provider and on the registered manager which required improvements

to be made, within six months.

In December 2017, we undertook a focussed inspection to check whether the service had addressed the concerns in the warning notices. At this inspection we only looked at the Well-led domain. We found that the requirements of the warning notice had not been met and there was still a breach of Regulation 17. Following the focussed inspection, we met with the provider to discuss how they were going to meet the requirements of the warning notice and improve the service to ensure that they were good in all domains.

At our inspection in November 2018, we found the quality assurance and governance arrangements for the home were still not sufficient to ensure people received safe, effective care. We found breaches of regulation 11 (Consent), 12 (Safe care and treatment), 17 (Good governance) and 18 (Staffing). Following this inspection, the provider submitted an action plan stating how they would make the required improvements. The service was placed in 'special measures'.

In May 2019 we completed a comprehensive inspection and found the provider had not made enough improvements. We found continued breaches of regulations 11 (Consent), 12 (safe care and treatment), 17 (Good governance) and a breach of regulation 9 (Person Centred Care). Following this inspection, the service stayed in special measures and we took action to remove the location from the provider's registration.

At our last inspection in January 2020 we found the provider had still not made enough improvements. We found continued breaches of regulations 9 (Person Centred Care), 11 (Consent), 12 (safe care and treatment) and 17 (Good governance). We also found breaches of regulations 10 (Dignity and Respect), 13 (Safeguarding service users from abuse and improper treatment) and 18 (Staffing).

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

Why we inspected:

This was a planned inspection based on the previous rating.

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.

Enforcement

We have identified breaches in relation to person centred care, dignity and respect, the Mental Capacity Act 2005 (MCA), the safe care of people, staffing, safeguarding service users from abuse and improper treatment, the governance of the service and the failure to notify the commission of an injury to a person.

Please see the action we have taken at the end of the report.

Follow up

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. This means we will keep the service under review and,

The service provides care and support for up to 25 younger and older adults with a diagnosis of learning disability and/or autism. Some people also have sensory impairments and/or physical disabilities.

Heatherside House Care Centre is in a secluded location which is geographically isolated. It is a large home, bigger than most domestic style properties. There were 17 people living at the service at the time of the inspection. This is larger than current best practice guidance. People lived together in one large group supported by one staff group. Laundry, cooking and most activities were carried out in communal facilities. The main kitchen was of an industrial style with a serving hatch into the dining room.

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 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 not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• The model of care and setting did not maximise choice, control and independence. People were not supported to understand and exercise their right to experience the wide range of opportunities that most people take for granted. As a result, the choices they made were limited to a small number of activities they had previously been offered.

Right care:

• People did not receive good quality person-centred care based on best practice guidance. Staffing levels meant people either received support as part of a group or spent substantial parts of the day alone. Plans to improve people’s experiences were still based on being part of a group and did not evidence any level of consultation with people living in the service.

Right culture:

• People did not live in a service where the ethos, values and attitudes of the management team and staff enabled them to lead confident, inclusive and empowered lives. The culture of the service focused on the barriers to enabling people to live better lives, rather than on creating the right environment to inspire people to understand and achieve their goals and ambitions. The provider had engaged a consultant and organised for another manager to support the registered manager. However, other than individual actions being added to an action plan based on the previous CQC report; there were no clearly laid out direction or objectives that the whole staff team understood, fed into and were working towards.

The provider’s infection control policy and some infection control practices had been improved.

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 13 January 2021).

At a comprehensive inspection in March 2017, we found ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included breaches of Regulation 12 (Safe care and treatment), 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed). We asked the provider to complete an action plan to show what they would do and by when, to make improvements. We also served a warning notice on the provider and on the registered manager which required improvements to be made, within six months.

In December 2017, we undertook a focussed inspection to check whether the service had addressed the concerns in the warning notices. At this inspection we only looked at the Well-led domain. We found that the requirements of the warning notice had not been met and there was still a breach of Regulation 17. Following the focussed inspection, we met with the provider to discuss how they were going to meet the requirements of the warning notice and improve the service to ensure that they were good in all domains.

At our inspection in August 2018, we found the quality assurance and governance arrangements for the home were still not sufficient to ensure people received safe, effective care. We found breaches of regulation 11 (Consent), 12 (Safe care and treatment), 17 (Good governance) and 18 (Staffing). Following this inspection, the provider submitted an action plan stating how they would make the required improvements. The service was placed in 'special measures'.

In May 2019 we completed a comprehensive inspection and found the provider had not made enough improvements. We found continued breaches of regulations 11 (Consent), 12 (safe care and treatment), 17 (Good governance) and a breach of regulation 9 (Person Centred Care). Following this inspection, the service stayed in special measures and we took action to remove the location from the provider's registration.

At a comprehensive inspection in January 2020 we found the provider had still not made enough improvements. We found continued breaches of regulations 9 (Person Centred Care), 11 (Consent), 12 (safe care and treatment) and 17 (Good governance). We also found breaches of regulations 10 (Dignity and Respect), 13 (Safeguarding service users from abuse and improper treatment) and 18 (Staffing).

At our last inspection in November 2020 we found the service had deteriorated. We found continued breaches of regulations 9 (Person Centred Care), 10 (Dignity and Respect), 11 (Consent), 12 (safe care and treatment), 13 (Safeguarding service users from abuse and improper treatment), 17 (Good governance) and 18 (Staffing). We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. The service was rated inadequate for the third consecutive inspection. The service has been in Special Measures since November 2018.

At this inspection the information shared with us did not evidence that the provider was no longer in breach of regulations.

Why we inspected

We undertook this targeted inspection to review action the provider told us they had taken to improve the service. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on, or to check 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 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 have found ongoing evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this report.

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

Enforcement

The service remains in breach in relation to person centred care, dignity and respect, the safe care of people, staffing, consent, and the governance of the service.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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

The overall rating for this service is ‘Inadequate’ and the service remains 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.

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 previously inspected the service on 3 November 2020. We found several concerns about infection control procedures and practice. These included some staff not wearing face masks, or not using correct surgical face masks; no evidence staff had completed up to date infection control training and cleaning arrangements not being appropriate. Subsequently we wrote to the provider on 6 November 2020 stating we would take urgent enforcement action unless urgent action was taken. We subsequently received from the provider an action plan outlining the action they would take. An infection prevention and control specialist nurse visited the service on 19 November 2020, and was happy with procedures and practice in place. Some further recommendations were given, and the registered provider was working to implement these. There had been no cases of Covid 19 at the service.

We found the following examples of good practice.

• The service allowed people to meet visitors safely, and suitable procedures were in place such as wearing face masks, and as necessary other personal protective equipment (PPE). These measures ensured the risk of infection was minimised.

• Staff had helped people to stay in touch with family and friends through phone calls, and through the internet.

• The service had suitable procedures for people to self-isolate if they had symptoms of Covid 19, and /or when they were admitted to the service. This ensured there was minimal risk from infection to other people at the service.

• Suitable testing routines had been arranged for staff and people who used the service. The registered manager said both staff and people who used the service had been happy to participate in regular testing. Where people were not happy to have regular tests this had been documented.

• Satisfactory admission procedures were in place, for example, where possible (if the person was not admitted in an emergency) the service required documentary evidence of Covid-19 test results before people moved in. All people admitted to the service were required to self-isolate.

• Staff had received suitable training and guidance regarding infection control, and how to respond to the Covid 19 pandemic. Face to face training was being completed for ten staff at the time of the inspection. During the inspection we observed staff demonstrating suitable knowledge of good infection control practice.

• The service had comprehensive policies and procedures in respect of Covid 19 and its implications on the running of the service. This included comprehensive risk assessment procedures.

• The service was clean. Effective cleaning routines were implemented to ensure infection control risks were minimised and people were kept safe.

• Suitable staffing levels were maintained at the service. Where necessary agency staff, had been used; but this had been minimal. The registered manager said agency staff previously used had been dedicated to work only at this service.

• When people and staff had their lunch suitable seating arrangements were in place to ensure appropriate physical distancing.

•Staff did not work across other services managed by the provider.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Staff were observed working with people in a safe, respectful manner, throughout the inspection, and appeared to have good, trusting relationships. People appeared well supported and cared for, and at the time of the inspection there was a happy and friendly atmosphere.

Further information is in the detailed findings below.

Heatherside House Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides care and support for up to 25 younger and older adults with a diagnosis of learning disability and/or autism. Some people also have sensory impairments and/or physical disabilities. There were 21 people living at the service at the time of the inspection. Three other people also used the service for respite care on a regular basis each week.

At a comprehensive inspection in March 2017, we found ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included a breach of Regulation 12 (safe care and treatment). This was because risks to people had not been assessed and documented. Routine fire checks were not being carried out. Some medicines were out of date; medicines were not always recorded appropriately.

At that inspection we also found breaches of 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed). This was because recruitment processes did not always include all the checks necessary to ensure that fit and proper people were employed; staff were not up to date with all the training required and did not receive regular supervision; Quality and safety systems were not robust and had not identified areas where improvement was necessary, including medicine administration audits, building checks, staff training and changes to care records.

Following the March 2017 inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Is the service safe? Is the service effective, Is the service responsive and Is the service well-led? to at least good. Because of the concerns in respect of the governance of the home, CQC took enforcement action by serving a warning notice on the provider and on the registered manager. These warning notices gave the service six months to meet the requirements of Regulation 17, good governance.

We undertook a focussed inspection in December 2017 to check whether the service had addressed the concerns in the warning notices. At this inspection we only looked at the Well-led domain. We found that the requirements of the warning notice had not been met and there was an still a breach of Regulation 17. We identified significant ongoing concerns which included:

• A lack of robust quality assurance framework and systems

• Risks relating to health, safety and welfare of residents had not been considered or addressed

• Audits of care records had not resulted in updates and amendments where needed

• Audits of buildings and equipment had not identified or address issues

• Communication systems were not robust and did not ensure that staff would be made aware of changes to people’s care

• People and their families had not been involved in meaningful decisions about the ongoing refurbishment work in the home

• The registered manager had not been aware of current national policy including Registering the Right Support and other best practice guidance.

Following the focussed inspection, we met with the provider to discuss how they were going to meet the requirements of the warning notice and improve the service to ensure that they were good in all domains.

At the current inspection we found the quality assurance and governance arrangements for the home were still not sufficient to ensure that people received safe, effective care. Environmental checks had not identified safety issues around the home. Audits and checks had identified areas of concern such as that staff training, however the shortfalls had not been addressed. Although directors from the provider organisation visited the home and undertook some qualitative assessment of the care, they had not identified or addressed the issues.

The home provided accommodation for more than the maximum six people recommended in “Registering the Right Support” and other best practice guidance. In other respects, the service had also not been developed to promote 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 were not supported to live as ordinary a life as any citizen. We found that the service was still not supporting people to be as independent as possible. Staff were recognised by health and social care professionals as caring, although professionals said they had concerns as the service had still not addressed areas for improvement which had been raised with them.

The home had a manager who had registered with the Care Quality Commission (CQC). 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.

The home had undergone extensive refurbishment which had enabled each person to have a bedroom with an ensuite bathroom. People were very positive about the improvements which also included redecoration of communal areas such as a reception area, dining room and two lounges.

Staff were caring and compassionate about people and spent time with them, chatting and laughing. Positive relationships between people and staff were very apparent. Where people presented behaviours that challenged others, staff showed knowledge and understanding about people and how to support the person and others impacted. Staff were able to describe and understood how they could communicate with people who did not communicate verbally.

People said they liked living at Heatherside and felt cared for and supported. Relatives also commented that they found the home provided good care for their family member. People were supported to eat healthily and have food of their choice. Appropriate food was provided for people on specialist diets including gluten free food and food prepared for people at risk of choking.

People were supported to do activities in the home and in the community. Some activities were undertaken as a group; however, people also chose to do some activities on their own accompanied by staff.

Where people had medicines administered by staff, the home followed national guidance. This meant they were meeting the requirements of the guidelines which describe how to receive, store, administer, record and dispose of medicines. However, risks associated with people who administered their own medicines had not be considered.

Staff were recruited safely. Staff were not up to date with training. This meant there was a risk that they would not follow current national guidance and legislation requirements when caring and supporting people.

The requirements of the Mental Capacity Act 2005 were not being met as applications for Deprivation of Liberty Safeguards authorisations had not been made. Where someone’s capacity to make a decision was in doubt, no best interest assessments had been recorded. Meetings involving the person, their family and professionals had not been undertaken to establish the least restrictive and most appropriate way to support the person.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also made a recommendation that the service should consider reviewing their complaints procedure.

This is the fourth consecutive time the service has been rated Requires Improvement. It is also the second time the Well-led domain has been found inadequate. The service has therefore been placed in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

You can see what action we told the provider to take at the back of the full version of the report.

Previously we had carried out a comprehensive inspection in March 2017, which had rated the home as requiring improvement overall. We identified the provider did not have effective systems to assess, monitor and improve the quality and safety of the services provided. After that inspection, we issued warning notices to the provider and to the registered manager as we found the service was not well governed and was therefore not meeting the requirements of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because audits and checks had not identified or addressed quality and safety issues. There was no overall quality assurance system which ensured that the provider monitored the quality and safety of the service. The warning notices specified that the home should address the concerns and be compliant with the Regulation by 30 September 2017.

Heatherside House Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Heatherside House accommodates people in two connected buildings.

The service provides care and support for up to 25 younger and older adults with a diagnosis of learning disability and/or autism. Some people also have sensory impairments and/or physical disabilities. There were 22 people living at the service at the time of the inspection.

The home had a manager who had registered with the Care Quality Commission (CQC). 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 found that people were still at potential risk because quality assurance and governance did not identify areas of risk or improvement required.

The home had been undergoing extensive renovations and refurbishment for since 2015, which had posed risks to people’s safety and well-being. Many of these risks had not been identified or addressed as part of the home’s quality assurance systems. During the inspection, we carried out a walk around the service with the registered manager and identified risks to people’s safety. After the inspection we wrote to the registered manager and provider asking them to provide assurances as to how these risks had been addressed. These included tools being left in a corridor and a fire exit being left open when used by workmen. The fire exit led to an area where there was a skip and building equipment which was accessible to people in the home. We also identified a laundry which was not suitable for use, a toilet with no running water at the hand wash basin and a ripped carpet in the main reception area. We received a response from the registered manager and the provider showing the steps they had or were taking to reduce the risks and keep people safe.

People and their families had not been involved in discussions about the ongoing building work or the impact this might have on stress levels and enjoyment of life.

Some audits and checks that were carried out within the home had not identified risks to people’s health and wellbeing. For example, checks of the building had not identified risks associated with extensive ongoing building works.

Communication systems in the home did not ensure that all staff would be made aware of changes to a person’s needs and care. Audits of care plans had not identified or addressed that they did not fully describe people’s risks, such as being at increased risk of falling. Audits of staff records had not identified there was some missing paperwork relating to recruitment of new staff.

Although senior staff visited the home frequently, and were also in regular contact with the registered manager, there was no information about how they monitored the quality and safety of the home.

The care service has not 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 were not supported to live as ordinary a life as any citizen. The home had a ‘paternalistic’ approach to providing care, rather than supporting people to become as independent as possible. Many of the people living at Heatherside had been resident in the home for a significant number of years. Although staff were recognised by health and social care professionals as caring, professionals said they had concerns as the service was “set in its ways” and people were not “supported to be as independent as possible.

The registered manager was well liked and respected by people in the home and staff. Professionals commented that the registered manager was very helpful and also very alert to changes in people’s health needs. There was good liaison with the local GP and other health and social care professionals. The registered manager had worked with the local authority to improve the running of the home.

We found a continuing breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

After the inspection, we arranged to meet with the provider to discuss the findings and explain the actions we may take if the service continues to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are also planning to undertake a comprehensive inspection of the service by the end of March 2018. This will enable us to check whether improvements have been made to ensure the service meets all the regulations.

You can see what action we told the provider to take at the back of the full version of the report. Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work there.

Heatherside is located in a village on the edge of Dartmoor about 7 miles northeast of Plymouth. The home provides accommodation and personal care for up to 25 adults and specialises in providing care to people with a learning disability.

The home had previously been inspected in December 2015 and January 2016. At that inspection we found breaches of two regulations. This was because people were not fully protected from the risks associated with unsafe premises; medicines were not always administered safely and clinical waste was not disposed of safely. We also found some areas of the home were not well maintained which meant people were exposed to the risks of infection.

People said they were happy and felt safe living at Heatherside. Comments included “Look after me proper, staff are nice” and “Staff are nice and friendly.” Relatives also made very positive comments about the care their family member received. For example they described staff as providing friendship and helping the person to have a laugh and a joke.

Since the last inspection, a major refurbishment programme had continued. This meant that there were significant improvements to bedrooms and communal areas. Some work was still being carried out which meant that one part of the home was not accessible to people or staff. Although some aspects of this had been better managed than when we last inspected, we found that people’s safety had been put at risk as routine fire safety checks were not being carried out. The home was clean and well-maintained.

Most aspects of medicines management were well managed. However some improvement was needed to ensure people received their medicines safely. Medicine audits had not identified that some medicines had been out of date when received. Some cream charts had not been fully completed.

The home was run by a registered manager who had been in post for a number of years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was very well known and liked by people, their families and staff. She and senior staff from the provider organisation encouraged a positive, homely and happy atmosphere. Staff reflected these values and behaviours. There were sufficient staff to meet people’s needs. The registered manager monitored staffing levels and took action when needed. Staff spent time with people both in groups and on their own, encouraging them to undertake activities they enjoyed. People were supported to go to clubs and groups in the community as well as on holiday.

The home’s recruitment processes did not fully ensure that people were protected. New staff were supported and trained when they first started working at Heatherside. Staff were supported to undertake a nationally recognised qualification to develop their skills. However staff had not completed or refreshed all the training needed to support people’s needs.

Supervision of staff was not carried out regularly, although staff said they were able to talk to the registered manager or a senior member of staff from the provider organisation if they needed to.

People were able to decorate and furnish their bedrooms to suit their tastes. Families were encouraged to visit and were able to have private space to meet their relative if they wanted to. People and their families said they had not had any reason to complain but felt able to raise concerns if they ever needed to.

Staff had an understanding of the Mental Capacity Act (2005). No applications for a Deprivation of Liberty Authorisation had been made.

People were supported to have a varied diet with meals of their choosing. Some people who required specialist diets received meals that were appropriate for their needs. People said the food was good and if they did not want a particular meal, they were offered alternatives. People were also supported to remain hydrated. Where necessary staff had taken advice from specialists including a dietician and speech and language therapist. This advice on how to support people when eating was being followed. Staff knew people and their needs well. Staff were able to describe people’s likes and dislikes and also how people communicated with them. Staff had worked with people and their families to develop care and support plans. Staff involved health professionals appropriately. However, care plans did not always reflect all the existing needs of people, including recently diagnosed conditions.

The provider did not have effective systems in place to monitor the quality of care and support that people received. Although some checks and audits had been undertaken, these had not identified safety and quality issues, including environmental risks. Audits of care records had not identified that some were not up to date. Records of training had not identified that some staff were out of date with their training.

We made two recommendations relating to national guidance in respect of safeguarding training and the Mental Capacity Act (2005)

We found breaches of the Health and Social Care Act (2008) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there