The Well House

The Well House is a residential care home providing support and personal care to up to 14 people. The service provides support to people with a learning disability and autistic people. At the time of our inspection there were nine people using the service. The home was separated into three buildings, the main house where five people lived, the annex where three people lived and one building for one person.

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

Risks to people were not always effectively assessed and managed. Where people had specific health needs which may put the person at risk, guidance and risk assessments were not always present or clear. Government guidance around infection control was not always followed. There were enough staff to support people safely, however improvements were needed to the recruitment process to keep people safe. Medicines were not always managed safely.

Quality assurance and risk management processes required improvement. Audit processes were not effective in identifying improvements needed at the service. Actions needed to improve the service were not recorded or monitored. The culture of the staff team was person focused and staff were kind and caring towards people. Staff worked well with professionals to ensure people received appropriate support. People and staff were given regular opportunities to feedback on the home.

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

Based on our review of safe and well led, the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support: Model of care and setting maximises people’s choice, control and Independence.

Although we saw that people were offered choices throughout the day and supported to make their own decisions, the processes around mental capacity and decision making were inconsistent. Some people who had restrictions to keep them safe, had not had their mental capacity assessed to see whether they could have made this decision for themselves. We saw staff had supported people to be independent in aspects of their day to day lives. People’s bedrooms were unique to each person and we saw that people had been consulted about where they wanted to live. People told us they were able to do and choose how they spent their time, one person told us, “I like it here because I get to do what I want.”

Right care: Care is person-centred and promotes people’s dignity, privacy and human rights

Staff treated people as individuals.

Staff supported people in a person-centred way. Staff knew people well and understood how to communicate effectively with each person. Staff spoke to people in a dignified and respectful way and enjoyed making people laugh. Information included in people’s care plans was individual and included what was important to the person. Relatives were positive about their loved ones’ experiences of the home. One told us, “[Person] isn't able to say if they're happy at the home, but when we ask, [their] face lights up and they shout yes.” People were supported by staff to have regular visitors and staff supported people’s relationships with their friends and family.

Right culture: Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

Whilst improvements were needed at the service, the management team led with a caring and affectionate attitude. The ethos of the service was family orientated and we saw that people were comfortable and enjoyed where they lived. Relatives told us, “I can tell [person] is happy because of how they relate to me about the staff, they truly love them.” And “The staff are so friendly, you really feel it when you walk in there.”

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

Rating at last inspection

The last rating for this service was good (published 10 December 2020).

Why we inspected

We undertook a targeted inspection to follow up on specific concerns we had received about the service. The inspection was prompted due to concerns received about infection control measures and staffing. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with infection prevention and control so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

Enforcement

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment relating to risk management and infection control and governance relating to quality assurance processes at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Well House is a residential care home that provides care and accommodation for people with learning disabilities. It was registered for the support of up to 14 people. Eight people were living at the service on the day of our inspection.

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 able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. Many people were not able to fully verbalise their views and used other methods of communication, for example pictures. Due to people's needs we spent time observing people with the staff supporting them.

Right support:

• People received personalised care and support specific to their needs and preferences. This had been effective in supporting people to achieve goals and encouraged them to learn and grow as individuals. People were protected from the risks of harm, abuse or discrimination because staff knew what actions to take if they identified concerns. There were enough staff working to provide the support people needed. Staff understood the risks associated with the people they supported. Risk assessments provided guidance for staff about individual and environmental risks. People received their medicines safely, when they needed them.

Right care:

• Care was person-centred and promoted people’s dignity, privacy and human rights. People’s individual needs and choices were recognised, and respected. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Right culture:

• Despite the need to keep people safe during the COVID-19 pandemic taking priority, the provider and staff had worked hard to develop strong leadership. Quality monitoring systems had been embedded and morale was high amongst the staff team. We received positive feedback in relation to the care people received and how the service was run. One relative told us, “[My relative] is very happy at the home. Before the Well House, he was bounced around a few homes and never settled, but he’s really settled and happy now”.

Due to the COVID-19 pandemic, the provider had ensured that appropriate infection control procedures for the pandemic were in place to keep people safe. This included increased cleaning and ensuring adequate supplies of personal protective equipment (PPE) were available. Staff completed training in relation to COVID-19. We were assured the provider managed infection prevention and control through the COVID-19 pandemic.

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

Rating at last inspection and update

The last rating for this service was Good (published 19 December 2018). At this inspection we found no concerns in the key questions we looked at.

Why we inspected

We undertook this focused inspection on 4 November 2020 in light of concerns we had received in respect to the care people were receiving. Concerns included, infection control, the management of medicines, recruitment practices, risk assessments, staff training, staffing levels and a negative and closed culture at the service. A decision was made for us to inspect and examine those risks. Therefore, this report covers our findings in relation to the Key Questions: Is it Safe? and Is it Well-led?. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe and Well-led sections of this full report.

For those key questions not looked at on this occasion, the ratings from the previous comprehensive inspection were used in calculating the overall rating at this inspection. The overall rating for the service has not changed from 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 Well House on our website at www.cqc.org.uk.

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 Well House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can provide accommodation and care for 14 people. This is in one detached building that is adapted for the current use providing a one bedded self-contained annex, a four-bedded self-contained annex and individual bedrooms on three floors in the main house. The home provides support for people living with a range of learning disabilities, and people may live with autism and have sensory needs. Some people live at The Well House on a permanent basis while others use the service on a rotational basis for short stays of one or more nights. There were seven people living at the home permanently at the time of our inspection and two people having a short stay.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 Well House was designed, built and registered before the Care Quality Commission (CQC) ‘Registering the Right Support’ policy and other best practice guidance was published. 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 other complex needs using the service can live as ordinary a life as any citizen.

At the last inspection on 5 October 2017 the service was rated as ‘Requires Improvement’ overall and there was a breach of regulation. This was because the provider had failed to display their performance rating on either their website or in the service from the previous inspection in September 2016. Provider’s must ensure that their ratings are displayed conspicuously and legibly at each location delivering a regulated activity. At this inspection the provider had displayed their performance rating and the breach of regulations had been met.

At this inspection improvements had been made in some areas and the overall rating of the service was Good overall. This report discusses our findings in relation to this. However, we found further areas of improvement that were needed.

Quality assurance systems were in place and being embedded to monitor the running and overall quality of the service and to identify any shortfalls and improvements necessary. Improvements had been made since the last inspection in relation to recording and equipment required to support infection control and medicines procedures. Records demonstrated that regular internal audits and checks were being completed. The provider had also identified in response to changes in data protection legislation that their systems needed to be reviewed and was in the process of completing this activity to ensure people’s rights were maintained. Despite these improvements, the care planning quality assurance systems required further embedding to ensure that the service kept pace with the positive work they had completed in relation to enabling people to make decisions and working in line with the Mental Capacity Act.

The provider’s electronic information systems also needed further embedding to ensure they could demonstrate their quality assurance and compliance in a timely and robust manner.

People and their relatives told us they felt safe and that staff cared for them. People were

protected from the risk of abuse because staff understood how to identify and report it. People, relatives and staff were confident their concerns were always taken seriously and acted on. One person told us, “It feels safe here there are lots of people to look after me.” A relative told us, “We are the happiest we have been by far about our relative’s safety. It’s because the people there know our relative so well.”

People were supported to have their medicine safely when they needed it. The provider had arrangements in place for the safe ordering, administration, storage and disposal of medicines. People were supported to be as independent as possible and self-administer their medicines and maintain good health and had access to health care services.

Accident and incidents were recorded and analysed to ensure appropriate action was taken and lessons learnt to reduce the risk of harm. Risks to people’s safety were assessed and detailed guidance and risk assessments were provided for staff to ensure they could support people safely in relation to their needs, including moving and handling, nutrition, personal hygiene and independent travel.

People and their relatives felt there were sufficient numbers of skilled staff to meet the needs of people living and staying at The Well House. One person told us, “There always respond to me when I need them.” Another person told us, “They help me speak up for myself.” Staff told us they received training to support the needs of people living with a learning disability, autism and complex health needs. Staff understood the importance of supporting people to make choices and the importance of ensuring that people living with autism and sensory needs could express themselves and understand the world around them. People lived meaningful lives and were supported to access activities, jobs and cultural and religious experiences in their local community.

Staff supported people to choose what they had to eat and drink and their nutritional needs were met. Where special dietary needs were required in relation to people living with diabetes, requiring artificial feeding directly into the stomach through a tube (PEG) or allergies staff followed guidance given by care plans and the health professionals.

People’s relatives told us and we observed that the staff were caring and respectful. One person told us, “The staff are caring, they look after me and are good to me.” Care and support provided was personalised and met peoples’ diverse needs including their equalities based choices in relation to sexuality, gender identity, ethnicity and wider cultural needs. People and their relatives were included in the assessment of their needs and development of care plans and the development of the service. Information was provided in an accessible format that met the needs of people and highlighted their needs to others who care for them.

Person centred care was demonstrated throughout the service. People, relatives and social care professionals spoke positively in relation to the homely friendly environment at The Well House. One relative told us, “The staff make a connection with the people they look after, they genuinely take an interest and enjoy what they do.” Another relative told us, “They are thriving, doing new things, new activities, they are flourishing.”

The service had a registered manager in place. 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.

At the last inspection undertaken on the 6, 8 and 22 September 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to people being unlawfully deprived of their liberty. The management and storage of medicines was not safe. Robust risk assessments in relation to bathing had not been maintained, accurate records had not been maintained and the provider’s quality assurance framework was not fit for purpose. Recommendations were also made in relation to staffing levels, cleanliness, implementing the principles of the Mental Capacity Act into the care planning process and submitting statutory notifications. The provider sent us an action plan stating they would have addressed all of these concerns by October 2016. At this inspection we found the provider had followed their plan and they were now meeting the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Part of the requirements of the provider’s registration is to ensure that when their service is inspected by CQC, that they display their performance rating, to provide members of the public with an awareness of the rating of the service. The provider had not displayed the rating of the previous inspection on their website. Failure to display a rating is a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. CQC served a fixed penalty notice for failure to display a rating, which the provider paid.

Steps had been taken to drive improvement and the provider was now meeting the legal requirements. Quality assurance checks were now in place and the provider was routinely submitting statutory notifications. However, further work was required to strengthen the provider's internal quality assurance framework. We have identified this as an area of practice that needs improvement.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLs) which applies to care homes. Where required, DoLS applications had been made and steps had been taken to embed the principles of the Mental Capacity Act 2005 (MCA) into the care planning process. However, further work was required to strengthen this. We have identified this as an area of practice that needs improvement.

Systems were in place for staff to support people with the management of their diabetes. Risk assessments and guidance were in place. However, the disposal of insulin needles required addressing. We have identified this as an area of practice that needs improvement.

All risks to people's safety had been assessed and were managed in line with individual risk assessments. Risks associated with bathing had been addressed and robust risk assessments were in place. Systems were in place to ensure water temperatures did not exceed recommended temperatures.

People were supported to take their medicines safely. People were supported to maintain good health and had access to healthcare services. People received support from dieticians, GP's, dentist and other healthcare professionals.

People were asked for their permission before staff assisted them with care or support. Staff had the skills and knowledge necessary to provide people with safe and effective care. Staff received regular support from management which made them feel supported and valued.

Staffing levels were safe and sufficient and enabled staff to provide care that met people’s care needs. People were empowered to live active and meaningful lives. One staff member told us, “The reason I love working here is that every day without fail, we go out and do something different.” Staff supported people to maintain important relationships and access the community.

People’s equality and diversity needs were respected and upheld. Visitors were made to feel welcome and relatives valued communication with staff and the management team. Systems and processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse.

Person-centred care was at the forefront of the service. Staff members described the key strength and values of the services as ‘homely and client-led.’ People’s views and opinions mattered to the provider and people were actively involved in the running of the service. Relatives spoke highly of the service and praised the care that their loved one received. One relative told us, “(Person) loves going to the Well House for respite. They help me pack their case ready to go and want to go back as soon as they’ve got home. I really love that they are so happy spending time at the Well House.”

The service had a registered manager in place. 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.

People, relatives and staff spoke highly of the service. One relative told us, “The Well House is wonderful. I can’t sing their praises enough.” Another relative told us, “I’m very happy with the care my loved one receives.” Whilst the feedback from people was positive, we found areas of practice that were not consistently safe, effective or well-led.

Management of medicines was not always safe. People received their medicines correctly, on time and as they wished to have them. However, best practice guidelines regarding storage and documentation of medicines were not being followed. We also found that the date of opening was not recorded on two open liquid medications which meant that people were at risk of receiving expired medicine which can be less effective.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLs) which applies to care homes. One application to restrict people's freedom had been submitted to the appropriate DoLS office. However, there was a risk that people’s rights under Article 5 of the Human Rights Act 1998 were contravened as robust systems were not in place to identify if other people were unlawfully deprived of their liberty. Where an application had been made, staff were not aware that this person was subject to a DoLS authorisation and what it meant for the individual.

The principles of the Mental Capacity Act (MCA) were not consistently embedded into practice. Further work was required to clearly demonstrate whether people had consented to their care plan, staff holding their personal allowance, photograph being taken or sharing of information. We have made a recommendation for improvement.

People felt staffing levels were sufficient. One person told us, “There’s always someone to talk to.” During the course of the inspection, we received intelligence of concern which raised concerns about insufficient staffing levels. Although people felt staffing levels were sufficient, the provider was unable to demonstrate how staffing levels were based on the individual needs of people. We have asked the provider to make improvements in this area.

Robust systems to monitor the safety and quality of the service were not in place. Governance systems to identify shortfalls were ineffective and complete, detailed and contemporaneous records were not consistently in place. Where risks were identified to people’s safety, documentation failed to evidence how those risks were mitigated. The provider's quality assurance system did not identify service shortfalls we found during the inspection, to ensure service improvements were made.

The provider did not routinely submit statutory notifications to the Care Quality Commission, as required. Under the Health and Social Care Act 2008, providers are required by law to submit notifications. We have asked the provider to make improvements in this area.

The principles of the Mental Capacity Act (MCA) were not consistently embedded into practice. Further work was required to clearly demonstrate whether people had consented to their care plan, staff holding their personal allowance, photograph being taken or sharing of information. We have made a recommendation for improvement .

Staff understood the needs of people and care was provided with kindness and compassion. People spoke highly of the care they received and confirmed they received care in a timely manner. Staff members were responsive to people’s changing needs. People’s health and wellbeing was continually monitored and staff regularly liaised with healthcare professionals for advice and guidance.

Staff were seen smiling and laughing with people and joining in activities in the home. From observing staff interact with people, it was clear staff had spent considerable time with people, getting to know them, gaining an understanding of their personal history and building friendships with them. One relative told us, “I can’t praise them enough. It’s a wonderful place and all the staff are amazing. We’ve looked for somewhere like The Well House for so long and I’m so grateful that we have found it.”

Staff had received safeguarding training and knew what to do and who to contact if they suspected any abuse. Staff employed by the provider were provided with a full induction and training programme which supported them to meet the needs of people. Appropriate recruitment checks took place before staff started work.

People's privacy and dignity was respected and staff had a caring attitude towards people. People spoke highly of the activities made available. One person told us, “I really enjoy going out and having fish and chips.” Staff spoke highly of the management team and commented they enjoyed working at the service. One staff member told us, “I love coming into work every-day.” The service had a friendly and homely atmosphere.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report.

We saw that communal areas and people's rooms were clean and comfortable and promoted people's privacy and dignity. People and carer's views and comments were taken into account through feedback. We found that people were encouraged to make decisions and saw that people were treated with dignity and respect.

People had their individual needs assessed and we saw evidence that the service provided care which was planned in a way that ensured people's welfare. The provider had put the appropriate measures and equipment in place to maintain the care and safety of people in the building.

Staff members demonstrated a good awareness of safeguarding, were able to discuss their actions in the event of a safeguarding concern and give examples of what may constitute abuse.

The provider had a formal recruitment and selection process in place with evidence of checks being undertaken for new employees. Staff completed a thorough induction process followed by on-going training and development.

The provider had effective systems in place to monitor the quality of service provision through feedback and audits. The provider effectively dealt with risks and complaints.

People told us they were very happy and felt that staff were their friends. Three people invited us to look at their rooms and said that they had everything they wanted. One person said they would like to book additional weeks for respite, and another person told us the food was very good and they had enjoyed their dinner. We found evidence that people were encouraged to make choices and observed people being treated with respect and dignity.

We examined three care plans. We found that people who used the service, and their relatives were involved in making decisions about the care provided. We spoke with three of the care workers and they demonstrated an understanding of people's needs, and discussed how they enabled people to make choices and be independent.

We looked at staff training and supervision records. Staff told us they received the training and supervision they needed to help them provide the care and support people needed and wanted.

There were a number of systems in place to review the quality of service being provided at The Well House, including regular meetings with people using the service.