United Response - 21 North View

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance the Care Quality Commission (CQC) follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

United Response – 21 North View is a residential care home providing personal care and support to people, some of who may be living with learning disabilities and autism. The service can support up to 6 people.

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

Right Support

¿ Staff supported people to follow their interests, such as swimming, music events, film nights and accessing the local community.

¿ People were supported to access specialist health and social care support by staff who knew them well and identified changes in their needs.

¿ Staff worked with a Positive Behaviour Support (PBS) specialist to help ensure there were positive strategies in place. PBS is a person-centred framework for providing support to people with a learning disability, and/or autism, including those with mental health conditions, who have, or may be at risk of developing, behaviours that challenge.

¿ Staff ensured people took their medicines safely.

Right Care

¿ Staff were well trained and received good ongoing support from the provider. There were sufficient staff to meet people’s needs safely. The registered manager did not have well established senior support in place. We have made a recommendation about this.

¿ Staff communicated with people well, using body language and demonstrating a knowledge of people’s non-verbal cues. The registered manager acknowledged they needed to improve the way people and families could engage with care planning and review. We have made a recommendation about this.

¿ Staff upheld people’s dignity by caring for them in a patient and skilled way.

¿ Staff had training on safeguarding and knew how to keep people safe. They worked well with other agencies to identify and reduce risks.

Right culture

¿ The ethos, values, attitudes and behaviours of the management and staff were in line with the key principles of guidance such as Right Support, Right Care, Right Culture. Staff felt well supported and there was a newly permanent core to the team. They understood their roles and responsibilities.

¿ Staff regularly reviewed and audited key information and documents. Lessons had been learned from previous incidents.

¿ People and those close to them had been involved in care planning but the provider needed to do more to ensure ongoing care reviews and engagement with people and relatives was accessible and inclusive.

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 12 August 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

21, North View is a residential care home providing personal care and support to six younger adults, some of who may be living with learning disabilities and autism. The service can support up to six people.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

The service was provided from one house and was registered to support six people. It therefore conformed with current best practice guidance.

The principles and values of Registering the Right Support and other best practice guidance ensure people with a learning disability and or autism who use a service can live as full a life as possible and achieve the best outcomes that include control, choice and independence. At this inspection the provider had ensured they were applied.

The vision of the service reflected these principles ensuring people with learning disabilities have opportunities and choice and are supported to achieve their aspirations. Staff adopted the ethos to provide person-centred care that enable individuals to develop skills and behaviours to live independent lives.

Some of the people who used the service had complex needs and they did not express their views verbally about the service. During the time we spent with people we saw they appeared comfortable with staff.

Staff knew the people they were supporting well. Care plans were in place detailing how people wished to be supported. Staff had developed good relationships with people, were caring in their approach and treated people with respect.

Arrangements for managing people's medicines were safe. People received a varied diet.

There were opportunities for people to follow their interests and hobbies. They were supported to be part of the local community and to go on holiday. People enjoyed their meals and their dietary needs had been catered for.

Information was accessible to involve people in decision making about their lives. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Systems were in place to protect people from abuse. There were enough staff available to provide individual care and support to each person. Staff upheld people's human rights and treated everyone with respect and dignity.

Staff receive training and support to help them carry out their role. We have made a recommendation about staff training.

Communication was effective and staff and people were listened to. Staff said they felt well-supported and were aware of their rights and their responsibility to share any concerns about the care provided.

The atmosphere was bright and welcoming and the building was well-maintained with a good standard of hygiene.

Relatives were kept informed and involved in decision making about people’s care.

The registered manager monitored the quality of the service through audits and feedback received from people, their relatives, staff and external agencies.

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 12 January 2017).

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.

United Response – 21 North View is a purpose built, six bedded care home providing personal care for people living with a learning disability. At the time of the inspection there were six people using the service.

All of the bedrooms and communal areas are situated at ground level, with a spacious kitchen, dining room and lounge. A garden area was available for people to use during warmer weather and bedrooms were of a good size, with overhead tracking if needed by people using the service.

We last inspected United Response – 21 North View on 18 and 24 November 2015 and found it was not meeting all legal requirements we inspected against. Specifically the provider had breached. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used the service, and others, were not protected against the risks of inappropriate or unsafe care because an effective system for monitoring the service was not in place.

Following the inspection the provider submitted an action plan detailing how they would meet the legal requirement. They said they would be compliant by 1 February 2016.

During this inspection we found that the registered provider had implemented actions and improvements had been made.

A registered manager was in post and had been registered with the Commission since April 2016.

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.

An effective system for monitoring the quality of the service had been implemented. Any areas for action were noted with a timeframe for completion and a responsible person. Where action was required this had been completed in a timely manner.

We have made a recommendation about the recording of best interest decisions.

The registered manager had made applications to the supervisory body for Deprivation of Liberty Safeguards to be approved which included the use of bedrails and wheel chair lap belts.

Staff understood people’s individual communication methods and engaged proactively with people, encouraging and supporting them to make decisions about their life and the care they received. Relationships were warm and caring. It was clear from the laughter and smiles that people were relaxed and enjoyed spending time with their staff.

People were safe, and staff understood safeguarding procedures. Risks were assessed and risk reducing actions were included within a section of the support plans.

Any incidents and accidents were recorded and analysed for lessons learnt to improve the quality of the service provided.

Medicines procedures had been improved following medicine errors and they were managed in a safe way.

Support plans were person centred, detailed and provided staff with the information they needed to support people safely and appropriately. Alternative support plans were included as it was recognised people may need slightly different support if they were feeling unwell.

Staff were trained, and had attended specific training to support them to meet the needs of the people living at 21 North View, this included nutrition, autism and behaviour training. This enabled staff to support people with specialist dietary requirements.

People had a range of healthcare professionals involved in their care and staff actively engaged with them as needed.

People and staff were involved in team meetings and staff told us they were useful and supportive. Staff said the registered manager had made great improvements and the staff team were working well together. The registered manager said. “I'm proud of the staff. We are moving in the right direction.”

There had been no complaints received since the last inspection. A procedure was in place should any concerns be raised.

There was a culture of inclusion which placed people at the centre of the service.

21 North View is a six bedded care home providing personal care to people with a learning disability. It is a purpose built house situated close to local shops and amenities.

No registered manager has been in place since August 2015. 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. It is a condition of the provider’s registration to have a registered manager. A new manager was appointed in September 2015 and is just in the process of applying to become the registered manager.

In recent months seven staff resigned and although new staff have been recruited at the time of the inspection there continued to be vacancies. The registered provider was ensuring that the staffing levels remain in line with those required either via the permanent staff completing additional shifts or the use of relief staff who know the people. They were also actively recruiting new staff. However we have not been notified of these difficulties and should have been.

We found the care records were comprehensive and well-written. The care records included pictorial images to assist the people who used the service understand the content. However, we found that the monthly evaluations had not been completed since the registered manager had left.

We met with four of the people who used the service and we were able to chat to one person and a relative. Three of the people who used the service were unable communicate verbally but we found that staff could readily interpret their facial and body language. We observed staff practices and saw that the people were treated with compassion and respect. We saw that people were very comfortable with each other and staff presence and there was lots of laughter.

We saw there were systems and processes in place to protect people from the risk of harm. We found that staff understood and appropriately used safeguarding procedures.

We saw that staff were aware of how to respect people’s privacy and dignity. We saw that staff supported people to make choices and decisions.

We saw that people were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments. We saw that people had hospital passports. The aim of a hospital passport is to assist people with a learning disability to provide hospital staff with important information they need to know about them and their health when they are admitted to hospital.

Staff had received a range of training, which covered mandatory courses such as fire safety, infection control and first aid as well as condition specific training such as working with people who have learning disabilities.

Staff had also received training around the application of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The staff we spoke with fully understood the requirements of this Act and were ensuring that where appropriate this legislation was used.

People and the staff we spoke with told us that there were enough staff on duty to meet people’s needs and we observed that were sufficient staff on duty to meet people’s needs. We saw that four to five staff were on duty when people were at home and one waking night and one person who sleep-in were on duty overnight. We found that the manager was on duty during the weekdays.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

We reviewed the systems for the management of medicines and found that people received their medicines safely. However we found that that last year a couple of incidents had occurred where people had not swallowed their medicine and staff were now double signing to say they had observed the people take the medicine.

We saw that the registered provider had a system in place for dealing with people’s concerns and complaints. We saw that there was an accessible complaints policy and relatives were regularly contacted and knew how to complain. We found that relatives felt confident that staff would respond and take action to support them.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. We found that all relevant infection control procedures were followed by the staff at the home.

The registered provider had developed a range of systems to monitor and improve the quality of the service provided. We found that when the registered manager left no one had consistently completed the audits and monitored the performance. This lack of oversight had led to staff not completing the monthly evaluations of the support plans and to issues arising with the medicine practices.

We found the provider was breaching one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also highlighted that the provider did need to ensure notifications were submitted in line with the requirements of The Care Quality Commission Registration Regulations 2009. This related to be open with good governance. You can see what action we took at the back of the full version of this report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found '

Is the service safe?

Most of the people who lived at the home were unable to tell us their opinions about it because of their disabilities. We observed that they were happy and relaxed in their communications with staff. We spoke with five relatives to find out their opinions of the service. They told us they were confident their relatives were safe at the home. One commented, "I feel confident in her safekeeping. I think they are fine. The (staff) seem nice people." Another told us, 'I've never had a problem where he is. I think they do an excellent job.'

We saw that risks to people's safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe. We observed that staff were attentive to people in ways that kept them safe. For instance, a member of staff linked arms with a person with visual impairment to keep them safe in the vicinity of the stairs. We asked relatives if the staff were aware of any risks around their relative's care. They were positive about this aspect of care. One commented, 'I know they strap him into a wheelchair to keep him safe.' This showed care and treatment was planned and delivered in a way that ensured people's safety and welfare.

We found that appropriate arrangements were in place to manage medicines.

Appropriate checks were undertaken before staff began working at the home which helped ensure that the staff were fit and proper people to work with vulnerable adults.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The provider had made six applications under these safeguards and notified CQC about this.

Is the service effective?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We found that people who used the service were receiving the care and support they needed. The staff we spoke with were well informed about the assessed needs of the people they were providing with care and we saw that they put this into practice. Relatives told us people received good, effective care. Their comments included, 'The staff know what they are doing' and '(My relative) is thriving.'

Relatives acting on behalf of people using the service were given appropriate information and support regarding their relative's care and treatment and understood the care and treatment choices available to them.

We found people were supported to be able to eat and drink sufficient amounts to meet their needs. Staff understood how to support people with nutrition in ways that kept people safe.

Is the service caring?

We saw that staff were caring and had good relationships with people using the service, who we noted enjoyed contact with the staff team. We saw that staff were confident when carrying out their roles and there were enough of them, so that care of people was never rushed or pressured.

Care was individualised and centred on each person. Staff communicated effectively with people using the service, no matter how complex their needs. Relatives were satisfied with the way care was provided. One told us, "She's happy. She seems to be cared for beautifully." Another relative commented, 'We've never had any problems with the care.' Another relative who had raised concerns about some aspects of their relative's care told us, 'They have improved their care a lot and they are trying to get permanent staff. It has improved since Linda (the manager) came. She is trying to get on top of everything.'

Is the service responsive?

People's needs were kept under review and advice was sought from external care professionals, when appropriate. People participated in a range of activities both within the care home and out in the wider community. They were supported to maintain relationships with their families.

We found that the service acted promptly on any concerns about people's health and wellbeing.

We spoke with the local authority commissioning officer who told us they had been working with the service to make improvements and that the new manager was working well with them.

Is the service well-led?

A manager was in place who was registered with the Care Quality Commission. Staff felt supported by her. One commented, 'It's really improved. It's much more organised; she has made sure there is a better skill and personality mix of staff. The people living here seem happier."

Relatives and health and social care professionals spoke positively about the manager and her leadership. A relative told us, 'It has improved since Linda (the manager) came."

Relatives told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. A relative commented, 'Linda is alright. She is doing her best.'

There were effective quality assurance systems in place. Audits were carried out to check people were cared for appropriately, for instance, to make sure medicines were managed safely and address any issues promptly.

We found there was an effective system in place to monitor the quality of service provided.

We observed care and found that staff could respond to people's individual needs and cared for people in a kind and respectful way.

We spoke with two relatives of people who used the service. One person told us they thought their relative was well cared for and 'happy'. They did raise concerns about staffing. We spoke to the manager regarding this. At the time of our inspection we saw sufficient staff on duty to attend to people's needs.

The other relative we spoke with said that 'everything seems fine'. They said that 'most staff are good'. They told us how their relative is encouraged and helped by staff to do their own laundry and they said they felt they were consulted on their relative's care.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We found that records were kept securely and could be located promptly when needed.

The provider did not have an effective system in place to regularly assess and monitor the quality of service people receive.

We undertook a short observational framework for inspection (SOFI) exercise to observe the interactions between the people who used the service and the staff. SOFI is designed to be used when inspecting services for people who have some difficulty in communicating their opinions on the services they receive.

During the SOFI, we observed people being offered choices; for example, people were offered a choice of drinks and a choice of meals. Staff were seen to be attentive and gave people the information about the drink and meal options in a way that was appropriate to their needs. One person was supported by staff to choose their own snack and a drink. We observed another person being supported to make their own hot drink. In addition, we observed staff trying to engage people in discussions about the activities they had taken part in that day. We observed staff discreetly speaking to one person when they were showing signs of becoming anxious.

Throughout the inspection, the staff members on duty were observed speaking to people in a kind and respectful way. We also observed that the people were clean and well groomed.