The Fremantle Trust - Buckingham Road

We previously inspected the service on the 24 and 25 May 2017. The service was rated Requires Improvement at the time. We found two breaches of the Regulations of the Health and Social Care Act 2008 and one breach of the Care Quality Commission Regulations 2009. We found people were not always protected from fire as staff did not know how to support people in the event of a fire. Staff were not always supported in line with provider’s expectations. We found the registered manager had not always informed us of events it was legally required to do so. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions, Safe, Effective and Well-Led to at least good. At this inspection we found improvements had been made.

The Fremantle Trust - Buckingham Road 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 Fremantle Trust - Buckingham Road can accommodate seven people in one bungalow. Five people with learning disabilities were living there when we visited. Each person had their own personalised bedroom and had access to a communal lounge, kitchen, dining room and bathroom facilities. People had access to a large private garden and outdoor space.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a registered manager in post. 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.

We received positive feedback from people, their relatives and staff on how the service was led. Comments included “Staff are excellent,” “I would say Buckingham Road definitely replicates a family home” and I do feel very comfortable that he is there, well cared for and well looked after.”

Staff were aware of the need to report any incidents and accidents. Systems were in place to monitor and identify any trends or learning to prevent a future similar event.

People were supported by staff that had developed a good working relationship with them. Staff were aware of people’s likes and dislikes. It was clear from the interactions we observed people were relaxed in the company of staff and welcomed their support.

People were supported to engage in meaningful activities and keep in contact with family and friends. People attended external social groups both during the day and in the evening. On day one of inspection one person was excited as they were going to a social club that evening.

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. Staff

Improvements had been made to the environment. Equipment used by people was serviced on a regular basis.

We received positive feedback about how the service was managed. One relative told us “(Name of registered manager) is driving improvements”. The whole staff team worked together to provide a homely environment and support people to live a fulfilling life.

We previously inspected the service on 29 April and 1 May 2016. The service was not meeting one the requirements of the regulations at that time. This was in relation to cleanliness and maintenance of the premises. This was because there was mould growth in the laundry room and more significant areas in the shower room. We asked the provider to take action to make improvements. They sent us an action plan which outlined the measures they would take. We found improvements had been made.

The Fremantle Trust – Buckingham Road provides care for up to seven people with learning disabilities. Six people were living there at the time of our visit.

The service had a registered manager in post. 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. There had been changes to management since the previous inspection. The current registered manager had been in post since July 2016.

We received positive feedback about the service. A relative told us they were very happy with their family member’s care adding they were “Very well looked after.” They said their family member “Goes out most days and is always quite happy with the place.” Another relative commented “The care is very good, she’s looked after very well and has a good key worker.”

People were protected against the risk of abuse. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. People’s medicines were handled safely and given to them in accordance with their prescriptions. People were supported with their healthcare and nutritional needs. Staff knew the people they supported well and treated them with kindness and compassion.

People were not always protected against the risk of fire. We found staff had not taken part in fire drills at the frequency the provider expected. There were no records of who had attended drills. This meant there was a risk of some staff not knowing the safest way to respond in the event of a fire. A recent inspection by the fire safety officer highlighted some areas where improvements were needed. One of these was to increase staffing levels at night time. We have made a recommendation for staffing levels to be reviewed in light of this.

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.

Care plans had been written to record the support people needed. Risk assessments were in place to reduce the likelihood of people experiencing injury or harm. People accessed the community and took part in a range of activities.

Recruitment procedures had been followed in all but one case in the sample of staff files we looked at. We have made a recommendation about protecting people from the potential risk of harm where one member of staff requires a criminal records check to be undertaken.

Systems to support and develop staff had not always been used effectively at the service. We found staff had not received supervision and appraisal in line with the provider’s expectations. Training for some staff had not been kept up to date to make sure their skills were refreshed.

People’s care was monitored by the provider through visits and audits. However, we found some areas of practice had not been maintained to the standards we noted at the previous inspection.

The registered manager had informed us about some of the events which the Care Quality Commission needs to be notified of. However, there were two serious injuries that we had not been told about.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to providing safe care and treatment and staffing.

We also found a breach of the Care Quality Commission (Registration) Regulations 2009, as the service had not notified us of all important events.

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

We set compliance actions for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant. They said they would have completed improvements by the end of July 2014.

We returned to the service on 29 August 2014 to check whether the improvements had been made. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found the provider needed to take action to ensure Buckingham Road provided a safe service.

There was some improvement to record keeping at the service and the office was now kept in better working order. This meant information was easy to locate when needed. There was improvement to care plans but further work was needed to make sure they fully reflected people's needs, so that staff could support people safely and appropriately. We found required documents were not always in place in recruitment files, to reflect that appropriate checks had been carried out. This meant some of the records were still inaccurate.

People who lived at the home were no longer prevented from accessing the kitchen. The provider had de-activated an upper door handle which had prevented people from going into the kitchen without staff supervision. The manager was aware of who to contact within the local authority if any applications were required to deprive people of their liberty. This helped to ensure people who used the service would only be deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards.

We saw appropriate checks were undertaken before staff began work. This included uptake of references and enhanced Disclosure and Barring Service checks for criminal convictions and inclusion on lists of people unsuitable to work with vulnerable adults. This showed the service used thorough recruitment practices to protect people from the risk of harm.

Is the service effective?

We found the provider needed to take action to ensure Buckingham Road provided an effective service.

We saw improvements had been made to ensure staff received appropriate professional development. Staff were now receiving supervision to discuss their developmental needs and staff meetings were taking place regularly.

Some training had taken place since our last visit. However, we found there were over 40 courses collectively that staff needed to be booked on to bring them up to date with the provider's training requirements. This meant staff may not have had the necessary skills and knowledge to meet people's needs safely and appropriately.

Is the service caring?

We found the provider needed to take action to ensure Buckingham Road provided a caring service.

The care plans we read had not been updated with all the information staff needed to support people safely. For example, one file lacked guidance on managing the person's behaviour and use of 'as required' medication to calm them. This meant there could be inconsistencies in how people's care was delivered.

Is the service responsive?

We found the provider needed to take action to ensure Buckingham Road provided a responsive service.

At our previous inspection, we set a compliance action for the provider to produce care plans in accessible formats for people. We found insufficient progress had been made with this work. This meant the provider had not made reasonable adjustments to reflect people's needs.

Is the service well-led?

We found Buckingham Road provided a well-led service.

We saw the provider was now using its systems to regularly assess and monitor the quality of service that people received. There was evidence of regular unannounced monitoring visits, for example, to check the quality of people's care. The provider may find it useful to note the home was working to an action plan to improve the service which had different timescales than the version submitted to CQC. This meant there were still actions which had not been fully completed, such as staff training. The provider had not informed us of any change to their submitted action plan. We therefore expected all improvements to be completed by the timescale they gave us of the end of July 2014. This showed there was still an element of monitoring which needed to be looked at by the provider.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

There were policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. No applications had been submitted to deprive anyone of their liberty. We noted staff restricted people's access to the kitchen at times, as they had concerns one person may come to harm. This action had not been authorised and prevented others from going into the kitchen when they wished to. This meant proper processes had not been followed in relation to the Mental Capacity Act 2005.

We looked at a range of records as part of our visit. We found people's personal records, such as care plans, were not always updated in a timely manner. This meant there could be inconsistencies in the way their care was delivered. Records overall had not been managed in a safe and organised manner. This made information difficult to find and unreliable.

There were enough staff on duty to meet people's needs. The staff we met and spoke with during the inspection were knowledgeable about people's needs and had established good rapport with people. We observed they were responsive to people's needs and provided care in a timely manner.

We looked at staff recruitment practice. We noted some gaps to required checks in one of the files we read. There were no references for the member of staff, to verify their conduct in previous employment and suitability to work with vulnerable people. This may have placed people at risk of harm and meant we could not be confident appropriate checks were always undertaken before staff began work.

Rotas showed temporary staff were regularly used at the home. These staff had been supplied by the provider's staffing agency. However, there was no documentation at the home to verify their skills and experience. This meant we could not be certain people were always cared for, or supported by, suitably skilled and experienced staff.

Is the service effective?

Staff completed a thorough induction, in line with the nationally-recognised Skills for Care induction. This meant staff were given an appropriate introduction to the care sector and the skills and attributes necessary for their role.

The provider had a programme for the on-going learning and professional development of staff. Records showed staff had not kept their training up to date. An analysis of training needs showed 12 staff needed to complete over 60 courses collectively, to bring their learning up to date. In some case, updates were overdue by several years. This showed staff had not received appropriate professional development.

Staff had not received the support and guidance required for their jobs. Supervision frequency was below the provider's minimum standard of six sessions a year. Only two staff meetings had been held in the past year. This meant staff were not provided with regular opportunities for personal development and to share ideas, to improve practice at the home.

Is the service caring?

People's needs were assessed but information had not always been updated in care plans to ensure they reflected their current circumstances. This meant there could be inconsistencies in how people's care was delivered.

When we visited the service in May 2013, we were told work would take place to produce care plans in formats which people could understand. During this visit, we found no progress had been made to achieve this. This meant the provider had not made reasonable adjustments to reflect people's needs.

We looked at one example where a person was prescribed calming medication. Staff were knowledgeable about the person's needs and the reasons why the medication was prescribed. They told us, and records confirmed, the medication was rarely used. This showed the person's care was delivered in a way that was intended to ensure their safety and welfare.

Risk assessments had been written for a range of activities and situations. For example, moving and handling, going into town and making hot drinks. These assessments had been written or reviewed within the past year. This helped reduce or control the potential for people to experience harm.

Is the service responsive?

People's privacy and dignity were respected at the service. We observed people were supported to look well presented, clean and tidy. Staff knocked on bedroom and bathroom doors before they entered, to safeguard people's dignity. All personal care was provided in private and people had single rooms. This ensured their privacy and dignity were promoted at the home.

People were supported in promoting their independence and community involvement. During the two days of inspection, we observed people were supported to go out into the community. This ensured they maintained links with the community and engaged in regular activities outside of the home.

Is the service well-led?

The provider had a system of carrying out annual quality assurance audits of its services. The annual audit for Buckingham Road was in progress on the first day of our inspection. We spoke with the staff carrying out the audit about their findings. They had noted areas where practice needed to be improved at the home. An improvement plan had been written by the second day of our visit, outlining the actions needed and timescales for completion. We saw prompt progress to ensure matters were put right.

The provider had a system to regularly assess and monitor the quality of service that people received. However, we saw this was not fully in place at Buckingham Road. We found monitoring of the service had not been undertaken monthly by senior management, as expected by the provider. This meant the quality of care provided at the home had not been regularly assessed and monitored, to ensure it was meeting people's needs.

We returned to the service on 23 May and 20 June 2013 to check whether improvements had been made. We saw pictures and photographs were used to help people communicate their wishes. Two people we spoke with told us they made choices about their care. Staff had supported one person to obtain an advocate to help them express their views. We saw one person's care plan clearly stated their preference for a female member of staff to help them with their personal care. This choice was respected.

We found one person had been referred for psychiatric assessment, to determine their capacity to make decisions about their medical care. This showed the service acted appropriately, and in accordance with legal requirements.

We were satisfied the service was meeting this standard.

Care plans contained information such things as who is important to me, important information you need to know about me. We saw records of peoples individual health needs such as opticians, dentist, epilepsy management, medication reviews and health checks were regularly carried out.

Appropriate arrangements were in place for obtaining, storing, administering, disposing of medicine and regular auditing. The records showed that staff signed for the administering of medication. Two staff signed for the administering of controlled medication in the controlled drugs book.

We were told that the service had not received any complaints within the last year. We saw that some concerns were raised in the people`s house meetings, which were appropriately addressed by the manager at the time to the persons satisfaction.

A person we spoke to told us that if they were unhappy about anything they would tell the manager.

Staff we spoke to told us that they received regular supervision, one person said "The senior staff are approachable and very supportive. We saw that staff received regular training and updates.