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Inspection carried out on 11 July 2017

During a routine inspection

This inspection was carried out on the 11 July 2017 and was announced.

Palm Care is registered to provide accommodation and personal care for up to six people. People living at the service had a range of learning disabilities. Some people were living with autism and required support with behaviours that challenged.

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 carried out an unannounced comprehensive inspection of this service on 19 and 20 May 2016 and Palm Care was rated ‘Requires Improvement.’ There were breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. We issued requirement notices relating to safe care and treatment, fit and proper persons employed, person centred care, need for consent and good governance. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. At this inspection, improvements had been made and the breaches had been met.

Since the last inspection, the manager had registered with the Care Quality Commission. Staff and relatives had fed back that the registered manager had a positive impact on the service. The registered manager had asked for regular feedback from stakeholders to ensure they felt improvements were being made. All the feedback was positive, and included comments such as, ‘Since [the registered manager] took over the standard of care, facility cleanliness and communication has risen sharply. Palm Care really feels more like a home for its residents now.’ There was a positive, inclusive culture within the service.

People were relaxed in the company of staff and staff knew people well. 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. When people’s liberty was restricted the registered manager had made Deprivation of Liberty Safeguards applications (DoLS) to the local authority. There was enough staff to keep people safe and people received their allocated one to one hours from staff to ensure they receive the support they needed. Risks relating to people’s care and support were assessed and mitigated. Some people displayed behaviour that could be challenging and there was clear guidance in place to minimise the chances of people becoming distressed. The environment was safe.

Staff treated people with respect and dignity. People participated in weekly ‘my time’ sessions where they spent time with staff and identified goals and things they wanted to achieve. People took part in a variety of activities and led busy and active lives.

Staff had made prompt referrals to healthcare professionals when they needed additional support and advice. When people’s health care needs changed, there was clear guidance available for staff. People received their medicines as and when they needed them. People were supported to eat and drink safely.

Staff knew how to recognise and respond to abuse and the registered manager had reported any safeguarding concerns to the local authority. Action had been taken to ensure they did not occur again. Complaints were documented and responded to in line with the provider’s policy. People and their relatives told us they were happy with the support provided.

Staff received appropriate training and were supported by the registered manager to carry out their roles effectively. The registered manager completed a

Inspection carried out on 19 May 2016

During a routine inspection

This inspection took place on the 19 and 20 May 2016 and was unannounced. Palm Care provides accommodation and support for up to six people who may have a learning disability, autistic spectrum disorder or physical disabilities. At the time of the inspection four people were living at the service. Palm Care was last inspected on 14 October 2014 where no concerns were identified. All people had access to a communal lounge, dining room, kitchen, shared bathrooms, a laundry room and garden.

This service requires that a registered manager be 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. The registered manager had resigned and had been de-registered from the service in October 2015. The provider had appointed a manager to manage the home. They were in the process of registering with the Care Quality Commission (CQC) at the time of our inspection. The new manager was present throughout both days of the inspection.

People had not received their one to one hours to enable them to pursue activities outside of the service because there was not enough staff on duty. The provider had taken steps to improve this and new staff were being recruited. People were not protected from robust recruitment procedures. The provider had not ensured newly employed staff were of good character and suitable for the role. People’s dignity was not always met.

Not all risk assessments had been kept up to date which meant staff did not have current guidance to follow to support people safely.

People had not always received their prescribed medicines, and the overall management of people’s medicines was not robust. There had been two recent incidents where people had not received their medicine due to staff errors.

Not all staff had completed or kept the essential training necessary to complete their role effectively up to date. People were not being supported by staff with the most current knowledge or understanding of good practice.

Capacity assessments and best interest decisions for less complex decisions had not been assessed or documented when restrictions were placed on people. When people had been deprived of their liberty the authorisations required had not been applied for. This was not meeting the requirements of The Mental Capacity Act 2005.

Some documentation was conflicting and out of date. The new manager had taken steps to start improving and updating some of the paperwork.

People were supported well to monitor their health care requirements. People were supported to access outside health professionals when needed. Not all staff had current training to support a person with their epilepsy although they had good knowledge of the protocols they should follow if the person had a seizure.

Staff had a good understanding of how to raise any concerns they may have about people’s safety and wellbeing. Appropriate guidance was available for staff to refer to.

Staff demonstrated caring attitudes towards people and showed concern for people’s welfare. When people required to be supported with their anxieties staff did this in a patient and compassionate manner.

The service lacked oversight and a robust system of auditing to improve outcomes for people. The new manager understood the key challenges of the service and had started to make changes to improve the service people received. Staff felt they were offered enough supervision and support by the new manager.

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

Inspection carried out on 14 October 2014

During an inspection to make sure that the improvements required had been made

An adult social care inspector carried out this inspection. We undertook this inspection to follow up on compliance actions in regard to care and welfare of people who use services, management of medicines and assessing and monitoring the quality of the service provision, which we gave at our last inspection in June 2014.

At the time of this inspection there were 4 people accommodated at Palm Care. We met all four people who used the service. Due to the communication needs of people, we observed how people spent their time and their interactions with staff and the registered manager. People indicated they were happy and relaxed in the company of staff.

We spoke with the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) and shares the legal responsibility for meeting the requirements of the law with the registered provider. We also spoke with two staff. We reviewed records including care plans, risk assessments, medicine administration, medicine guidelines, an incident report and daily report, mental capacity assessments and checklists, supervision monitoring, provider quality assurance visits and other records relating to the management of the service.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, discussions with the registered manager and staff and the records we looked at.

Is the service safe?

Risks associated with people’s care had been assessed and guidance was in place to ensure staff took a consistent approach and people remained safe. For example, risks related to challenging behaviour.

Where medicines were prescribed “as required” guidance was in place to ensure that people received medicines consistently and safely.

The manager had introduced a new system that would evaluate incidents and accidents once they had happened, so that staff would receive a debriefing session and lessons could be learnt, reducing the risk of further occurrence.

Is the service effective?

It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well.

People’s needs were assessed by the service. Care plans were in place for each person, which detailed people’s wishes and preferences, their skills and abilities and what help they required from staff. This meant care and support was delivered in a consistent way promoting people’s independence as much as possible.

There were no Deprivation of Liberty Safeguards authorisations in place, although one application had been made. Staff understood the importance of supporting people to make their own decisions. They were getting to grips with linking their training in the Mental Capacity Act 2005 to practice, such as identifying when a formal assessment of a person’s mental capacity was required. For example, when restrictions, such as locked doors were in place. Further training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was booked.

We saw that changes had been implemented in line with the service’s action plan to meet regulatory requirements in regards to the shortfalls identified at the previous inspection. For example, most of the service had been redecorated, resulting in a bright and more homely environment for people who lived at Palm Care.

Improved reporting and monitoring procedures had been introduced, which highlighted areas where improvements could be made in the service and we found that these changes were working well to improve the quality of the service provided.

Is the service caring?

We saw that people’s privacy and dignity was respected. For example, the registered manager asked a person if they could show the inspector their new shower, before he did so.

During the inspection we saw that staff adopted a kind and patient approach when dealing with people. Staff were patient when supporting a people and understood what their actions and body language meant when they were trying to make their needs known. We saw good interactions between staff and people who lived at Palm Care.

Staff demonstrated a kind and caring approach when discussing people that used the service during the inspection.

Is the service responsive?

Staff were responsive to people’s needs. We saw and heard during the inspection that people were able to make their views known about what they wanted in relation to their day to day care and support. We saw that staff responded and respected these wishes. People had regular review meetings with staff, their relatives and their care manager to discuss their future.

Is the service well-led?

There was a clear management structure in place. Staff knew their roles and responsibilities. Staff had an understanding of the ethos of the service and quality assurance processes had been strengthened and were effective. Staff received supervision. We saw that the manager was accessible to both people who used the service and staff.

Inspection carried out on 9 June 2014

During a routine inspection

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

During this inspection we spoke with two people who used the service. Due to the communication needs of people only one person was able to talk to us about their experience of living at Palm Care. The other person we spoke with indicated that they were happy and liked living at Palm Care. We observed how people spent their time and their interactions with staff. We also spoke with two staff and a health care professional who was visiting the service during our inspection. We reviewed care plans and other records relating to the management of the home.

We later telephone three relatives to get their feedback on the care and support provided.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People and their relatives told us they felt the service was safe. Safeguarding procedures were robust and staff understood their role in safeguarding the people they supported.

The service had systems in place to keep people safe and we saw that the majority of risks associated with people’s care and support had been assessed. However the assessments did not always promote the rights of people or give clear guidance about how to support a person safely. We have told the provider to take action about these concerns.

Staff had received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DOLS). There were no Deprivation of Liberty Safeguards authorisations in place, and no applications had been made.

People who used the service, at times displayed behaviours, which might challenge others, such as aggression. We found that assessments giving guidance to staff about how to manage such behaviours required further information, in order to keep people safe. We have told the provider to take action about these concerns. Staff had the necessary skills and training to manage challenging behaviour and there had been a decrease in the number of incidents relating to one person using the service.

People received their medicines when they should. Medicines were stored and administered safely. However where medicines were prescribed “when required” there were not always clear guidelines in place for staff, to help ensure people received this medicine safely, at the right time and in the right doses. We have told the provider to take action about these concerns.

Is the service effective?

People had their needs assessed prior to moving into the service. There was a thorough transition period for people including visits to the service.

People told us that they were “happy” with the care they received, they “liked living here” and felt their needs were met. Relatives said they were satisfied with the care and support people received. One relative said, “I’m quite impressed”. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well.

Care plans were in place for each person, which reflected our observations of the care and support received. However there was a lack of evidence of people’s or their representative’s involvement in care planning or reviews. One relative told us they had attended a review meeting and had seen their family members care plan.

People had access to health care professionals to make sure their health care needs were met.

Staff had opportunities for individual and team meetings and appraisals. They had received training to meet the needs of the people living at the service.

Is the service caring?

People told us “all the staff are kind”. Relatives spoke positively about the staff and felt they were “professional” and “very attentive”.

During the inspection we saw that staff adopted a kind and caring approach when dealing with people. Staff were patient during medicine administration, they explained what they were doing, whilst encouraging people to take their medicines. We saw very good interactions between staff and people who lived at Palm Care.

People were treated with dignity and had their privacy respected. Staff demonstrated a kind and caring approach when discussing people that used the service during the inspection.

We saw that people’s communication skills were detailed in their care plans, in order that staff understood when people were making their needs known.

Is the service responsive?

We saw during the inspection people were able to make their views known about what they wanted in relation to their day to day care and support. We saw that staff respected these wishes and choices. One relative said, “They think about how to involve X (family member)”.

Staff told us relatives had been sent quality assurance surveys last year, but none had been returned. One relative had written a positive compliment following a visit to the service. However there was a lack of evidence of other opportunities to offer views and feedback, such as review meetings.

People were subject to some restrictions within the service, such as access to rooms and some food and drink. We saw that care plans lacked information about people’s capacity to make decisions in relation to their care and support and these restrictions were not based on assessments, but the behaviour of some people living at the service. We have told the provider to take action about these concerns.

People had opportunities to undertake a variety of activities. People told us they went out regularly to appropriate activities and attractions. We saw that people were able to spend time as they wished within the service.

Is the service well-led?

The majority of relatives who we spoke with felt they had opportunities to feedback their views informally on the service provided, but were not asked specifically for feedback. The majority felt that communication with the service and accessibility of the registered manager was good.

People benefited from a service where there were systems in place to monitor and learn from accidents and incidents, so that risks to people of future occurrences were minimised.

Staff undertook regular audits and checks within the service. However we found that these were not always effective in identifying shortfalls or where shortfalls were identified they were not always reported or resolved in a timely way. We have told the provider to take action about these concerns.

Staff felt supported by the registered manager. They felt there was an open and supportive culture meaning they felt comfortable in taking any concerns forward. There were systems in place to monitor that staff had the necessary training and skills to meet the needs of people who used the service.

Inspection carried out on 6 June 2013

During an inspection to make sure that the improvements required had been made

At the time of inspection three people were living at the service. We used different methods to help us understand the experiences of people because they had complex needs which meant they were not able to tell us their experiences. We spoke with the manager and one staff member about the service. The staff member told us there had been changes since the new manager came into post, they told us “I want to come to work now.” They added “It was nice to see things actually being done. The service users are happier since the changes”. They told us that one person’s bedroom had recently been redecorated and the person now slept better at night and spent more time in their bedroom.

At our inspection on 17 May 2012 we identified concerns in relation to the maintenance of the environment. At this inspection we saw that areas identified had been addressed and there were systems in place to effectively monitor the safety of the environment.

Inspection carried out on 17 May 2012

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not always able to tell us their experiences. We observed how people interacted with staff and the management of the service. We saw people were supported appropriately.

Reports under our old system of regulation (including those from before CQC was created)