Bole Aller House

Bole Aller House (hereafter referred to as Bole Aller in the report) is a residential care home providing accommodation and personal care. The home is registered to provide care to up to 23 people. The home specialises in the care of people who have mental health needs and/or a learning disability. At the time of our inspection there were 19 people living at the home. The home is made up of different living areas known as The Main House, The Stable Block, Angel House and The Bungalows.

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

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 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.

Right Support:

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Where people lacked capacity to make decisions, the provider had failed to put in place documents to support decision making. Restrictions in people’s lives had not been considered to ensure the least restrictive options for individual people were identified.

The senior team in the home were responsive to our questions about restrictive practices and started to implement a program of review and change.

People did not all have up to date outcome focused support plans. People were not always supported to contribute to and agree support plans in ways that were meaningful to them.

Risk management was inconsistent. A lack of support plans and assessments in place meant the staff approach to risk varied. People were mostly not put at risk of harm due to this inconsistency however, it did lead to people being required to accept varying levels of restrictions in their lives.

A failure to record and monitor incidents consistently meant there were missed opportunities to avoid and reduce risks in ways that respected people’s views.

People lived in an isolated physical setting that meant most people needed staff support to go into town. Staff were alert to the potential risks associated with this, and most people went into town on a minimum of a weekly basis. The physical environment also had an impact on people’s access to the internet which put people at risk of reduced access to information and online activity. The provider was seeking to redress this issue.

People accessed specialist health and social care support where appropriate. People’s medicines were managed safely, and they received them in the way prescribed

Right Care:

People’s care plans did not show how restrictions had been agreed upon with them. There was little evidence that historical restrictions were reviewed to enable people more responsibility and freedom. In some instances, restrictions were imposed on people because of the assessed needs of other people living at the home.

Staff spoke with genuine warmth and affection for people and this care and warmth was felt by the majority of people living in the home. However, this care was not always designed to promote people's human rights.

There was a core team of staff who knew people's needs and were kind and caring.

Right Culture:

There was a failure to identify and mitigate institutionalised practices. A number of restrictive practices were found, and the routines within the home were not always personalised to individual people. The service had not been supported by the provider to ensure they were aware of and implementing current best practice and guidelines.

Internal quality assurance systems and governance processes were in place to audit or review service performance and the safety and quality of care. This oversight had not always identified or prevented issues occurring or continuing at the service. People’s rights were not embedded in these oversight tools.

There was a caring culture evident in the service. The senior team were available to the people and staff team.

The senior team in the home were committed to ensuring the best possible care and support for people.

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 22 February 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

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 risk management, consent and governance 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.

Why we inspected: This was a scheduled/planned inspection based on previous rating. The inspection had been brought forward by a few months due to complaints and concerns we received about the service.

People’s experience of using this service:

People told us they were happy living at Bole Aller. A person told us, "I love it here".

The management team had worked with health and social care professionals to address the issues that had resulted in recent concerns and complaints about the service. They had reviewed their procedures, investigated issues, and had made changes and improvements to improve the care. They had admitted to making mistakes, and had learned lessons. The improvements had resulted in people now receiving safe care.

Improvements had been made to the administration of medicines. The service had been visited by their local pharmacist a few days before this inspection who found safe systems of medicine administration and storage were in place.

They had also made improvements to their admission procedure to ensure people are carefully assessed before they move in to ensure their needs can be met.

There were sufficient staff employed with the skills and knowledge needed to meet people’s needs. Staff were well supported and spoke positively about the management team.

Support plans provided information for staff on all aspects of people’s health and personal care needs. Staff knew people well and understood how they needed to be supported. Staff were caring, patient and treated people with respect.

Rating at last inspection: At our last inspection, the service was rated "Good". Our last report was published on 19 January 2017

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

We carried out an unannounced comprehensive inspection of this service in October 2015. Breaches of legal requirements were found. We returned on 10 and 15 March 2016 and undertook a focused inspection to check whether requirements had been met. We found improvements had been made. However, we found two further breaches due to people not always receiving their medicines as prescribed; written guidance was not available to support staff to give people some of their medicines in a safe and consistent way and the provider had not acted on external advice about the implementation of written guidance for staff to follow when administering medicines. This inspection found improvements had been made.

Bole Aller House is situated in a rural area between Broadclyst and Cullompton. Accommodation is provided in two separate houses, plus a converted stable block and self-contained bungalows. The home provides support and accommodation to up to 23 people primarily with a mental health need, although people may also have a learning disability. A minibus and transport is available so people can access the community. Bole Aller House Ltd is a subsidiary of Allied Care Ltd. There were currently 13 people living at Bole Aller House.

At the time of our inspection there was no registered manager in post. 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. However, there was a manger in post who had applied to the CQC to become the registered manager at the service. During the two dates of our inspection they had a ‘fit person’ interview with a registration inspector. They have since been registered by CQC as the registered manager of the service.

Medicines management had improved greatly since our inspection in March 2016. People’s medicines were now managed so they received them safely.

People were safe and staff demonstrated a good understanding of what constituted abuse and how to report if concerns were raised. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service. People were supported to maintain a balanced diet, which they enjoyed. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff were motivated and inspired to offer care that was kind and compassionate. People engaged in a wide variety of activities on site and spent time in the local community going to specific places of interest.

There were effective staff recruitment and selection processes in place. Staffing arrangements were flexible in order to meet people’s individual needs. Staff received a range of training and regular support to keep their skills up to date in order to support people appropriately.

Staff spoke positively about communication and how the manager worked well with them and encouraged their professional development.

A number of methods were used to assess the quality and safety of the service people received and make continuous improvements.

Bole Aller House is situated in a rural area between Broadclyst and Cullompton. Accommodation is provided in two separate houses, plus a converted stable block and two self-contained bungalows. The home provides support and accommodation to people primarily with a mental health need, although people may also have a learning disability. A minibus and transport is available. Bole Aller House Ltd is a subsidiary of Allied Care Ltd.

There was not a registered manager in post at the time of our inspection. However, there was an acting manager from one of the organisation’s sister home overseeing Bole Aller House. 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.

At our last inspection in October 2015 we found that people did not always receive their medicines as prescribed due to reoccurring medicine errors. At this inspection we found the provider had taken action to improve the handling of medicines and ensure that staff identified mistakes quickly. However, there had been two further mistakes when people had not received their medicines as prescribed for them. Written guidance was not available to support staff to give people some of their medicines in a safe and consistent way.

At our inspection in October 2015 we found people were not getting out as much as they would like due to both the staffing arrangements, including not having enough drivers available. This inspection found improvements had been made. Staffing levels had been increased which meant people were able to get out more and engage in meaningful activities to aid their general well-being. The service was in the process of revisiting care planning, Wellness Recovery Action Plans (WRAPs) and how to further increase activities.

At our inspection in October 2015 we found audits were completed on a regular basis as part of monitoring the service provided. However, problems remained with regard to staffing arrangements to meet people’s specific activity needs, staff retention and morale and medicine errors had continued to occur. This inspection found improvements had been made. However, good practice suggestions had not been implemented by the time we spoke with the acting manager on 12 April 2016 for when required medicines and creams.

Prior to the inspection we had concerns raised by health professionals involved with the service. We therefore looked at people’s nutrition and found people were offered a balanced and varied diet and health promotion was encouraged.

There were two breaches in regulation. You can see what action we took at the end of the report.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 18 people living at Bole Aller and one person currently away from the home.

The summary is based on our observations during the inspection, we spoke with ten people using the service, the manager, deputy manager and six staff supporting them. Following our visit we made contact with three health professionals involved with people using the service to ask their views.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Systems were in place to make sure that the manager and staff learn from complaints, concerns and investigations carried out by the home. We looked at how complaints had been dealt with, and found that the responses had been in line with the homes policy and were open, thorough and timely. We saw the complaints procedure was available on the noticeboard in the main entrance.

The home environment was safe, clean and hygienic therefore not putting people at unnecessary risk.

Recruitment practice at the home was thorough. Staff recruitment files showed us that the service had undertaken appropriate checks.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager told us they had recently liaised with the local DoLS team for advice but not needed to submit any applications.

Is the service effective?

People's health and care needs were assessed with them, and they were involved with their care plans and monthly reviews. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service caring?

People who lived at the home told us they felt safe and were happy with the support they received. Comments included 'this is my home' and "the staff are my friends I wouldn't want to leave here". We spoke with staff who were able to tell us how they met people's care needs. We observed the support provided and spoke with the people who lived in the home. This gave us evidence that staff knew people well.

People were supported by staff who were understanding and sensitive to their needs. We saw that staff showed patience and gave encouragement when supporting people.

We spoke with three healthcare professionals, comments included, 'I am relatively happy with the care provided I have seen improvements over the past few months'.

Is the service responsive?

People completed a range of activities in and outside the service co-ordinated with the care and activity staff. The home had its own vehicle, which helped to keep people involved with their local community. On the day of our visit people told us they were going to a local pub for lunch. One person commented, 'I like to keep busy, someone will always pop me down to the town'.

We observed during our visit that several people came to speak to the manager or staff if they wanted to discuss something. We felt satisfied that the service had responded to matters to people's satisfaction.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. We spoke with three healthcare professionals who told us they had confidence in the manager and staff at the home. One comment included, 'I have recently seen improvements at the home and recognise the challenges for the staff due to the diversity and complex needs of the people living there.

Staff told us they were clear about their roles and responsibilities. We saw that there were regular staff meetings. Staff told us that they had confidence in the manager and felt well supported. Comments included, 'I know if I have a problem it will be sorted out'.

People living at the home, their relatives, staff and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed. This helped to ensure that people received a good quality service at all times.

We tracked the care provided to four people by reading their care plans and all records relating to their care, by speaking with them, and by speaking with staff and two health professionals who visited the home that day. People told us they were happy living there.

Care plans were detailed and provided staff with the information necessary to meet people's care needs. However, monthly reviews failed to cover some important areas of people's needs and this meant some risks to their health were not adequately monitored or reviewed. There was no evidence to show how people people had been consulted and involved in drawing up and reviewing their care plans.

The provider had taken action, or was in the process of taking action, to redecorate and improve the environment. The home was safe, comfortable and homely in appearance. All areas appeared clean. However, there was an odour problem in one area. We also found poor hand drying facilities placed people at risk of cross infection.

People received care and support from competent, well trained staff. There were good communication systems and staff spoke positively about their jobs.

People told us their health needs have been met through good communication between the home and health professionals. We saw that the home had supported people through illnesses to help them receive the treatment they needed.

People's involvement with the local community was encouraged even though the rural location of the home presented challenges. A good range of activities were available including gardening, growing vegetables and keeping hens.

While the grounds and smaller houses were well maintained we found that the main building was not being maintained as well as it should be or set out in a way that met the needs of people living there. The outside of the building needed redecoration and areas of the inside needed redecoration and new furniture. The communal space here was not relaxing, private or very pleasant to spend time in. Limited office space also presented problems to the efficient running of the home.