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Inspection carried out on 25 July 2017

During a routine inspection

We inspected this service on 25 July 2017. This was an unannounced inspection.

The service is registered to provide accommodation and personal care for up to six people. People who use the service have learning and physical disabilities. At the time of our inspection five people were using the service. The service is owned and managed by Community Integrated Care [CIC], which is a non-profit making organisation. Staff members are on duty twenty-four hours a day. The people who live in the home have resided there for many years.

At our previous inspection in February 2017, we rated the service as 'Inadequate’ and placed it into special measures. This was because there were a number of regulatory breaches. Risks to people's health, safety and wellbeing were not always assessed and planned for. People did not always receive their prescribed medicines in a safe way. People's health needs were not always effectively monitored and advice from healthcare professionals was not always followed to promote people's wellbeing. Staffing levels were not consistently maintained to ensure people received their care in a timely and responsive manner and there were some gaps in staff training. The requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were not always followed, which meant some people were potentially being unlawfully deprived of their liberty. The information staff needed to provide people with consistent care was not always available. People were not always enabled to be involved in making choices about their everyday care. Effective systems were not in place to assess, monitor and improve the quality of care. The registered manager and provider did not always notify us of reportable incidents and events that occurred at the service and the service's inspection rating was not being displayed as required by law.

At this inspection, we identified significant improvements had been made to ensure people received care that was safe, effective, caring, responsive and well-led. We have taken the service out of special measures.

The service has 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’. 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.

Most people living in the home were unable to converse with us, but we observed staff providing support to people throughout our inspection visit. We saw they were kind and patient and showed affection towards the people in their care. We saw that people who lived at the home were clean and well dressed and they looked relaxed and comfortable in the care of staff supporting them.

There were good systems in place to protect people from harm. Risks were assessed and planned for. Staff had a good knowledge of people’s individual needs and of what people liked or disliked and of how they wished to live their life. Care plans were person-centred and people were consulted in areas such as who supported them, what they did with their day and making decisions about their lives.

People's nutritional needs were met. We saw regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration.

People had access to healthcare professionals and their advice and guidance was followed to ensure people’s healthcare needs were addressed. People were given their prescribed medicines at the right times.

The registered provider understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant they were working within the law to support people who may lack capacity to make their own decisions.

The service had a complaints procedure which was made available to people and their relatives.

We found staff had been recruited safely and were appropriately trained and supported. They had the skills, knowledge and experience required to support people with their care and social needs. Staffing levels were sufficient to meet the needs of people who lived at the home and enable them to play an active part in the local community. Discussions with staff members identified that they now felt happy and supported and worked well as a team.

The provider had now implemented a robust quality assurance system which used various checks and audit tools to monitor and review the practices within the home. These included seeking the views of people who used the service and their families or representatives, seeking the views of staff and a regular programme of audits carried out by the registered manager, the regional manager and their Quality Excellence team.

The home’s inspection rating was displayed and the registered provider had notified us of reportable incidents and events since the last inspection.

The local authority who commissioned care for people who lived at Holmdale told us that they thought it was now a good service.

Inspection carried out on 15 February 2017

During a routine inspection

We inspected this service on 15 February 2017. This was an unannounced inspection. At our previous inspection in February 2015, we rated the service as ‘Requires improvement’. This was because improvements were needed to ensure people received care that was safe and effective.

At this inspection, we identified that the required improvements had not been made, and we also identified further areas that required improvements to ensure people received care that was safe, effective, responsive and well-led. We identified a number of Regulatory Breaches. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore been placed into ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service is registered to provide accommodation and personal care for up to six people. People who use the service have learning and physical disabilities. At the time of our inspection five people were using the service.

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’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Risks to people’s health, safety and wellbeing were not always assessed and planned for to ensure people received care that was consistently safe.

People did not always receive their prescribed medicines in a safe, effective and dignified manner.

People’s health needs were not always effectively monitored and recorded as planned, and advice from healthcare professionals was not always followed to promote people’s health, safety and wellbeing.

The provider’s recommended staffing levels were not consistently maintained to ensure people received their care in a timely and responsive manner. There were some gaps in staff training that meant the staffs’ training needs were not always being met.

The requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were not always followed. This meant some people were potentially being unlawfully deprived of their liberty.

The information staff needed to provide people with consistent care that met their preferences and needs was not always available.

People’s dignity was not consistently promoted and, people were not always enabled to be involved in making choices about their everyday care. This was because appropriate communication tools were not always available.

People were supported to eat and drink, but this support was not always provided in accordance with professional advice to protect people from the risk of choking.

Effective systems were not in place to assess, monitor and improve the quality of care.

The registered manager and provider did not always notify us of reportable incidents and events that occurred at the service and the service’s inspection rating was not being displayed as required by law.

A complaints procedure was in place for people to follow if required.

Staff knew how to identify and report potential abuse.

We observed some positive and meaningful interactions between the people who used the service and the staff, which showed staff knew people well.

Inspection carried out on 27th February and 12th March 2015

During a routine inspection

This inspection took place on 27 February and 12 March 2015 and was unannounced.

Holmdale can support up to five adults with a learning disability and physical disability. Holmdale is owned and managed by Community Integrated Care, which is a non-profit making organisation. The service is located in Runcorn near to local amenities. The building is purpose built and can accommodate people with mobility needs as they have various specialised equipment including ceiling track hoists. Staff are on duty 24 hours a day.

Holmdale has 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’. 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.

During our last inspection on 3 September 2014 we found that Holmdale was not meeting the regulations inspected. We found breaches for Regulation 22 regarding not having enough staff in place, Regulation 10 not having an adequate system to monitor the quality of the service and Regulation 20 not having appropriately recorded records. We received a detailed action plan from the provider stating what actions they had taken to meet the regulations and show compliance. We found improvements to the management of the home and compliance in the management of staffing levels, records and monitoring of the quality of the service.

There were five people at the home on the day of our visit. We spoke with people living at Holmdale and relatives/representatives who acted on their family member’s behalf. They were happy with the care provided and the staff providing support. We observe a friendly rapport between people being supported and the staff. The atmosphere was relaxing and calm.

Everyone in the service looked happy and comfortable with the staff.

Staff knew the people they were supporting very well. Care plans were in place detailing how people wished to be supported. Relatives/representatives and people receiving support were involved in making decisions about their care. Staff were knowledgeable about risks and how to protect each person in keeping them safe and comfortable.

Most of the staff were up to date with training necessary for their role and felt well supported with their training needs. They had the skills and knowledge required to support young adults with their health and care needs.

Staffing levels were provided in accordance with the commissioned hours funded and agreed with the registered provider. Everyone was happy with the staffing levels provided.

We found the home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and staff followed the Mental Capacity Act 2005 for people who lacked capacity to make decisions for themselves.

Staff supported people to attend healthcare appointments and liaised with their GP and other healthcare professionals as required to meet people’s needs.

Medicines were securely stored in a locked cupboard and were safely managed.

The registered manager was accessible and approachable. Staff, people who lived at Holmdale and their relatives felt able to speak with the manager and provide feedback about the home. The registered manager worked at the home each week in a ‘hands on’ capacity. The area manager regularly visited the service to review the quality of the service provided.

Inspection carried out on 3 September 2014

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

We considered our inspection findings to answer questions we always ask;

• 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-

Is the service safe?

There was no evidence that staffing levels were accessible and shared with people living at the service. There was no evidence of any tools to show how the staffing levels were reviewed and monitored to people meet each person's needs. We found no evidence of how staffing levels were managed to organised weekly support to people socially within the community.

Is the service effective?

One relative/representative told us they were happy with the care that had been provided to their relative and they felt their needs were being met.

Following our last visit the service had purchased weighing scales which were specific for the needs of people living at Holmdale. This meant that the staff were regularly identifying, by using this equipment, any issues with weight loss. Staff were supporting people appropriately with nutritional assessments.

Is the service caring?

One relative/representative told us they always saw positive standards of support provided. They felt the staff knew each person very well and they noted how well they got on with each person, every time they visited Holmdale.

We did note various examples of good practice and good communication and support by most of the staff team who interacted with people in a positive manner. However we noted that on two occasions staff members did not acknowledge people sat in the lounge as they entered their home. Then later in day, staff were openly having a discussion about concerts and events within hearing of the people they were supporting. We discussed these points with the manager and the provider following our visit.

Is the service responsive?

Each person living at the service had a person-centred support plan in place to help to show how their needs would be met at the service. However records showed that people's social needs and interests had not always been recorded and reviewed. Support plans had been developed with the use of activity sheets but on occasions some records identified just one trip out in a month for one person. The manager advised that everyone was supported to go out socially at least once a week. Records had not been kept up to date and were unable to demonstrate that each person was being supported to access activities that were important to them on a daily basis.

Is the service well-led?

Staff told us they felt well supported by the manager and felt confident they could raise any issues and suggestions. Staff felt well led and well managed. The manager produced various audits for medication, health and safety and daily handovers between staff. These audits included a lot of checks that staff signed to confirm they had been carried out. Regular audits and checks helped to show how the service was managed for the benefit of keeping people safe.

We have noted that there have been issues around the management of records at both inspections over a three month period and this indicated that the service was struggling to keep records organised and accurately reviewed. We discussed these points with the manager and the provider following our visit.

Inspection carried out on 24, 25 April 2014

During a routine inspection

We considered our inspection findings to answer questions we always ask;

• 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-

Is the service safe?

Staff told us they had enough staff on duty to meet the needs of the people living at Holmdale. The manager offered regular support and was included in the care hours and regularly worked 'hands on' with her staff team to ensure the support was delivered safely and effectively. However we found just two staff on duty with four people living at the service all dependant on staff for support.

Staff had received updated training in safeguarding and felt confident in being able to maintain people's safety. Staff were confident they would be listened to by managers and supported with reporting procedures to safeguard people living at the service including assistance and support to go out socially.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had been submitted, the service did have appropriate policies and procedures in place including guidance on the 'Mental Capacity Act.' These arrangements helped protect the interests of vulnerable people who lacked ability to consent on various issues.

Is the service effective?

One relative told us they were very happy with the care that had been provided to their relative and they felt their needs were being met. We observed the support being provided and it was clear the staff were knowledgeable of people's needs, in particular their non-verbal signs for communicating. Staff discussed the individual needs of each person they supported. Staff described the care and support they provided on a day to day basis including 'passive exercises' and support with semi solid drinks to assist people with specific needs with swallowing.

A range of policies were in place and accessible by all staff. Updated policies ensured staff were effective in delivering care measured against good practice.

Is the service caring?

We observed staff speaking respectfully to people as they approached them so they were aware who was supporting them. Staff always asked them what they would like to drink, eat and what they wanted to wear. Staff were friendly and helpful to the people they were supporting. We observed that people being supported were relaxed and happy in the company of their support staff.

We spoke with two relatives/representatives of people living at the service. They made various positive comments such as: "I can't fault them" and "I am more than pleased with how my relative is supported."

Is the service responsive?

Each person living at the service had a person-centred support plan in place to help to show how their needs would be met at the service. However records showed that people’s choices, interests and diverse needs had not always been recorded or reviewed and care and support had not been planned to show how they would be supported with their healthcare needs. Although staff and relatives felt that support was provided to meet people's social needs, support plans were unable to demonstrate that each person was being supported to access activities that were important to them.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities and that they felt well supported by the manager and the provider and felt confident they could raise any issues and suggestions. Staff felt well led and well managed.

The services manager and area manager organised and carried out various audits regarding the management of the service to ensure consistent good practices. However we found some disorganisation with in-house audits. One audit in December 2013 found that care plans needed improvements but at the time of our inspection we found that these improvements were still outstanding.

Relatives told us they were always kept informed and updated regarding their relatives support and needs. However the service lacked evidence to show how people living at the service and their relatives and representatives were included in the development of their support and the management of the service.

Inspection carried out on 15 May 2013

During a routine inspection

We met everyone living at Holmdale throughout the day. One person was out shopping with staff. People living at the service looked happy and comfortable with the staff supporting them.

We spoke to two people who supported their relative while they lived at Holmdale. They made various positive comments such as:

“They are very welcome and we have been told we can visit at any time, our relative seems very happy there” and “they appear well cared for.”

We met all of the staff working for the service. They were knowledgeable about the people they supported and were positive about the support they provided. They were able to describe how they would support people to ensure they offered the assistance that people needed and requested.

Staff told us that they always based their support around each person’s right to choose what they wanted to do each day. One person told us they get to know each person’s likes and dislikes in particular those people who had non verbal signs of communication. The staff supported people in making their own choices regarding what they wanted to do for the day

Inspection carried out on 10 July 2012

During a routine inspection

People who lived at the home were not able to tell us about their experiences of using it or comment about the care and support they received, due to their complex needs. We therefore spent time observing how people were cared for and how they communicated with the staff. General observations were made throughout the visit and we had discussions with staff, a visitor and a relative to obtain their views. We also looked at two people’s care records.

We spoke with a relative and a visitor who told us what it was like at the home and how staff provided the care and support. The following comments were provided:

“I call here every week and I am always made welcome.”

“I know he is happy and well cared for.”

“I have never seen any mistreatment. If I did I would tell them. (Staff).”

“I attend all the care reviews and I have an input.”

“The manager is very approachable.”

“X has been in the home since it was opened.”

“I am very happy with her care.”

“X is very happy.”

“I visit regularly.”

“The staff are very kind. They are absolutely wonderful. I have trust in them.”

“There have been a few staff changes recently.”

“The manager is marvellous. She is very approachable if I need to talk to her about anything.”

“They always listen.”

“X loves to go out and they take her to the theatre and she loves shopping. She shows me all her new clothes she has bought.”

“I go to all the meetings regarding her care. I usually agree as I am very happy with the care provided and give my consent.”

Inspection carried out on 27 October 2011

During a routine inspection

The people using the service are unable to communicate their wishes and feelings verbally. On the day of our visit we observed that they appeared relaxed and content in their home and with the staff supporting them.

As part of this review of compliance we asked relatives to comment on the operation of the service. We also asked Halton Borough Council, LINKs* and health professionals who regularly support people using the service their views. LINKs had no up to date information for this compliance review.

An expert by experience accompanied us on this visit. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service.They made observations, spoke to the manager and staff.

The expert by experience found that the staff treated the people using the service with dignity and had a relaxed and caring manner. They reported that staff were dedicated to their role. They found the home to be clean and cosy with bedrooms having been made personal to the people living there. The expert by experience identified some issues around the management of medication where improvements could be made which have been included in this report.

We spoke to some relatives of people using the service. They were happy with the care and support provided at Holmdale. They said "my relative is very well looked after." "Staff are attentive, caring and kind." They said they are kept informed. They also said that the home is clean and well presented.

Halton Borough Council undertook a monitoring visit to this service on 13th October 2011. They identified that Holmdale is a warm and welcoming home and that the people using the service appear happy, are well cared for and that staff interact well with them. They identified a number of improvements that need to be made around medication, care planning, record keeping and staff training and support.

We asked health professionals who regularly visit the service their views about how the service is operating. We received positive comments with the staff described as helpful and following any advice given. They also said that advice is sought from them as this is needed.

* LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers. LINks aim to involve local people in the planning and delivery of services.

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