The Maltings

The Maltings is a residential care home providing personal care to three people with learning disabilities. At the time of the inspection three people were living at the service.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

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

Risks assessments and support plans were combined and included the measures to reduce the risk of harm to people. For example, for one person textured meals were served to reduce the risk of choking. Support plans were not always person centred and for some people the reviews had not been updated since 2017. Some support plans were task focused and the language used was not always in line with a person centred approach. The registered manager had identified in the improvement plan that the quality of support plans needed to improve.

Where people became distressed or anxious the staff knew how to manage the situations. The registered manager had agreed to review the behaviour plans. This was to ensure there was detailed guidance to staff on how to support people when they were asked to go to their bedroom to regain control of their emotions. We recommended the registered manager seek guidance on developing behaviour support plans that have detailed guidance to staff.

Although communication plans were in place and acknowledged people’s sensory needs. The actions did not include developing records in formats that helped people understand the support to be provided. For example, picture formats and audio recording will help people understand the care being delivered.

Quality assurance systems were in place and effective. The areas identified at the inspection were already set for action by the registered manager.

There were in-house activities and staff told us people were supported with in-house or community activities.

People were not able to tell us about their experiences of living at the home or on how the staff supported them. People did not show signs of distress while staff were present. We saw people accept staff support and interaction.

We saw examples of good engagement between people and staff. The staff told us how they ensured people were treated with kindness and compassion. The relative we spoke with gave positive feedback about the care and support delivered by the staff.

The staff had attended safeguarding of adults from abuse training. They knew the procedure for safeguarding people which included the types of abuse and reporting their concerns.

There were sufficient staff on duty to meet the needs of people. The recruitment procedures followed ensured suitable staff were employed.

Medicine systems were safe. The registered manager acted promptly and added the person’s ability to express pain to the “when required” protocols.

New staff received an induction which included the Care Certificate. Staff attended mandatory training set by the provider. Staff were supported with the responsibilities of their role which included regular one to one supervision.

Mental capacity assessments were in place for specific decisions. The staff were knowledgeable about the day to day decisions people made. People at the service were subject to continuous supervision and restrictions and appropriate Deprivation of Liberty Safeguards applications were made.

People were supported with their ongoing health. People had access to community health such as therapists, dentists and opticians.

People’s dietary requirements were catered for.

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 on 27 August 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.

At the previous inspection dated July 2016 we found breaches of Regulation 11 and 17 and at this inspection we found there had been improvements with quality assurance systems. We also found members of staff were knowledgeable about the principles of the Mental Capacity Act and consent to care had been mainly sought in line with legislation and guidance.

A registered manager was 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 staff were knowledgeable about the principles of the MCA and had attended the training. Mental capacity assessments were in place for some specific decisions which included dental treatment and personal care. However, personal care assessments did not cover staff making decisions for administration of medicines and topical creams.

Care plans and combined risk assessments were in place. However care plans were not always updated for some people as their needs changed. The care plans describing the support for one person were not consistent with other documentation about the person’s ability to move around the home independently.

Risk assessments and care plans were combined. The staff were aware of the risks to each person and how they were managed. Staff said there were risk assessments in place on how risks were to be minimised.

Medicine systems needed some improvements. There had been persistent errors, however the registered manager had taken appropriate action to ensure safe handling of medicines. Where people took their medicines other than in accordance with the prescription, for example they chewed the tablets or had them in food rather than swallowing, the pharmacist had not been contacted to ensure that this was appropriate..

Medicine Administration Records (MAR) charts were signed by staff to show the medicines had been administered. Body maps were in place for the applications of topical creams.

Daily routines included people’s preferences as well as the assistance staff had to provide. Where people were able; guidance was given to staff on supporting the person to manage some of their personal care needs for themselves.

People were not able to tell us what feeling safe meant to them. We saw people approach staff for company and when they needed assistance or support. We heard people singing with staff and depending on the situation we saw staff treat people with kindness and firmness when it was needed. The staff we spoke with were knowledgeable about the procedures for safeguarding adults from abuse. We saw copies of the No Secrets guidance pinned onto notice boards in the office and kitchen. This meant the procedure was available to staff and visitors to the home.

The staffing levels had improved within the last 12 months and there was a stable team. New staff were recruited to vacant posts. The rotas in place showed there were two staff on duty at all times of the day and night. At night the staff slept in the premises. Staff told us the staffing levels were appropriate to meet people’s needs and to undertake activities with them.

Staff were supported to meet the responsibility of their role. New staff had an induction to prepare them for their job. Staff attended training set by the provider as mandatory and other training specific to the needs of people living at the service. Staff had an opportunity to discuss issues of concerns, performance and training needs during one to one supervision with their line manager.

People were subject to continuous supervisions and DoLS applications were made. However authorisations had not been received. While DoLS applications were made we noted they did not cover monitoring systems for people at with epilepsy. The registered manager understood when they needed to make applications and that the applications had been made appropriately.

Health action plans and Hospital passports were in place. We saw people had access to GP and other healthcare professionals. Staff said the GP trusted their judgements and acted upon their observations. People had regular check-ups with opticians and dentists. Speech and Language Therapist (SLT) assessments were in place for one person at risk of choking.

Staff told us about the importance of developing relationships with people and were clear that people were their priority. Staff gave us examples on how they respected people’s rights. We saw two people move around the home without staff support and one person relied on the staff to support them around the home.

The views of people were gathered. Quality Assurance systems were in place. The registered manager consolidated all actions from audits and visits into an action plan. Target dates and people responsible to meeting the action were identified within the plan.

We have made a recommendation about care planning.

A registered manager was not post at the time of our inspection visit. An application to register as manager was received at the Care Quality Commission. 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.

Members of staff said the team worked well together. They said the team was long standing and supportive of each other but there had been a period of instability with the three changes of manager in 12 months

Members of staff had some understanding of enabling people to make decisions. However, they were not clear who would be responsible for making decisions that may be made in peoples best interests. . Next of Kin without power of attorney had given consent inappropriately for care and treatment. Mental Capacity Assessments (MCA) 2005 were not developed for specific decisions, such as audio monitors.

DoLS procedures within MCA 2005 require providers of care homes to apply to the supervisory body for authorisation to deprive people of their liberty where they lack capacity to make decisions and subject to continuous supervision. Deprivation of Liberty Safeguards (DoLS) applications were not made by staff at the home to the supervisory body for people under continuous supervision.

People were referred to specialists such as Speech and Language Therapists (SaLT). Members of staff followed the guidance given by the specialists but care plans were not developed on how the recommendations made by specialist were to be consistently followed. The Care plans in place needed updating and they lacked detail on how staff were to meet the needs of people. Records were not personal and confidential for each person. Communication books held information about people’s health and wellbeing. For example, outcome of GP visits and medicines administered.

Members of staff were knowledgeable on managing risk and the actions needed to minimise the risk to people’s health and wellbeing. However, risk assessments were not always developed. For example, risk assessments were not in place for people at risk of choking or for people with low weight.

The views of relatives were gathered but their suggestions about activities were not always acted upon or used to improve the service. Quality Assurance systems were not effective. Where gaps in the standards of care were identified, action plans were not developed on improving the service for people.

We observed good interactions between people and staff. Members of staff were knowledgeable about developing relationships with people to gain their trust and meet people’s needs in their preferred manner.

We saw people approach staff and by their facial expression, the attention from staff was welcomed. We saw people use their preferred communication method to request specific activities. Members of staff knew the types of abuse and were clear on the responsibilities placed on them to report suspected abuse.

Sufficient staffing levels were deployed to meet people’s needs but there were vacancies for bank staff to cover annual leave.

Staff attended training set by the provider as mandatory and other specific training to meet people’s changing needs. One to one meetings with the manager gave staff opportunities to discuss concerns, the people they delivered care and treatment to and their performance.

Medicine management systems met people’s needs. Individual profiles with pictures and words were in place which gave staff guidance on how people preferred to take their medicines. Protocols to administer medicines “when required” were in place.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Below is a summary of what we found. The summary is based on our observations during the inspection, communicating with people using the service, the staff supporting them and from looking at records.

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

Is the service safe?

Care plans instructed staff how to meet people's needs in a way which minimised risk for the individual. Each person had health support guidelines and a health action plan. People's diversity, values and human rights were respected.

Safeguarding procedures were robust and staff had a clear understanding of their responsibilities with regard to protecting the people in their care. There had been no safeguarding referrals made in 2013 or 2014.

Mental Capacity Act assessments were included, as appropriate in all plans of care. Staff understood mental capacity, consent, choice and deprivation of liberties safeguards (DoLS). The home had not made any Deprivation of Liberty Safeguards referrals in 2013 or 2014. We saw that people had best interests meetings and advocates were involved in decision-making processes, as appropriate.

The home had been altered to ensure the physical environment was as safe as possible for the people who lived there.

The home made sure that there were enough staff on duty to ensure people's comfort and safety.

Systems were in place to make sure that managers continually monitored the quality of care offered to people. Health and safety was taken seriously by the home and all the appropriate safety checks had been completed. This reduced the risks to people and helped the service to continually improve.

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Is the service effective?

The families of people were involved in their care planning and knew what actions would be taken to support them.

People's health and care needs were assessed with them, and/or their relatives, as appropriate. They were involved in developing their plans of care, as far as they were able, if they chose to be. Care plans were detailed, they clearly identified people's health and well-being needs and how they should be met.

Is the service caring?

People were supported by well trained, experienced and knowledgeable staff. We saw that care staff interacted positively with people who used the service. We saw that staff were able to interpret people's individual methods of communication. They responded sensitively and appropriately to people.

People's preferences, interests and diverse needs had been recorded. The home ensured that they gained people's views by using a variety of methods. People's wishes were, often, interpreted from the behaviour they displayed if they were unable to communicate them verbally.

Is the service responsive?

People completed a range of activities in and outside the service regularly. Each person had an individual weekly activities plan, which met their current needs.

The home took a number of actions in response to views expressed by the people who lived in the home or their advocates. It had a comprehensive complaints procedure.

Is the service well-led?

The service had a robust quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was being maintained or improved.

Staff told us that they were offered good training opportunities and were well supported by the manager.

We spoke with family members who said their relatives were 'quite happy' and the staff were 'excellent.'

During the visit we observed positive interactions by staff with all three people. Staff were responsive to individual needs. For example, by offering different activities to reduce anxiety.

We spoke with staff and they were able to demonstrate they knew people well. This was confirmed by family and other professionals.

Records showed staff worked with other professionals and family to make decisions about care and treatment in people's best interests where people could not do this for themselves.

Other records demonstrated there were systems in place to check for improvements of the quality and safety of care in the service. This included audits of the administration of medicines and complaints. Staff felt well supported and had completed a range of training.

Each person had a support plan that detailed how to meet care and welfare needs. We found information was missing in some areas that could help staff to be consistent with the support they gave to people.