Archived: Peacock House

About the service

Peacock House provides accommodation and personal care for up to 18 younger adults and older people who are autistic and/or have learning difficulties. At the time of the inspection six people were living at Peacock House.

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

Right Support

Peoples medicines had not always been well managed. Guidance was not always in place for ‘as required’ medicines. Immediately after the inspection the manager put protocols in place. People who suffered with specific health conditions did not always have guidance in place to inform staff how to support them. This was put in place immediately after the inspection. The service worked with people to plan for when they experience periods of distress so that their freedoms were restricted only if there was no alternative. For example, one person had a traffic light system to inform staff which intervention would be necessary and least restrictive depending how distressed the person was. Staff did everything they could to avoid restraining people. The service recorded when staff restrained people, and staff learned from those incidents and how they might be avoided or reduced.

Right Care

Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it. Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care. For example, one person liked spicy foods so the kitchen ensured they could provide this and had several spicy condiments to choose from. People who had individual way of communicating, using body language, sounds, Makaton a form of sign language, pictures and symbols could interact comfortably with staff and others involved in their care and support because staff knew them well. For example, one person uses gestures and the staff understand what they are trying to communicate.

Right culture

Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity. Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. For example, staff supported a person to regularly go to their local shop as part of their routine they wanted to maintain.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 9 November 2021) and there was a breach of regulation 17 (Good Governance). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection there had not been enough improvement and there was still a breach of regulation 17.

Why we inspected

We undertook this focused inspection to due to concerns regarding staffing and staff training but also to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. During inspection we also assess that the service is applying the principles of right support right care right culture.

Follow up

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 good governance such as, daily record keeping and the documentation of medicine management at this inspection.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Peacock House provides accommodation and personal care for up to 18 younger adults and older people who are autistic and/or have learning difficulties. The service can also support people who live with dementia or need support to maintain their mental health. At the time of inspection, the service was supporting 13 people.

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

There were not always enough staff to support people in line with their care and support plans. Staff did not always feel supported by the registered manager.

Systems did not always highlight shortfalls in record keeping and reporting of notifications to CQC. The registered manager were unable to consistently mitigate risk to people due to low staffing levels.

People told us they felt safe living at Peacock House. One person said, “The staff are my friends.” Most relatives were happy with the service and felt their loved ones were safe.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. The home was registered to support up to 18 people. This is larger than the current best practice guidance. However, they were able to reduce the impact to people by the way the building was used. Three people had their own self-contained flats, two resided in Peacock house, and there were no obvious, identifying signs it was a care home, such as cameras or industrial waste bins. Staff encouraged people to make their own choices and maintain their independence. Staff would encourage and support people to help make meals. Information was provided to people in different formats relevant to their communication preference. Staff understood safeguarding and how to keep people safe.

Medicines were being administered safely and in line with people’s support plans. Infection, prevention and control guidelines were being followed, including risk associated with COVID-19. There were systems in place to analyse incidents and accidents and where trends found, action was taken.

The registered manager encouraged people to be involved in the service. They also worked well with other partner agencies. This included GP’s and psychiatrists.

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 13 May 2021).

Why we inspected

We received concerns in relation to staffing levels falling below the safe assessed number. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has changed from good to required improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Peacock 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 to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to the registered manager not always having systems in place to highlight shortfalls of recording an reporting at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Marshlands is registered to provide accommodation and personal care for 18 younger adults and older people who have learning difficulties and/or have adaptive needs due to austism. It can also support people who live with dementia and/or who need help to maintain their mental health.

In practice, the service can only accommodate 13 people. This is because the number of bedrooms has been reduced to allow parts of the accommodation to be remodelled. At this inspection there were 12 people living in the service.

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

The service applied the principles and values of Right Support, Right Care, Right Culture and other best-practice guidance. These ensure 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.

The outcomes for people using the service reflected the principles and values of Registering the Right Support, Right Care, Right Culture by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

The service was a larger home, bigger than most domestic-style properties. It was registered for the support of up to 18 people. This is larger than current best-practice guidance. However, the size of the service having a negative effect on people was reduced by the way the building was used. There were no obvious identifying signs, intercom, cameras, industrial waste bins or anything else to indicate it was a care home. Two people had their own self-contained flats and more flats were going to be created.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff recognised that people had the capacity to make day to day choices and supported them to do so. People were encouraged and supported to be independent. People were engaging in the community including going shopping and enjoying leisure activities.

People were happy living at the service. Comments included, "I like the staff and we get really well because they help me do what I want." A relative said, “I’m completely confident my family member is safe and well at Marshlands.”

People were safeguarded from the risk of abuse and received safe care, support and treatment from staff who knew how to manage potential risks to health and safety.

Support plans described what people were able to do for themselves and what assistance they needed to promote their independence whenever possible. People were involved in reviewing the support they received and in setting any personal goals they wanted to achieve.

There were enough trained and experienced staff on duty and safe recruitment practices were followed.

Infection was prevented and controlled including risks associated with COVID -19.

Quality checks had been completed and people had been consulted about the development of the service. Regulatory requirements had been met, good teamwork was encouraged and joint working was promoted.

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 19 October 2018).

Why we inspected

We undertook this focused inspection to gain an updated view of the care and support people received. This was a planned inspection based on the previous rating. This report only covers our findings in relation to the Key Questions ‘Safe’ and ‘Well-led’.

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 infectious outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service remains as Good. This is based on the findings at this inspection. Please see the ‘Safe’ and ‘Well-led’ sections of the full report.

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

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.

This inspection took place on 21 and 23 August 2018 and was unannounced. Marshlands is a ‘care home’ for people who may have a learning disability or autistic spectrum disorder. 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 care home accommodates up to 18 people in one adapted building. Two people had their own personal flats external from the main house. All people had access to two communal lounge / dining areas, kitchen and shared bathrooms. There was a large garden which people could access. At the time of our inspection, there were 14 people living at the service.

Marshlands was last inspected on 12 May 2017 and was rated as Requires Improvement in the safe and well-led domain, and Requires Improvement overall. Shortfalls identified at that inspection included tools being left unattended within the service placing people at potential risk, actions identified by the fire service had not been implemented, and work was needed on the structure of staffing and their understanding of their responsibilities. At this inspection, the provider had made improvements in these areas and worked through an action plan of the issue we identified during our inspection. Environmental risk assessments had been put into place, and staff were aware of the risks of leaving tools unattended. The provider had installed a ramp at the front of the building as recommended in the risk assessment completed by the fire brigade. Following concerns raised at the previous inspection, staff received the support they needed from a structured management team. This service has been rated Good overall.

There was 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. A new manager had been appointed and was in the second week of the induction when we visited. The new manager was in the process of submitting an application to take over the management and registration of the service from the registered manager. They are referred to throughout this report as the manager.

The care service had not 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.

Marshlands was designed, built and registered before this guidance was published. The provider has not developed or adapted Marshlands in response to changes in best practice guidance. Had the provider applied to register Marshlands today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. The service accommodates more than the recommended number of people, and is not based within a community setting with easy access to local amenities. However, the service was working within the principles of promoting choice and impedance, and was in the process of reviewing the service with the goal to create a more person-centred service, which would meet the guidance for registering the right support.

People told us they were safe at the service. Staff were trained in safeguarding and knew how to report any concerns.

Risks to people and the environment had been assessed and minimised and people were supported to take positive risks such as accessing the community independently, and exploring supported living services. People told us, and we observed there were enough staff to meet people’s needs and deliver safe care.

Medicines were stored and administered safely by staff who had received training in medicines administration.

People were protected by the prevention and control of infection; we observed the service was clean and tidy.

Accidents and incidents were recorded, and used to drive improvements at the service.

People’s needs had been assessed in line with good practice and legislation. Staff had the skills and knowledge to deliver effective care and treatment.

People’s nutritional needs were being met. People told us they enjoyed the food, and we observed a relaxed, friendly atmosphere as staff and people ate together. Staff worked externally and internally to provide people with access to healthcare professionals when required.

Staff understood the importance of gaining people’s consent and action to take if people were unable to consent. Staff promoted choices with people in a variety of ways to suit the individual.

There were positive relationships between people and staff. Staff treated people with kindness respect and compassion. People were supported to make their views known through house meetings or during reviews.

People’s privacy and dignity were respected, and staff promoted people’s independence.

People received person centred care responsive to their needs. Staff understood how to treat people as individuals. There was a range of individual and group activities for people to be involved in. People told us they were happy with the activities at the service.

People knew how to raise concerns and complaints but told us they were happy at the service.

There was an improving culture at the service, which focused on positive outcomes for people. Staff were aware of their responsibilities, and the registered manager complied with their regulatory responsibilities.

People’s views were sought, and used to make improvements within the service. The registered manager had formed good working relationships with healthcare professionals that they used to improve the service.

Marshlands was last inspected on 25 and 26 October 2016 where six breaches of our regulations were identified. The well led domain was rated as inadequate, an overall rating of requires improvement was given at that inspection. The breaches of regulation related to care and treatment, dignity and respect, medication, the environment, staffing and leadership. The registered manager and provider was issued with a warning notice for a continued breach of regulation 17, which related to the leadership of the service.

The previous registered manager had left the service and was in the process of de-registering with The 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. A new manager had been appointed and was present throughout the inspection; they had started the process of registering with The Commission.

At this inspection the provider had made significant improvements, but more were needed to improve the outcomes people experienced.

Although there was a comprehensive set of environment risk assessments, tools had been left out in the garden which had not been assessed. This posed a risk as some people’s behaviour could result in them throwing objects which could harm others or themselves. People had their own individual risk assessments according to their needs. Risk assessments had been completed to support people to remain safe.

The atmosphere in the service was more inclusive, open and relaxed. There was a positive change in how staff supported and interacted with each other and people. The manager said that more work was to be done to stabilise the staff team and change the culture of the service but this would take time. Staff were generally positive about the improvements made although some staff fedback further improvement was necessary in how the team worked together and communicated.

Staff said they felt well supported and now received more regular supervision. There were safe processes for storing, administering and returning medicines. Staff were trained to administer medicines and dispensed them in a person centred way.

There were enough staff available to support people with their needs and throughout the inspection we noticed how the quality of engagement by staff had improved since the previous inspection. Robust recruitment procedures helped to ensure people were protected against the risks of receiving support from unsuitable staff.

Staff were trained in safeguarding and understood the processes for reporting abuse or suspected abuse. Appropriate checks were made to keep people safe. Safety checks had been made regularly on equipment and the environment. There was good management and oversight of accidents and incidents. Incidents were recorded and audited to identify patterns.

The manager demonstrated a clear understanding of the Mental Capacity Act (MCA) 2005 and the process that must be followed if people were deemed to lack capacity to make their own decisions. They ensured people’s rights were protected by meeting the requirements of the Act.

People had choice around their food and drinks and staff encouraged them to make their own decisions and choices. People moved freely in their home and were at ease in the company of staff. Staff demonstrated caring attitudes towards people and spoke to them in a dignified and respectful way.

People were supported to manage their individual behaviours and staff demonstrated they had the right skills and knowledge to respond to this appropriately. Care plans were meaningful and contained specific detail so staff could understand people better, care plans were a reflection of what happened in practice.

People chose to participate in a variety of recreational activities inside and outside of the service. Throughout the visit some people went out to do various activities and some people participated in activities in the day centre located within the grounds.

The provider conducted their own internal audits in the form of monitoring visits, observations, and quality visits. Feedback was sought from people and staff so the service could improve and any areas of concern could be responded to.

Marshlands was last inspected on 16 and 17 December 2015 where five breaches of our regulations were identified, an overall rating of requires improvement was given at that inspection. The breaches of regulation related to medication, risk assessment, safeguarding, staffing and leadership. The provider had made some improvements, but more were needed in a number of areas, and not enough improvement had been made regarding the management and leadership of the service.

The service is run by 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. The registered manager was not present on either day of the inspection. Two senior managers were present throughout both days of the visit.

The provider had not deployed staff to ensure people had their needs met and had ongoing engagement. We witnessed several incidents involving people which were managed by the people themselves but could easily have escalated as staff had not been present to intervene.

People were at risk of receiving their medicine inappropriately because staff did not have up to date and clear information to refer to.

Not all areas of the service were clean or well maintained, staff were expected to perform cleaning duties as well as support people with their individual needs.

Staff did not have a clear understanding about how to respond appropriately to some of the behaviour people displayed. Staff did not always act in accordance with people’s individual behaviour guidance.

Some of the language used in records were not dignified or respectful and was judgemental. There were some positive and engaging interactions between people and staff, although at other times this was limited.

Although people’s care files were written in an easy read format which included pictures to help people understand its content it was not always clear that what happened in practice was a reflection of the information in the care plans. People’s individual needs had not always been thought about or supported well. Other parts of the care plans were detailed, informative and person centred.

When areas of improvement had been outlined it was not always clear what action the provider had taken. There was a culture within the service that the registered manager and senior managers were seeking to change. Staff were unsettled and team relationships were fractured with a ‘them and us’ culture emerging.

Staff received regular supervision; Staff had appropriate training and experience to support people with their individual needs.

Incidents were recorded and audited to identify patterns. The registered manager or senior staff analysed reports to identify any emerging trends or patterns so that action could be taken to reduce the risk of recurrence and further harm occurring.

People had their own individual risk assessments according to their needs. Risk assessments had been completed to support people to remain safe.

Staff were trained in safeguarding and understood the processes for reporting abuse or suspected abuse. Appropriate checks were made to keep people safe. Safety checks had been made regularly on equipment and the environment.

The service was good at responding to people who needed help to manage their health needs and people were supported to access outside health professionals.

Staff demonstrated caring attitudes towards people. Interactions between people and staff were positive and encouraged engagement.

People were helped to complain and staff supported people who were unable to use the easy read complaints policy by understanding what their body language meant if they were unhappy.

People had choice around their food and drinks and staff encouraged them to make their own decisions and choices.

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.

We found that people's capacity to consent was assessed and documented, and there was access to local advocacy services for people who were unable to make their own decisions. We saw that care plans had been written and regularly reviewed based on assessments of people's individual needs and contained detailed information. We saw evidence of monitoring and regular evaluations of the support that was provided.

We found that records were maintained which demonstrated that medicines were dispensed accurately and stored safely. Staff told us that they received regular training and assessment in medicines handling and administration.

We saw that there were suitable recruitment and selection procedures in place, and found that personnel files contained current information on the suitability of a staff member for their role. We found that staff were supported through the induction process, and had access to a programme of regular training.

We found that there was information on how to complain in formats which enabled the people who used the service to make their views on the service known. We saw that where people complained or made comments about the service, action was taken to address the concern.

People we spoke with said they liked living at the home and they were able to make choices about their lives and things that were important to them. People chose when to get up and go to bed, what to do and what to eat and staff respected their choices.

People had been asked how they liked their care and support to be provided and were supported to learn and maintain independence skills. People chose how to spend their time at home and in the community. They helped with household tasks and to keep their rooms clean and tidy to the level of their ability. People said 'I do my laundry on Thursday', 'I help with the washing up' and 'I help with gardening and painting'.

People were provided with opportunities to experience a range of activities at home and in the community. People said 'I like singing we put on a show' and 'I do trampolining and karaoke'.

Staff understood people's needs and had the training they needed for their roles. People had good relationships with staff and were comfortable in their presence. A person told us 'staff are nice 'and 'I like the manager'.

People were asked for their views about the home and told us they went to house meetings.