Archived: Melling Acres

Melling Acres is a residential service that provides specialist intensive support and rehabilitation facilities for up to 16 people with a learning disability and autistic spectrum conditions. The accommodation is provided in several properties on one site, which is located in a rural location of Melling. It is set in three acres of private gardens and woodlands.

A registered manager was not in post. The home was being managed by in interim manager with support from a regional manager.

Prior to the inspection we received information indicating that risk was not being safely managed. In particular, we were concerned that risk assessments were not being followed or appropriately reviewed following incidents.

We found multiple examples of risk assessments that had not been reviewed following incidents. In one case we saw that a person had been involved in numerous incidents which followed a similar pattern. The person’s risk assessment clearly indicated this risk and provided basic strategies for diffusing situations. The incident forms demonstrated that staff had deployed these strategies with varying degrees of success. It was clear that the behaviours were more likely to occur with younger female staff. However, the risk assessment had not been reviewed following these incidents and the person continued to be supported by young females on a regular basis.

At the previous inspection we identified that specific unsafe behaviours (putting liquids in eyes & cutting wrists) a person presented with were not being managed effectively, which meant the person’s health and wellbeing was at risk. Since the previous inspection, we identified that there had been a further eight occasions whereby incidents had occurred involving these unsafe behaviours. The incidents had happened even though the person had continuous staff support.

We saw that the care records for a person with epilepsy were incomplete. We were unable to locate a risk assessment or management plan and staff equally could not find these documents.

Staff had not always followed people’s care plans. Failures to follow care plans had exposed people living at the home, staff and members of the public to risk of harm.

People were exposed to risk of harm because the safety of the physical environment was not adequately managed. We saw that fire doors were wedged open or not fully operational. We also saw that access to dangerous chemicals and materials was not adequately restricted.

At the previous inspection we identified a breach of regulation in relation to the safe management of medicines. The errors were in relation to stock control, missed doses and recording. However, additional staff had received training from an external pharmacy and the overall level of medicine’s errors had reduced since the last inspection.

At the previous inspection we saw evidence that restraint was being used inappropriately by staff who were not trained in the relevant techniques. At this inspection we saw evidence that additional staff had been trained and that other training had been arranged. None of the records that we saw indicated that restraint had been used unsafely or inappropriately since the last inspection.

Following our inspection on 12 and 15 July and 1 August the provider produced an action plan which detailed actions would be undertaken to improve safety and quality at the home. We used this as a point of reference in discussions with the interim manager and regional manager and looked at other sources of evidence to see what progress had been made towards the objectives.

We saw that a number of important elements of the action plan had not been completed as planned. These included; daily checks at the home, the recruitment of nurses to cover all scheduled administration of medicines, the provision of personal alarms to staff and an urgent review of health and safety. The failure to complete the action plan compromised the safety of people living at the home and staff.

Prior to the inspection we received information of concern relating to the quality and effectiveness of management responses when issues were raised by staff. We saw evidence that records and care practice had not been reviewed and updated as required when staff reported concerns.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

You can see what action we told the provider to take at the back of the full version of the report.

Melling Acres had a comprehensive inspection on 14 July 2015 and was judged to be ‘Good’ overall. This inspection was undertaken in response to an increase in concerns raised about the service, in particular concerns that the service was not effectively managing the risks people living there presented with.

Situated in a rural location, Melling Acres provides specialist support and accommodation for up to 16 adults with profound complex needs associated with a learning disability and/or autism. Each person living there has support from a dedicated member of staff during waking hours. The accommodation is set in three acres of private gardens and woodlands and located two miles from the towns of Kirkby and Maghull. Accommodation includes Melling House that can accommodate up to seven men, Melling Lodge that can accommodate up to three people and Melling Mews, which consists of eight single-occupancy self-contained apartment style cottages.

At the time of the inspection there were 14 people living at the home. This number had reduced to 13 by the third day of the inspection.

There was no registered manager in post. They had left the service shortly before our inspection. A new manager had been appointed and they were planning to register. 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.

People living at the home told us they did not feel safe and were scared of some of the other people living there. Women in particular did not feel safe as a man had moved into the accommodation that had historically been just for women. When the man displayed behaviour that was challenging the women and staff had to vacate the premises and wait outside to ensure their safety. The women living in this accommodation had not been consulted prior to the man moving in there.

People were not protected from abuse. There were recorded incidents where people had been subject to assaults from another person living there. Some of these assaults were serious in nature. In addition, numerous medicine errors had not been reported, and incidents had occurred when people were not receiving their correct level of support. Not all of these incidents had been referred to the local authority as safe guarding concerns. Staff were not up-to-date with adult safeguarding training. New staff had not received this training prior to supporting people.

The provider was not working in accordance with the principles of the Mental Capacity Act (2005) as unlawful restrictive practice (restraint) was being used by staff on some people living at the home. Deprivation of Liberty safeguards (DoLS) were in place for people in relation to restricting people to live at the home with continuous staff supervision. The DoLS authorisations did not cover the use of restraint. Risk assessments and individual support plans were not in place regarding the use of restraint.

Individual risk was not managed effectively. Staff told us that when new people were admitted they received very little information about the risks the person presented with. Staff were working to old care records for a person who presented with significant behaviour that challenges and the file contained minimal information about the person. Risk assessments and a risk management plan were not in place for a person admitted three months ago. Support plans were not always adhered to. For example, we observed a person being supported to use a taxi in an unsafe way that was contrary to their support plan. The manager immediately addressed the matter and ensured the safety of everybody there.

We were advised of a number of serious incidents involving staff being assaulted by a person living at the home resulting in personal injury. Serious incidents had been ‘downplayed’ when reported by management. We checked two of the most serious incidents staff told us about. One incident had not been reported at all. The other incident was recorded in a way that minimised the seriousness of the assault. There was no evidence provided to suggest incidents were routinely being monitored and analysed in order to identify emerging themes.

The management of medicines was not robust and we found numerous errors in relation to the administration, provision, storage and monitoring of medicines.

Everybody living at the home had a minimum of one-to-one support during working hours. Mixed views were expressed about staffing levels. At times we observed a lot of staff about the home but staff told us there were other times when there were not enough staff to provide support. Agency staff were being used. There were new staff who had no prior experience of care work, had received a variable induction and had not received any training prior to supporting people. This meant there were insufficient numbers of staff with the appropriate skills and experience to support people safely.

Effective staff recruitment processes were in place. Relevant checks were carried out to ensure staff were suitable to work with vulnerable adults. Staff training was not up-to-date. The new manager confirmed that all staff had received supervision since they took up the post.

Risks associated with fire were evident. We found a fire door missing and were advised that it had been removed over a month ago by one of the people living there. It was replaced after the second day of our inspection. We also found the closure of another fire door had been removed and some fire doors did not close effectively. Personal evacuation plans for people had not been updated since December 2014.

People were supported by their dedicated staff to purchase their food and make their own meals and drink. We observed people had their own food store areas and these were well stocked. One person needed a lot of encouragement to get up and sometimes did not get up at all so went for very long periods without food or drink. There was no evidence that any action had been taken in relation to the person was going without food and drink for such lengthy periods.

Some staff were exceptionally kind to people. They took the time to ask people about their particular needs and what they wanted to do that day. They demonstrated a commitment to supporting people in a positive way and it was clear they wanted to make a difference to people’s lives. Not all staff demonstrated this positive approach and we noted some staff were less encouraging in their approach when supporting people.

When a person with specific cultural needs moved to the home staff were not given any instruction in their culture so the person had been receiving support in a way that did not meet their needs.

Families expressed dissatisfaction with the cleanliness of their relative’s accommodation and also expressed that their relative’s personal care needs were not being effectively met. One family raised a concern that their relative’s Motability car had been inappropriately used by staff.

Although there were pockets of good practice, the service overall did not follow the principles of person-centred care. There was no evidence in the care records that the person and/or people important to them were consulted when developing or reviewing support plans. We could not see that outcomes for each person, their capacities and the support required to meet their outcomes was identified. From our discussions with families, visiting professionals and review of care records we determined that meaningful activities based on people’s preferences were not routinely happening for people.

Staff identified two people who did not like noise. Given that Melling Acres is a specialist service for people with autism and it is well acknowledged in the literature that people with autism can be sensitive to noise, the provider had not taken this into account when accommodating these people within the service.

Staff were aware of whistle blowing procedures but said did not feel they could escalate any concerns within or outside of the organisation because they believed there would be reprisals. We found evidence that the service was not operating in an open and transparent way.

A complaints procedure was in place and the manager provided details of a recent complaint that was in the process of being addressed.

Structures to monitor the quality and safety of the service were in place. These included a monthly audit by the regional manager, an internal regulatory audit and both weekly and monthly incident reporting. These systems were ineffective as improvements had not been made based on findings and concerns identified. Furthermore, the concerns we identified from the reported incidents had not been picked up.

Confidential files were not being held securely and we found people’s care records were exposed in communal areas and the cupboard they should be stored in was not lockable.

The provider was not informing the CQC of all the events CQC are required to be notified about.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found '

Is the service safe?

We found that arrangements at the home had been enhanced to ensure that people living there were safeguarded against the risk of abuse. We also found that people's medication was managed and administered in a safe way.

There were sufficient numbers of staff on duty so that people consistently received their funded 2:1 care and at a time when they needed it.

The approach to risk management had been strengthened, in particular the management of challenging incidents. Each incident had been scrutinised by the manager to ensure it had been managed by staff in accordance with the person's positive behaviour plan and support plans.

Is the service effective?

People were supported to maintain good health care and had access to a range of health care professionals when they needed it.

The number of challenging incidents had decreased significantly. Staff told us this was because people were receiving consistent and structured support from a core staff team.

Is the service caring?

Staff had a thorough knowledge of the person they provided support to. The care records we looked at reflected people's current needs and we could see that risk assessments and support plans had been reviewed on a regular basis.

Is the service responsive?

This was a responsive inspection to follow up on previous non-compliance against the regulations and we did not look specifically at this area.

Is the service well led?

Systems to regularly monitor the quality and safety of the service provided had been enhanced. Incidents were being scrutinised to ensure they were managed and reported correctly. Arrangements were in place to ensure that lessons learnt from incidents were shared with staff. Incidents were also checked to ensure they were appropriately reported to external organisations and regulatory bodies.

An effective approach to auditing medication had been introduced, which meant errors were identified, resolved and learnt from in a timely way.

We heard from staff that the leadership and organisation of the service had improved since the new manager took up post. Staff said they were clearer about their role and that communication and morale amongst staff had greatly improved. They felt their views about how the service should develop were being listened to.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, spending time with people who lived at the home, talking with their relatives, staff providing support, talking with health and social care professionals and looking at records.

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

Is the service safe?

We found there were sufficient numbers of staff on duty to meet the needs of the people living at the home. Staff personnel records showed the home had appropriate and safe recruitment practices in place.

People living at the home were not routinely safeguarded against abuse as the home had not always responded appropriately when abuse had occurred or it was suspected that it had occurred. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Mental capacity assessments had been undertaken for each of the people and these highlighted what decisions people could make for themselves and the decisions they needed other people to make on their behalf.

Effective arrangements were not in place to ensure the people living there were protected against the risks of receiving care and support that was inappropriate or unsafe. Risk assessments and risk management plans for situational contexts, particular community settings, either lacked rigour or were not in place. This is being followed up and we will report on any action when it is complete.

People were not protected against the risks associated with medicines because appropriate arrangements were not in place to manage medicines safely. This is being followed up and we will report on any action when it is complete.

Is the service effective?

The people we spent time with who could verbally communicate with us said they were happy with their care and the support they received. Staff showed a genuine regard for the people they were supporting. We observed staff supporting people in a meaningful way and encouraging them to participate in activities.

Family members had some concerns in relation to mixed messages they received about the care of their relative who lived there. Person centred plans (PCP), positive behaviour support plans and support plans were in place for each person. We observed from the care records that people did not always participate in community activities identified in their PCP, which meant they were not achieving their personal outcomes. This is being followed up and we will report on any action when it is complete.

Is the service caring?

People who could verbally communicate with us said they felt happy with their staff team. We observed that staff had good relationships with the people they were supporting.

Regarding the people who were unable to verbally communicate with us or did not wish to spend time with us, we talked with the staff supporting them and looked at the care records, in particular the daily record logs. We determined that people had positive interactions with their dedicated staff team.

Is the service responsive?

Not everyone had a pre-admission assessment in place so it was unclear how some people were assessed before they moved into the home.

Staff had a good awareness of people's preferences, likes and dislikes.

Each person had their own dedicated staff team. Management and staff told us the wider staff team were being introduced so they could work with everyone living there. Because of people's complex needs and known preference for familiar faces, we explored how this was being approached. There were no recorded plans in place. External professionals who were responsible for overseeing people's care and welfare had not been consulted about this change to staffing arrangements. A family member had expressed reservations about introducing new staff to their relative and their views had not been taken into account. This is being followed up and we will report on any action when it is complete.

Is the service well-led?

Processes to seek people's views about the quality of the service were in place. A survey had been conducted in 2014 and the feedback from people living there was positive. In addition, meetings with people living at the home took place and they were chaired by one of the people living there. A suggestion box was available and we observed that this was well used. People living at the home were involved in the process for recruiting new staff.

Systems were in place for regularly monitoring the quality of the service. These included monthly 'provider monitoring visits and medication audits. Senior staff meetings and staff wide meetings were held regularly to communicate about quality and safety matters. The systems in place were not effective, particularly the audits and checks, as they had not highlighted many of the concerns we identified at the inspection. We found there was an inconsistency regarding the reporting of incidents and how the service was reporting incidents was not in accordance with the organisation's incident management and reporting policy. There was limited evidence to suggest that learning from incidents took place. The home was not notifying the Care Quality Commission of incidents and events. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

In this report the name of a Registered Manager appears who was not in post and not managing the regulated activity at this location at the time of our inspection. Their name appears because they were still a Registered Manager on our register when we inspected.

The care records we looked at were person-centred and detailed in content. They informed us that risk assessments and support plans had been developed for each person, and they were reviewed on a regular basis. They took into account people's preferences, choices and decisions in the way the support was provided.

The service was supporting some people with behaviours that presented a risk, including unpredictable behaviours that can be challenging. Effective arrangements were not in place to manage challenging behaviour, in particular behaviours of an unpredictable nature.

The staffing levels were sufficient to meet the needs of the people who lived at the home. Staff were receiving support in terms of induction, training and supervision to carry out their role.

Effective systems were in place to monitor the quality of the service.

We spoke with three family members who provided us with positive feedback about the care and support their dependent relative received. Because of the rural location, family members said Melling Acres was difficult to access without transport. One family member said, 'Everything is good; no problems with the place, it's just too far to get to.'

Care records informed us that individualised assessments, risk assessments and care plans had been developed for each person and these were reviewed on a regular basis. Health and social care professionals monitored and reviewed people's care needs regularly.

People were not supported at all times by the correct number of staff. Staff induction, training and support was not adequate to ensure staff were fully equipped to provide the most effective and safe support.

We observed that staff were knowledgeable about people's needs and preferences and supported them in making choices which promoted their independence. We saw evidence of this in the choices people made around daily living, leisure and work activities. Comments included," I'm very happy here." "I feel really independent."

We were told by staff that continuity of care was supported through daily records and handover reports and we saw that these were in place and were detailed and up to date.

We found that the home had begun monthly quality audits and we saw the reports for August and October which were detailed and included observation of care delivery and support, review of care records and documentation and environmental checks.

Records showed that regular communication meetings had taken place which supported staff to carry out their work. People were involved in feeding back their views through regular meetings with their key worker and "your voice" meetings. We saw evidence that these had taken place and that the home had taken note of suggestions for example in the activities people wanted to take part in.