Tithe Barn

Tithe Barn is a residential care home providing personal care to up to 13 people. The service provides support to people with learning disabilities or autistic spectrum disorder.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

Risk management needed improvement. There was improvement needed in the oversight of lessons learnt and the actions taken to reduce the risk to people.

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. The provider’s governance systems were not always effective in identifying the actions needed to reduce the risk to people.

Right Care:

Care was person-centred and promoted people’s dignity, privacy and human rights. Safeguarding procedures were followed and appropriate action had been taken to protect people from abuse and poor care. Care was delivered in line with standards, guidance and the law.

Right Culture:

The ethos, values, attitudes and behaviours of leaders and care staff ensured people using services lead confident, inclusive and empowered lives.

The systems for reporting were open and transparent.

Rating at last inspection

The last rating for this service was good (published 5 August 2021)

Why we inspected

The inspection was prompted in part due to concerns received about a safeguarding incident. A decision was made for us to inspect and examine those risks.

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.

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

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

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

Enforcement and Recommendations

We have identified breaches in relation to management of risks and management and governance of the service.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tithe Barn is a residential care home providing personal care to people with learning disabilities or autistic spectrum disorder.

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.

The service was a large home, bigger than most domestic style properties. It was registered to provide support to up to 13 people and there were six people using the service at the time of our inspection. The service is larger than recommended by best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other larger domestic homes of a similar size.

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

People were supported by staff that understood their individual needs.

People’s care needs were appropriately assessed. Staff had received specialist training to keep people safe during times when behaviours became challenging.

People were supported by staff who had been trained and understood how to protect people from abuse.

Safe practices were followed to reduce the risk of infection. Staff wore personal protective equipment (PPE) in line with current guidance. The registered manager reviewed any accidents and incidents ensuring any lessons learnt were acted on and shared with the staff team.

Safe arrangements were in place for the administration and management of people’s medicines.

People were supported to access healthcare professionals where required.

People were supported to be as independent as they could be. People were actively encouraged to choose what they wanted to eat and what activities they wanted to do.

People and their relatives had access to information on how to raise any complaints. Procedures were in place for the manager to monitor, investigate and respond to complaints in an effective way.

The provider had governance systems in place to drive improvement.

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.

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 the underpinning principles of Right support, right care, right culture. The Model of care and setting maximises people’s choice, control and independence. Care is person-centred and promotes people’s dignity, privacy and human

Rights. The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

The manager, senior managers and support staff shared person centred values in relation to how people were supported. People were supported to make clear choices for example what they did and how they spent their day.

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 inadequate (published 27 October 2020). The provider was in breach of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 14 November 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. The provider had demonstrated they had made improvements; systems were in place to ensure these were sustained. This included regular checks by the operations director, who also supported staff by working from the home regularly.

Why we inspected

This was a planned inspection based on the previous rating.

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 inadequate to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tithe Barn 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.

Tithe Barn is a residential care home providing personal care to people with learning disabilities or autistic spectrum disorder.

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.

The service was a large home, bigger than most domestic style properties. It was registered to provide support to up to 13 people and there were seven people using the service at the time of our inspection. The service is larger than recommended by best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other larger domestic homes of a similar size. At the time of the inspection the provider was going through a refurbishment programme to improve the accommodation.

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

Overall improvements had been made to care plans as these were clearer to read and reflective of people’s individual needs.

People were supported by staff who were deployed in sufficient numbers to meet their needs.

Staff were aware of how to safeguard people from abuse and had good knowledge on how to recognise and respond to concerns.

We assessed infection control procedures within the home and processes were in place to keep people safe.

Medicines were managed in a way that had improved since the last inspection, and audits ensured the provider and management team had a good oversight of this. We found some minor shortfalls in the medicines we looked at, but the registered manager took actions to address immediately.

Relatives and staff were complimentary about the changes in the management of the home since our last inspection.

Improvements of the governance systems ensured better oversight of performance and quality. However, these needed to be embedded with evidence to show sustainability.

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.

The outcomes for people using the service reflected the principles and values of Registering the Right Support 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.

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 inadequate (published 02 January 2020). The provider was in breaches of regulations. The provider told us what they had done after the last inspection to show how they had improved. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection 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.

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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service including information supplied to us before the inspection was undertaken. We did not inspect the other key questions as part of this inspection. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained Inadequate. This is based on the findings at this inspection.

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

Follow up.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Tithe Barn is a residential care home for people with learning disabilities.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 13 people. Eleven people were using the service at the time of our inspection. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

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

The service didn’t always (consistently) apply 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.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons [lack of choice and control, limited independence, limited inclusion] e.g. People did not have choice in the food they ate or at what times meals were served. Menus were developed by staff with no input from people who lived at the service.

Since our last inspection the provider had started to make improvements in reducing risks to people’s safety. The risks to people's health, safety and welfare were now being reassessed, recorded and kept under review. Incident and accident records had been completed or signed off by the senior management to confirm all necessary actions had been taken.

Staff member’s knowledge and skills were being reassessed to ensure they had the skills to care for the people who lived at the home.

The provider's quality assurance systems and processes had started to address issues with documentation, medicines found at our last inspection. Although staff members felt more supported, professionals continued to express mixed views about and varying confidence in the management team.

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 Inadequate [published 15 November 2019].

At this inspection although the provider was making improvements to the areas we identified at the last inspection this needed to continue and evidence provided to show the sustainability of the improvements. The provider continues to be in breach of regulations

We reviewed the information we held about the service. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. We have found evidence that the provider still needs to make improvements. Please see Safe and Well-led sections of this full report.

Follow up

We will continue to monitor the service closely and discuss ongoing concerns with the local authority. 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.

Special Measures

The overall rating for this registered 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. 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.

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. We will have contact provider following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Tithe Barn provides accommodation and personal care for up to thirteen adults who have learning difficulties and may also autism and/or have behaviour that may challenge. Some people had sensory impairments, epilepsy, limited mobility and difficulties communicating.

The home is split up into five shared flats.

The service was a large home, bigger than most domestic style properties. This is larger than current best practice guidance. There was a risk the size of the service had a negative impact on people.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, independence and inclusion. The outcomes for people at Tithe Barn did not reflect the principles and values of Registering the Right Support. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interest. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them. People with learning disabilities and autism living at Tithe Barn were not supported to live as ordinary a life as any citizen.

People's experience of using this service

The management and staff had not supported an empowering, inclusive culture.

People were not treated with dignity and respect. The language and actions of some staff was disrespectful and at times allegedly abusive. The local authority safeguarding team were investigating, and the investigations have not yet been concluded.

People were not always safeguarded from abuse and improper treatment. The registered persons failed to consistently ensure people were protected from avoidable and intentional harm. Some incidents had not been reported to local authority safeguarding team when they should have been. Individual risks to people had not been fully identified and mitigated.

People were not being supported to be as independent as they could be with their daily activities. There was lack of choice and people were controlled by staff. People were told what they could do and when they could do it. The kitchen doors in the flats were locked so people who were able to with staff support could not freely help themselves to drinks and snacks. People said if they wanted drinks or snacks outside meal and drink times they had to ask permissions from the staff. Apart from one person, people were not supported to choose what they wanted to eat and were not able to choose the activities they wanted to do. These decisions were made by staff.

People's health needs, such as constipation and epilepsy, were not always being met effectively. When people's fluid intake was monitored this was not accurately recorded to make sure they were drinking enough. People did not always receive personalised care. Some people's communication needs were not met in a personalised way.

Medicines were not managed as safely as they should be. Medicines delivered to the home had not been booked in correctly. Medication temperatures were not consistently monitored. Medication keys were not kept secure. People’s ‘when required/’PRN medication protocols were not giving staff clear instructions as to when they should be administered.

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Some of the staff working with people did not have suitable skills, understanding and values to work with people. These concerns had been identified at staff meetings, but no action was taken by the registered persons. Staff continued to work with people in a controlling, disrespectful and restrictive ways.

Staff told us that they had made complaints to the registered manager about the way people and they were being treated but their concerns had not been taken seriously and no action had been taken.

Action was not taken to learn lessons and improve the service people received when things went wrong.

People were not involved in planning their care and support in the way they would have preferred.

The governance arrangements including the checks and audits had not picked up the range of issues found at the inspection. The culture of staff being in control had not been identified and addressed, so it continued. The home environment was not always clean, and measures were not in place to prevent the spread of infection.

There was a lack of oversight and scrutiny by the registered provider and senior management. This had led to unsafe risks and care for the people living at Tithe Barn. Systems for checking and improving the quality of care and support people received did not identify concerns and affect change. Concerns relating to keeping people safe, protecting them from abuse, minimising restrictions upon people, the staff culture and oversight of the care and support people received to stay safe, had not been recognised, identified and improvements had not been made.

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

The last rating for this service was Good (The last inspection report was published on 17 January 2019).

Why we inspected

The inspection was prompted due to whistle blowing concerns received about the restrictive and controlling culture of the staff. A decision was made for us to inspect and examine those risks.

The provider has taken action to mitigate the risks and we are monitoring the service to ensure the action the provider is taking is effective.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

Enforcement

We have identified breaches in relation to failing to protect people from avoidable harm, failing to effectively risk assess, failing effectively monitor the service, failing to safeguard people, failing to provide person centred care, failing to ensure competent and trained staff were deployed at this inspection, failure to supervise and monitor staff and failing to submit statutory notifications to CQC.

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 request an action plan for 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.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the 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.

• People enjoyed living at Tithe Barn and were cared for by staff who understood their preferences and were kind.

• Systems were in place to identify people’s individual safety risks and to promote people’s safety. Staff were available to meet people’s safety needs and reassure them when needed. The risk of accidental harm or infections was reduced as staff used the resources and equipment provided to do this.

• Staff administered people’s medicines safely. Staff provided people with support to have the medicines they needed to remain well and people’s medicines were regularly reviewed and checked.

• People were supported to enjoy a wide range of activities which reflected their interests, and enhanced their lives. Staff sought ways for people to continue to do things they liked, whilst maintaining their safety.

• People, their relatives, staff and other health and social care professionals worked together to assess people’s needs and plan their care. This was done so people’s needs and preferences would be met, and they would enjoy an enhanced sense of well-being.

• People were supported by staff to make decisions about their care. Staff used their knowledge of people’s preferred ways of communicating, to assist people to make their own choices.

• Staff promoted people’s right to independence, dignity and respect.

• People received support to keep in touch with family and friends who were important to them and to express their individual lifestyle choices.

• Staff supported people to have timely access to external health care. This improved health and well-being outcomes for people living at Tithe Barn.

• Staff had received a comprehensive induction and on-going training to develop the skills they needed to care for people.

• People, their relatives and staff were encouraged to make any suggestions for developing the care provided further.

• The provider and registered manager checked the quality of care provided and developed action plans to improve people’s care, so people would continue to enjoy living at Tithe Barn.

• We found the service met the characteristics of a “Good” rating in all areas; More information is available in the full report

Rating at last inspection: Good. The last report for Tithe Barn was published on 29 July 2016.

About the service: Tithe Barn is a is a residential care home, providing personal care and accommodation. There were thirteen people with learning disabilities or autistic spectrum disorders living at the home at the time of the inspection.

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service remained rated Good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

The inspection took place on 13 June 2016 and was unannounced.

There was a registered manager at this home, but they were not present on the day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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’s individual needs were known by staff. Staff understood that keeping people safe included upholding their rights and reducing their anxieties. People’s freedom was promoted, whilst ensuring their safety. Staffing levels and deployment were based on the needs of the people living at the home. People received their medicines from trained and competent staff.

People were supported by staff who understood their individual health and wellbeing needs. People were supported to eat and drink and to enjoy a healthy and varied diet. People received specialist input from a range of health professionals and staff followed the guidance given by them. Staff understood the need to offer people choices and obtain their consent.

People enjoyed positive relationships with staff. People were treated with dignity and respect. People’s individual communication needs were known and they were encouraged and supported to try different communication methods so that their views could be heard.

People’s changing needs were responded to by staff. People were supported to maintain individual hobbies and interests, as well as encouraged to try new opportunities. Information about how people could complain was provided in a way which they could understand.

There was an open and inclusive culture in the home and feedback from people, staff and relatives was encouraged and acted upon. Staff were supported in their roles by the registered manager and were motivated and positive about their roles and the running of the home. The registered manager and provider carried out regular quality assurance and competency checks and took appropriate action where issues were identified.

Below is a summary of what we found. The summary is based on our observations during the inspection, observations of 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 our full report

Is the service safe?

From our observations and from the information we saw set out in care plans, policies, procedures and audits the provider's safety systems were robust. The staff showed that they had a clear understanding of their role in providing care and safeguarding the people they supported. The staff demonstrated that they knew the people well and had read and understood the instructions set out in individual care plans.

We saw evidence that people were supported to make as many decisions for themselves as possible. The care plans set out detailed instructions for staff as to how each person could give consent. When people lacked the capacity to make important decisions, meetings were held to make decisions for them that were in their best interests.

We found that medicines were safely stored, handled and administered. Medicine records audited on a regular basis and staff received regular training.

The staff we spoke with understood about the risk management plans that had been written for all the people and how these met with their particular needs. Staff showed that they understood how to show people respect and maintain people's dignity at all times.

The registered manager told us that there were no deprivation of liberty safeguards in place for the people living at Tithe Barn. They said that they had previously contacted the service for advice.

The staff rotas showed that the manager had taken people's care needs into account when making decisions about the number of staff required, the skills mix and experience staff would need. The rotas showed where additional staff had been used by way of bank workers, overtime and more recently agency to ensure safe staffing levels were maintained. The night time staffing levels and on call system showed that out of main hours the staffing provision was safe.

There were systems in place to make sure that management and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This meant that people were benefiting from a service that was taking on board lessons learnt.

Is the service effective?

People's health and care needs had been assessed and care plans were in place. There was evidence of people and their representatives being involved in assessments of their needs and planning their care, particularly people with epilepsy.

Specialist health care needs were always assessed and included in care plans and health action plans. Specialist health and social care professionals regularly gave input to the service. All care, activity and risk assessment plans were being reviewed regularly. Every person had a representative and advocacy services were available if required.

Is the service caring?

We observed during our visit and saw in people's care plans that people were supported and encouraged to live full and active lives. People took part in a wide range of leisure and social activities. Activities were organised to include families and promote friendships. We saw that everyone was supported to access the activities they enjoyed.

The staff we spoke with demonstrated to us that they were committed to providing the best levels of care and to facilitate activities for the people who used the service. They demonstrated to they were aware of potential risks, people's rights and their responsibilities.

Is the service responsive?

We found that care plans were person centred and contained lots of information about people's choice and preferences. We saw that everyone's care plans contained detailed information about each person's support preferences.

We found that people's health and care needs were being regularly assessed. There was regular input from external social care and health professionals when needed.

We saw that a new service satisfaction questionnaire had been developed to allow families and representatives to comment more easily and responsively to the service provided at Tithe Barn.

We saw when we reviewed the complaints log that action had been taken in all instances to address any concerns expressed regarding the care and support provided at Tithe Barn.

We were told about and we saw that staff received regular training to meet the support needs of the people who used the service. For example training had been provided about the care and support of people with epilepsy. In the future new autism training is being developed.

We were told by the registered manager how people were supported when a hospital admission was required. This support was provided by the provision of additional staffing from Tithe Barn and support from community nurses. When a person went into hospital they took with them a hospital passport with information about the person and their care needs.

Is the service well-led?

The service has had stable management for some years. There is a clear management structure within the service and the provider organisation. From the discussions with the registered manager, they were knowledgeable about the service, the people and staff. They met with their managers and peers regularly to maintain up to date their knowledge

The service had a quality assurance system in place. Records seen by us showed that any shortfalls identified had been addressed. There were systems in place to provide feedback to staff about changes and developments by team meetings, the communications book and training.

The staff we spoke with had a good understanding of the provider's policies and procedures. Information was available around the building on posters about safeguarding and whistleblowing. All of the staff we spoke with said that if they witnessed poor practice they would report their concerns

Staff we spoke with told us that they had work with the people for some time and enjoyed their work. They told us that there was a good team spirit and that they were supported by the managers.

We found that people were supported to make their own decisions where possible but most people needed others to make decisions for them on a daily basis. Some decisions made in people's best interest had been recorded as required by the Mental Capacity Act 2005 but there was scope to improve this area.

We found that people's health and care needs had been assessed and their care plans had been kept under review. People's wellbeing and any concerns were taken seriously and external professionals were involved when needed. People were encouraged to do activities they liked. Staffing levels limited how often some people could access the community due to individual funding arrangements.

Systems were in place to support staff and appropriate training was provided. Staff felt reasonably well supported with their work but team morale needed improvement.

The senior management of the home had remained stable. There were effective leadership arrangements in place to manage the care service and monitor health and safety risks.

At this review we found that the situation had improved. Rotas we sampled for August and September 2012 showed that shifts were no longer staffed by six care staff. On about half the shifts the target of eight care staff had been achieved. The practice of moving one person into another flat had stopped.

The registered manager told us that more effort now went into offering regular activities and outings. The three senior care staff we spoke with and the activity records sampled for three people confirmed this. The registered manager committed to monitor the outcomes for people using the service closely.