Archived: Middlefield Manor

There was no registered manager in post at the time of our visit. 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. The previous registered manager had left the service in July 2017 and cancelled their registration with CQC in August 2017. They were followed by another manager who commenced work at the service in August 2017 however they left their employment at the beginning of October 2017 without notice.

At our last inspection in July 2016 we rated Middlefield Manor as Requires Improvement in safe and responsive and as a result Requires Improvement overall. This was because we were concerned about the management of people’s medicine and improvements to people’s support plans were needed. The service has a history of non-compliance and concerns. Our past four inspections have highlighted concerns and the past three inspections have been rated Requires Improvement overall. Following this inspection we are planning to meet with the providers to review the management of the service and discuss the plans they have for making and embedding the necessary improvements.

Risks were identified through a range of comprehensive individual risk assessments to help keep people safe however these were not updated following incidents to ensure that they were reflective of the most up to date support needs and risks.

High numbers of agency staff were used at the service due to challenges with their recruitment of permanent staff. This resulted in high ratios of agency staff on shift who did not always have the required level of training and experience.

Medicines were administered by staff who were trained to do so but some aspects of medicines

management needed improvement.

Improvements were needed to the environment; there was damaged paintwork and walls.

The service was poorly managed. The provider did not have an effective governance system to monitor the quality of the service and identify the risks to people. Care records were not dated. Effective audits were not being carried out. The provider had not picked up issues that were identified in this inspection and had not taken appropriate action to make improvements when we had identified them at a previous inspection.

Staff had an understanding of abuse and safeguarding procedures. They were aware of how to report abuse as well as an awareness of how to report safeguarding concerns outside of the service. Staff undertook safeguarding training providing them with knowledge to protect people from the risk of harm.

The provider had a recruitment procedure in place. People were supported by staff who had only been employed after the provider had carried out checks. Once employed, however, staff were not supported in their role through regular training refreshers.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them.

We found the home was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The service had a comprehensive rating inspection in January 2015 and the overall rating was requires improvement. A responsive inspection was undertaken in December 2015 and the overall rating remained requires improvement.

The service had a registered manager who was present on one of the two days of the inspection. 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 service supported individuals with very different needs in close proximity and there were some issues about compatibility. There was a greater awareness of these issues and there was a more proactive approach to safeguarding. Progress had been made in identifying risk and learning from incidents but further work was needed to ensure a better balance between safely, risk taking and supporting people to lead fulfilling lives.

The premises and equipment was managed to keep people safe. We saw that a range of checks were undertaken to make sure that the safety systems were working effectively. The environment was in an adequate state of repair and efforts had been made since the last inspection to make it more homely.

Medicines were not consistently well managed. We found numerical discrepancies and could not be assured that people were always receiving their medicines as prescribed. There were gaps in the records which could lead to confusion and these issues had not been identified by the audits. We have made a recommendation regarding this.

There were sufficient numbers of staff to meet people’s needs but the service continued to be dependent on agency staff although made efforts to use consistent team members. Checks were undertaken on new staff to reduce the risk of the provider recruiting staff who were unsuitable.

Staff were positive about the training and the levels of support from the service management. We saw that staff received training on a range of areas including first aid, health and safety and autism. Staff also received training on how to defuse situations without the need for restraint. There were some gaps in the training for some individuals but the manager had already identified this and had scheduled further training to update staff.

Staff understood the principles of consent and told us that they had undertaken training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments and best interest decisions were in place and the manager confirmed that they had made referrals to the local authority as required by the legislation.

There were systems in place to support people with their nutritional intake and ensure that they had a varied diet. People were supported to maintain their health and staff accompanied people to appointments and scheduled checks with dentists and chiropodists. Where people had specific health conditions there were plans in place setting out how they should be managed and monitored.

The majority of staff knew people well and had good relationships with the people who lived in the service. There were systems in place to promote effective communication. Efforts were made to identity peoples preferences and ensure that people had choice.

Care plans were in place but were not fully completed and staff were not always familiar with the contents which meant that people were risk of receiving inconsistent care.

Appropriate systems were in place to manage complaints.

The manager was enthusiastic and committed to making changes to improve the wellbeing of the individuals who lived at the service. The manager was supported by a duty manager and senior staff. Staff told us that they were supportive and were positive about the developments in the service. Audits had been undertaken to ascertain the quality of the service and drive improvement. Progress had been made but some changes need to be further developed and embedded.

This service accommodates 15 adults in two houses named Cambridge House and Norfolk House. People who use this service have a learning disability and live with autism. Some people show distressed behaviour and need support to manage that.

This service required a registered manager and the person in charge had recently become the 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 on leave at the time of our visit and did not participate in the inspection process, but had supplied information.

When we arrived at this service most people and staff were leaving the building and going out for the day on a mini bus because there were carpets being fitted throughout the downstairs areas. The registered manager was not available as they were on paternity leave. Team leaders were in place and had access to senior managers if they needed additional support.

Middlefield Manor provides a large house with extensive grounds and several opportunities for people to access day care and the local community as it has transport in the form of mini buses. The large group living in a converted period house that requires group transportation to access community facilities whilst meeting the needs of some people is not as progressive, individualised and able to fully develop independence and individual choices.

We found some good opportunities for people, such as accessing the community. People told us about recent events and trips out. Whilst some people had their dignity and privacy maintained and promoted this was not actively developed. There were sufficient staff on duty and medicines were well managed. We found that people were safe and measures were in place to respond to situations that arose through people’s distressed behaviour.

We met and spent time with the majority of people who used the service, spoke with three people and interviewed eight staff. We attended the service both during the day and early evening.

We looked at three people's care records. Other records viewed included policies and procedures, medication administration records, staff rosters, staff training records incident and accident reports, satisfaction questionnaires completed by people who used the service, quality monitoring systems and we toured most of the communal areas of the service. We considered our inspection findings to answer the following questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Is the service safe?

We found that risk assessments to keep people safe when accessing the community were detailed and contained all the information needed for staff to follow, detailing strategies to use and therefore keeping all concerned safe. This enabled people to access several activities and facilities within their community and so enhance their life experiences.

We examined the medication systems in use in both houses and found that these did not protected people, specifically in relation to security of medication and decanting medication from its original containers. The manager informed us of action taken very shortly after the inspection to keep people safe.

One application had made under the Mental Capacity Act (MCA) 2005 in relation to a Deprivation of Liberty Safeguards (DoLS). We saw that there was a policy and procedure in place and that staff had received training. However, staff we spoke with were unable to translate their recent training into practice in the service. The service was in the process of addressing the issue that everyone was deprived of their liberty because they were locked in the premises and could not leave when they wished.

Is the service effective?

We spoke to two relatives of people who used the service and they believed the service was effectively meeting the needs of their relative. We observed that people were being treated with kindness, dignity and respect. However, systems were not in place to audit medication or health and safety which may mean that the delivery of care was ineffective.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

We found that the service had eight long term staff vacancies that they had been unable to recruit to, despite an ongoing recruitment campaign. These vacancies had been covered by agency staff, but this had placed additional stress and responsibility on the regular staff group because of the length of time recruitment was taking.

Is the service caring?

We saw that the most of the staff generally interacted with people living in the service in a caring, respectful and professional manner. We feedback our observations of the evening time where staff appeared to be less engaged and were seen to be observing and waiting to intervene. One person told us, 'The staff listen to me and take me seriously'. One relative felt that the staff and manager were good at communicating and keeping them informed of their relatives health. The staff showed care and compassion for this person and the relatives were deeply touched.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken into account and listened to. This included regular trips out to the local facilities and transport was provided. We could see that people had access when needed to medical professionals.

The service had a complaints procedure in place. We found that the service was responsive to concerns and acted to put matters right. People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to regularly review the care plans. This included seeking support and guidance from health care professionals, including end of life specialists.

Is the service well-led?

The service worked well with other agencies and services such as health and social care professionals to make sure people received their care in a joined up way.

The service had some quality assurance systems in place. To ensure that the service continuingly improved and listened to people who used the service, this needed to be further developed. The service had a registered manager, but they were shared with another registered service. Recruitment for a full time manager for Middlefield Manor was still on-going.

We saw that people had consented to their support plans. In cases where this was not possible, due to their capacity to understand, the support was agreed by relatives and professional staff in the person's best interest.

One person told us, 'I am very happy at Middlefield Manor and told us that they liked the staff that supported them. We spoke on the telephone with two people's relatives about the service. One person said, 'We are so content to know our [relative] is well looked after'we love it.' Another person said they were very satisfied with the care provided and that staff maintained good communication about the progress of their relative

We found that records relating to people who used the service provided an accurate reflection of their needs. Records relating to people's safety and wellbeing were readily accessible. The environment was checked routinely for fire and health and safety issues. Staff had received training and supervision and spoke knowledgably about the people they supported.