Pelham Manor

Pelham Manor is registered with the Care Quality Commission as a residential care home providing the regulated activity of personal care and accommodation for up to 7 adults with a learning disability and autistic people. At the time of the inspection there were seven people using the service. People had complex care needs, including learning disabilities, autism and physical health needs. Most people had limited verbal communication so were unable to provide feedback by speaking to us directly.

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.

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

Right Support: People were not always supported to have maximum choice and control of their lives and it could not be assured staff supported them in the least restrictive way possible and in their best interests; staff did not always follow the policies and systems in the service to support best practice. Mental capacity assessments had not always been undertaken to assess if people had the capacity to make specific decisions. There was inconsistency in meeting the conditions of people’s Deprivation of Liberty Safeguards (DoLS) and DoLS had not been applied for in a timely manner to ensure any restrictions on people were lawful.

The service gave people care and support in a clean environment, but government guidance had not been followed to minimise the spread of any infection. There were plans to improve the furnishings and decoration. People were involved in personalising their rooms so these were decorated to their taste and contained things that were important to them.

Staff supported people to take part in activities and pursue their interests in their local area. They had access to day services provided specifically for autistic people. Staff communicated with people in ways that met their needs and planed for when they may experience periods of distress and anxiety.

Staff enabled people to access specialist health and social care support in the community. Staff supported people with their medicines in a way that achieved the best possible health outcome. Staff prepared food and drink to meet people’s dietary needs and requirements.

Right Care: Information about people’s care, treatment and support needs were not always easy to access to ensure peoples’ wellbeing was promoted. Although staff turnover had been high, people received kind and compassionate care from staff who understood and responded to people’s individual needs.

People were supported by staff who understood the wide range of strengths, impairments or sensitivities people autistic people may have. People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language) and pictures, could interact comfortably with staff and others involved in their care and support because staff had the necessary skills to understand them.

People and relatives were mostly positive about the quality of the service. People told us or indicated by the ‘thumbs up’ sign that staff gave the support they needed. Relatives commented that staff were caring, but there had been a high turnover of staff and managers that was not ideal for autistic people who liked routine.

There were enough staff to meet people’s needs and keep them safe. Staff understood how to protect people from poor care and abuse.

Right Culture: Quality assurance and monitoring systems were not always effective in identify shortfalls and improving the service for the people who used it. People and their family members were not involved in providing feedback about the service so their views could be acted upon.

People benefitted from the open and positive culture of the service where the management team was approachable and listened and responded to people’s views.

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 Requires Improvement (published 3 June 2019) and there was a breach of regulation. At this inspection we found additional breaches of regulation. The service remains rated requires improvement. This is the second time the service has been rated requires improvement.

Why we inspected

This inspection was prompted by a review of the information we held about this service. Also, in part due to concerns received about care planning, risk assessment and oversight of the service.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall 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.

We have found evidence that the provider needs to make improvements. 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 Pelham Manor on our website at www.cqc.org.uk.

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.

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.

People’s experience of using this service:

The outcomes for people using the service reflected the principles and values of Registering the Right Support in the following ways; staff recognised that people had the capacity to make day to day choices and supported them to do so. People were encouraged to be independent. People were engaging in the community.

Risks to people’s safety had not always been identified. Fire safety had not always been checked adequately. Fire drill records did not show which staff had undertaken a drill. Water temperatures had not always been checked and recorded each week as scheduled within the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service did not always support this practice. Best interest meetings had taken place when people lacked capacity to make a decision. Best interest decision records did not show who had been involved in the decision making process. This is an area for improvement.

The service was well led. The registered manager knew people well and people were comfortable communicating with them. The registered manager carried out the appropriate checks to ensure that the quality of the service was maintained. The audits and checks were robust but had not captured the issues relating to risk management we had identified. This was an area for improvement.

There was a positive atmosphere at the service. People were happy, and staff engaged with people in a kind and caring way. People were busy when we visited, engaging in activities, undertaking daily living tasks.

The service continued to provide effective support to people living with a learning disability and or autism. People were provided with good support to communicate, staff knew people well and understood their communication. People were supported to manage their emotions and had positive behaviour support strategies in place. People were supported to feedback on their experiences and contribute to planning their own support in ways which were suitable for their communication needs. For example, through using pictures, stories and electronic communication.

Staff were kind and caring and had the skills, learning and training they needed to support people. People were encouraged to increase their independence. The service supported people to maintain family relationships.

The service met the characteristics of Requires Improvement in some areas. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: Good when we inspected on 02 August 2016 (the report was published on 22 September 2016).

Why we inspected: This inspection was a scheduled inspection based on previous rating.

Follow up: We will visit the service again in the future to check if they are changes to the quality of the service.

This service was previously inspected on 21 July 2014 and we issued one requirement notice in relation to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We asked the provider to make improvements in relation to documentation not being accurately maintained for day and night time records and this action has been completed.

The service had 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.

Staff had good knowledge of safeguarding adults and knew what actions to take if they suspected abuse was taking place. The provider had ensured that appropriate employment checks had taken place to ensure that staff were safe to work with people at the home. There were sufficient numbers of staff to keep people safe. The provider had a system in place that allowed the registered manager to recruit more staff when the numbers of people living at the home increased. The provider gave staff appropriate training to meet the needs of people. Staff received supervisions and appraisals from the registered manager.

Medicines were stored securely and safely administered by staff who had received appropriate training. Staff were recording the storage temperatures of the medicine cabinet but were not recording what actions were taken when reporting high temperatures. We have made a recommendation for improvement.

The principles of the Mental Capacity Act 2005 (MCA) were applied. People were being assessed appropriately and best interests meetings took place to identify least restrictive methods. Staff had received training on MCA and had good knowledge. The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people's freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

People's needs had been assessed and detailed care plans developed. Care plans contained risk

assessments for daily living needs that were personalised for the people staff supported. People were given options on what they would like to eat and those that required support to eat were supported. Relatives told us and records showed that people were involved in the planning and the reviews of their care plans.

People were being referred to health professionals when needed. Records showed that people were being supported with routine health appointments with their GP, dentist and chiropodists.

People and relatives spoke positively about staff. Staff communicated with people in ways that were understood when providing support. People’s private information was stored securely and discussions about people’s personal needs took place in a private area where it could not be overheard. People were free to choose how they lived their lives. People could choose what activities they took part in and would decorate their bedrooms according to their own tastes.

The provider had ensured that there were effective processes in place to fully investigate any complaints. Records showed that outcomes of the investigations were communicated to relevant people. People and their relatives were encouraged to give feedback through resident meetings and yearly surveys. The provider had ensured that there were quality monitoring systems in place to identify shortfalls and the registered manager acted on these appropriately.

People, relatives and staff spoke positively about the registered manager. The registered manager had an open door policy that was used by staff.

Below is a summary of what we found

Is the service caring?

Our observations showed that people had a positive experience of their care and they appeared settled and relaxed. We saw that staff greeted people politely and warmly and asked how they were. A relative we spoke with told us that the service was 'Excellent', the staff were 'Very understanding'. They added that 'They are very caring' and '[Their relative] is very fond of them'. This meant that people received support from staff who were caring towards them.

Is the service responsive?

We saw that the accommodation was used flexibly to meet people's needs. A relative we spoke with told us that the provider had altered the environment in response to their relative's changing needs. The provider had paid for alterations to be made to the building to enable their relative to continue living at the service when their needs had changed. They added that the staffing rota had been altered to ensure there was a driver on duty to support their relative to be able to access the community.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented.

Is the service safe?

There were systems in place to ensure staff were competent in being able to meet people's needs safely and effectively. We saw that new staff received an induction to the service.

There were systems in place to monitor health and safety within the service. These checks included water temperature checks, fire safety checks, gas safety inspections and electrical inspections.

We saw that the service was suitable in lay out for people with disabilities, including mobility difficulties. It was clean, tidy and well furnished. There was a system in place to report and monitor repairs needed at the service.

There were arrangements in place to deal with foreseeable emergencies.

Is the service effective?

We saw that there was a system in place to assess people's capacity to give consent to care and treatment, should the service need to. We saw examples of assessments of people's mental capacity in relation to significant decisions. Where people did not have the capacity to make an informed choice about a significant aspect of their care, staff acted in accordance with the legal requirements of the Mental Capacity Act 2005.

People were involved in making decisions about their care. For example, a relative we spoke with told us that their relative was asked whether they wished to live at the service before they moved in. Staff respected people's right to refuse care.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Records showed that risk assessments had been completed to balance people's independence with their safety and their health.

People's health needs were met and staff recorded health information on people's health records. We saw that people's appointments with health professionals were recorded.

People were given opportunities to participate in a range of activities. For example, on the day of inspection people were going out into the community. Other people visited two local day centres. We saw one person doing a puzzle at the service. One person's records showed that they went bowling, visited a gallery and played golf. This meant that people spent their time as they wished.

There were enough staff on duty to meet people's needs effectively. The service had assessed the needs of the people using the service and provided staff accordingly. The deputy manager told us how many staff should be on duty to be able to meet people's needs effectively. This was based on a tool used to assess people's level of dependency and inform staffing levels. We saw that this amount of staff were on duty.

Is the service well led?

There were systems in place to monitor the quality of service delivery. These included meetings with people living at the service and surveys provided to people and their relatives. There were opportunities provided to staff for them to feedback about the service. We saw that there was a complaints process in place and there were systems in place to monitor staff training.

However, records were not always kept to show the delivery of care to be able to monitor whether care was being delivered in line with people's needs. For example, staff did not record when they had checked a person at night to show that it was done regularly in line with their support plan.

Records were not completed to show whether people had given their consent to the use of audio monitors at night for health reasons. There was no written information to show that people had been invited to sign documents related to the use of such monitoring devices to demonstrate they had given their permission to do so. Or to show that they had been unable to sign or they had declined to do so.

Records were not kept to show that the decision to lock one person's bathroom, so they accessed it only with staff support for safety reasons, had been recorded. There was no written information to show that this was the most appropriate course of action to take or that this decision had been reviewed.

There were systems in place to ensure staff were competent in being able to meet people's needs safely and effectively. We saw an example of a completed induction record. This meant that staff received information and support to prepare them for their role.

We spoke with two care staff who told us that they supported people to be as independent as possible to help them work towards and achieve personal leisure activities and social goals. We looked at three care files that demonstrated the personalised approach in place to support the staff's comments. We observed that the provider operated a model of good practice by offering staff regular supervision and access to a framework of training and support that enabled them to provide a high quality of care.

We observed staff treating people with respect and were able to see that there was a good relationship between staff and people who use the service. We observed staff assessing people's needs and ensuring that care was provided in line with individual care plans. We were able to see that people were comfortable and that there was adequate numbers of staff available to provide the individualised support needed.