Archived: Acrefield House

Acrefield House is a residential care home providing support and personal care for up to 12 people in one adapted building; at the time of our inspection seven people were living in the home.

At our previous inspection in December 2018 the service was in breach of Regulation 9 and 17. This was because the provider had not ensured that people’s care and support always met their needs and reflected their preferences; and the provider had not taken adequate steps to improve the safety and quality of the service provided for people. At this inspection we found enough improvement had been made and the provider was no longer in breach of regulation.

At this inspection we observed a cultural shift in how staff interacted with people. People were treated with dignity and respect and we observed many positive and empowering interactions between staff members and people supported; we also saw that staff paid attention to detail and were very thoughtful.

There was a distinct improvement in how people were consulted with and how they were supported to make decisions. People were now supported to make decisions in every aspect of their day to day lives and support. Their views and decisions were listened to and respected. People were supported to set goals for the future, to express themselves and start planning towards aspirations that they had for themselves

The service ensured people were kept safe by staff having safeguarding training. Staff felt empowered to speak up if they had any concerns that a person was at risk of abuse and the provider ensuring appropriate policies were in place. The service was open and honest in raising appropriate safeguarding alerts.

The service was provided 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 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. People were participating as active members of their community and had many more life enriching experiences. The activities people took part in were tailored to people’s interests and tastes; they did not follow a set plan or schedule which enabled people to have maximum choice and control.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 12 people; at the time of our inspection seven people were using the service. If the home became full this would be 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 was deliberately little to differentiate the building as a care home other than five large industrial bins that were at the font of the home; we spoke with the registered manager about how this could be improved.

The registered manager and deputy manager were knowledgeable about people and spoke with a passion about people receiving a high standard of care and support. Staff members described the registered manager as very supportive, approachable and proactive. There was a service improvement action plan and, the registered manager demonstrated that most of the actions set were completed or were in progress.

Staff at Acrefield House had worked in partnership with the local authority, people’s families and health and social care professionals to help improve the lives of a number of people since our previous inspection

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 3 December 2018) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. 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 December 2018. 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.

Why we inspected

This was a planned inspection based on the previous rating.

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.

Acrefield House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large Victorian style building over three floors in a residential location. The home provides care and support to people who have a learning disability, autism or a brain injury. The home is registered to provide care and accommodation for up to 12 people. At the time of our inspection nine people were living at the home.

The home is required to have a registered manager. Since our previous inspection there was a new manager in place. The new manager was in the process of applying to become registered with the Care Quality Commission (CQC). 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.

During our previous inspection in November 2017 we had found breaches of regulation 10 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for the service was ‘requires improvement’. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; ‘Is the service safe?’ ‘Is the service effective? ‘Is the service caring? and ‘Is the service well-led?’ To at least a rating of good.

At this inspection we found that there had not been sustained improvements to the quality of the service provided for people and the majority of the actions we were told the provider would take had not been completed. Although the service was no longer in breach of Regulation 10, there was a breach of Regulation 9 and there was a continued breach of Regulation 17 for the third inspection in a row. This is because the provider had not ensured that people’s care and support always met their needs and reflected their preferences; and the provider had not taken adequate steps to assess and improve the quality of the service provided for people. Therefore, arrangements made by the provider for leadership of the service have not been adequate.

This service was not provided in line with the values that underpin the Registering the Right Support and other best practice guidance. The values underpinning Registering the Right Support include choice, promotion of independence and inclusion; to help enable people with learning disabilities and autism using the service to live as ordinary a life as any citizen.

Whilst people were cared for and kept safe; we saw little evidence that showed choice, promotion of independence and meaningful inclusion were integral to people’s support. Many aspects of people’s support appeared to be aimless, it did not regularly promote people having enriching and everyday life experiences.

We have had some concerns with the quality of the service provided for people since our last inspection. One staff member raised concerns about bullying within the home; their concern was then followed by other staff members raising concerns. Also, we learnt from the local authority that historically staff at the home were not following the correct procedures in recording and reporting allegations that people at the home had made. When the manager became aware of these concerns they responded, took appropriate action and were open about these concerns. However, this is the third inspection where we have concerns about the culture and leadership within the home. We are meeting with the provider to address these concerns and we will inspect the home within six months to ensure that action has been taken.

Staff all had received training in safeguarding vulnerable adults with an upcoming training refresher booked for staff. Safeguarding and whistle blowing had been agenda items at recent team meetings, which ensured that staff knew how to raise an alert.

The administration of medication at the home was safe. The medication was stored securely in a well-equipped medication room that was temperature controlled. Each person had detailed information recorded about their medication which helped staff ensure they administered it accurately.

The environment of the building was safe, it was clean and well maintained. We saw that environmental health and safety audits had been completed on the equipment and services at the home.

The service was working within the principles of the MCA. We saw that appropriate capacity assessments were in people’s files. These assessments showed an understanding of the person’s right to be involved in the decision-making process as much as possible and in regard to the specific decision being made, this had helped staff to support people with specific decisions effectively.

People told us that they liked the food provided at the home. The food looked and smelt tasty and appetising, in a home cooking style with a varied menu. There had been an improvement to the breakfast experience with a new breakfast bar enabling people to choose and help themselves to breakfast. Staff told us this had been a positive change and some people were much more involved in the preparation of their food.

People’s rooms were personalised and decorated the way they wanted them. There had been improvements since out last inspection to bathrooms and the kitchen. The home made use of assistive technology to support people to have greater independence around the home whilst remaining safe.

People’s support plans contained information on how to support the person with communicating their needs and wishes. Also, information in relation to their medication and health care had been reviewed. This had led to some positive changes for people.

Staff members told us that they felt the new manager was positive and approachable. They told us that the team changes had been positive in that people no longer work in set teams and work alongside all of their colleagues. When the manager had become aware of any complaints or information of concern we saw that they had investigated and responded to these.

Acrefield House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home is a large Victorian style building over three floors in a residential location. The home is registered to provide care and accommodation for up to 12 people. At the time of our inspection nine people were living at the home.

The home requires and had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The previous inspection was in February 2017. During the previous inspection the service breached regulations 11, 12, 13, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had also found breaches of Regulation 18 of Care Quality

Commission (Registration) regulations 2009. Failure to notify the Commission of notifiable incidents.

At this inspection we found that improvements had been made. This meant the service was no longer rated inadequate and could be removed from 'special measures' by the CQC. The service was no longer in breach of Regulations 11, 12, 13, 16 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. And Regulation 18 of Care Quality

Commission (Registration) regulations 2009.

At this inspection we found that there were breaches of Regulation 10 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This is because the language and approach of staff both verbally and in written care plans did not always treat people as equals with dignity and respect. We saw that relationships between people and staff at the home were friendly and that staff cared about people; however the predominant approach towards people was paternalistic. We recommended that there needs to be a greater focus on dignity and respect in the language and approaches used when supporting people.

We looked at the record of incidents that had happened at the home since our previous inspection. We saw that the number of incidents had reduced. The response to incidents from the registered manager and the provider had improved. Incident records showed that the manager and staff had taken time to explore the possible reasons that may have prompted a change in the person’s behaviour. Records of physical interventions did not always give a clear picture of what happened or had led to updates to people’s risk assessments or care plans. Also the rationale for decisions made in supporting a person were not clearly recorded to show that they followed the best interest decision making process as outlined in the Mental Capacity Act.

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

During this inspection it was clear that the registered manager and staff had worked hard to make improvements to the service provided to people. During this inspection we saw that there had been improvements in the culture and atmosphere at the home. People’s family members, staff and health and social care professionals spoke positively about the registered manager and his style of communication. One person’s family member told us, “When [registered manager] came in it stepped up a level and communication improved. They have always been available for us when we need them.” We did see that new thoughts and ideas of different and more person centred ways of supporting people had been written on the plans and there was a culture starting to develop of trying new ways of supporting people.

A number of processes and audits had been introduced or strengthened by the registered manger.

Some of these audits had been effective and others had not highlighted the areas that we saw that required further improvements.

Staff told us that they felt well supported in their role. There was a clear system in place for monitoring staff training and ensuring staff undertook and remained up to date in areas the provider considered mandatory.

People were supported with their health needs; important information about people’s health was kept in a central place. People’s relatives were happy with the way their family member was supported with their healthcare. One relative told us, “They [staff members] are quick in spotting problems and getting medical attention.”

We saw that people were supported to access their community and lead active lives. People told us what they enjoyed doing. One staff member told us, “People do more now that they used to do.” One person’s relative told us, “They are amazing in terms of keeping [name] involved. They arrange for [name] to go to all the home games of his local football club with support. He loves this.” Another relative told us the staff enable the family member to have a, “Really good quality of life, [name] enjoys it.”

The registered manager and the regional manager that we spoke with and gave feedback to were open, honest and transparent when we discussed areas needing further improvements. They told us that the service is not where they want it to be, but described plans that are in place to make those changes.

Acrefield House is a large Victorian style detached building in a residential area of Prenton, Wirral. The building is over three floors, with well-kept front and rear gardens. The home is registered to provide care and accommodation for up to 12 people. At the time of our visit 10 people were staying at the home.

Accommodation is in 12 bedrooms over three floors, the upper floors are accessible by a staircase. There is a ground floor extension at the rear of the building providing accessible bedrooms. All of the bedrooms are single occupancy. There are suitable toilets, and bathing facilities on each floor.

The home required and had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our inspection we found breaches of regulation 11, 12, 13, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found breaches of Regulation 18 of Care Quality Commission (Registration) regulations 2009. Failure to notify the Commission of notifiable incidents.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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.

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.

During our inspection we found that there had been failings by the registered manager to alert the CQC of notifiable events and to alert the local authority of incidents and allegations that are reasonably considered to be safeguarding alerts. There was also a failure of the registered manager to investigate specific safeguarding allegations. As a result of the inspection safeguarding alerts were made to the local authority by the CQC for five people living at the home.

People at the home had not been kept safe. Risk assessments had not been effective in reducing risks. At times physical restraint had not been used in a safe way. Altercations between people living at the home caused people to be upset and not feel safe.

Incidents had been recorded, but this information had not been used to reduce the likelihood of any reoccurrence. There was little evidence to suggest staff and people living at the home were de-briefed and supported after any incident.

Staff told us that often staffing levels were lower than those that had been planned.

Staff told us that they liked working at Acrefield House. But they told us they were not confident in supporting people during challenging situations and that appropriate guidance was not in place for them to be effective supporting people. Different staff members responded in different ways, which led to inconsistent support and at times unsafe and inappropriate use of restraint.

There was a poor culture amongst the staff team, there was in fighting amongst the staff. One staff member commented on how this has had a negative effect on the atmosphere at the home where people lived.

The support provided was not in line with the Mental Capacity Act 2005. In people’s care files information relating to people’s mental capacity and deprivation of liberty safeguards was incomplete and at times contradictory. The registered manager had failed to give relevant information to a person’s legal representative. This meant that the person’s legal representative did not have relevant information to make decisions that were in the person’s best interests.

During our inspection staff had a caring approach to people and we saw they were at times considerate of people. Staff spoke positively about the people they supported and were keen to tell us of the progress some people had made and positive experiences such as going on holiday. However there were mixed opinions from people supported about the support staff.

However because of the prevailing culture at the home, people’s support was not always caring. We found the atmosphere to be tense at times. When we spoke with staff many of them also told us of divisions and in-fighting amongst the staff team. One staff member told us that this impacts on the atmosphere in people’s home. Although staff listened to people on a regular basis with regard to their care, the organisation had not investigated people’s concerns or taken effective actions to resolve them. People’s verbal and non-verbal communication was not always listened to.

People had personalised care plans which recorded their needs and preferences. We saw that this information was reviewed regularly. However the reviews had not always led to changes in people’s care plans, new information being added or actions being taken.

Acrefield House lacked clear leadership and good governance. There was a poor culture amongst the staff team which was well known. The registered manager had not assessed and monitored people’s care to a sufficient degree so that he was able to be assured that it was of good quality. There was poor communication with other professionals involved in people’s lives.

Medication was usually administered safely, there had been some recent medication errors that the provider had investigated and was addressing.

We saw and people told us that they were supported to engage in activities within the home and in their community. People were supported to engage in everyday activities such as going to the cinema, the local church, shopping, to local coffee shops and further for trips out. Some people had been supported to take a holiday.

The environment within the home was clean and well maintained. It was decorated in a homely and non-clinical style. Some bedrooms had been recently renovated to a high standard. There were safety features of the building that ensured people were kept safe. People who wished to show us their rooms told us they were happy with them and they had been supported to personalise then.

Below is a summary of what we found

Is the service safe?

We saw there was several deprivation of liberty conditions in place which were in people's best interests and ensured their safety. We saw there was several deprivation of liberty conditions in place which were in people's best interests and ensured their safety. Deprivation of Liberty Safeguards' (or DOLS) were introduced to protect individuals from the unlawful deprivation of their liberty as a part of the Mental Health Act 2005. We saw the provider maintained all the correct paperwork for every person who required a deprivation of liberty as well as a capacity assessment.

We saw that the provider was responsible for most people's finances at the home. We saw the provider regularly reviewed financial risk assessments and capacity assessments for these people. We saw all cash was stored securely.

We saw the provider had policies and procedures in place for emergency situations. The staff we spoke to knew where to locate these. We looked at the accident and incidents book. We saw evidence in records staff were able to respond appropriately in emergency situations.

Is the service effective?

We looked at four care plans, all of which had a range of risk assessments, for example, mobility, nutrition and behaviour. We saw care plans were person centred and reviewed regularly. We saw staff had completed care plans that related to people's long term illnesses and when asked we found staff were very knowledgeable about these conditions. We saw staff completed assessments in order to understand the person's family involvement, social history, likes and dislikes. The one relative we spoke with told us staff at the home always respected the person's wishes and gave them choices in all aspects of their care. We saw people's needs were taken into account when care plans were developed.

Is the service caring?

We observed staff communicating in a sensitive and supportive manner to those who were confused and anxious. We saw staff were skilled at detecting changes in behaviour and were able to quickly reassure people diverting their attention to more positive thoughts and activities.

Is the service responsive?

We saw evidence that people who lived at the home, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We saw the provider conducted monthly reviews with people who used the service. This looked at whether the people were pleased with their care and the activities they were involved in at the home. From the reviews, we saw people told staff they were happy at the home. We saw people had made suggestions about different foods they wanted to see on the menu and different activities. We saw people's suggestions and preferences were acted upon and implemented into their care. This meant the provider was responsive to people's needs.

Is the service well-led?

We asked people who lived at the home and staff about the manager and their ability to deal with concerns. They all felt the manager dealt with any issues very promptly and everyone we spoke with gave positive comments about their management style and personality.

We saw the provider conducted annual audits in order to review the quality of the service. This included the audit of care plans, medication sheets and maintenance records. We saw from the action plan some maintenance logs needed completing and all medication was recorded correctly. This was disseminated to staff.

"This is their home and they are very happy here. I visit every week and I feel part of the family here.'

'I attend my relative's reviews with them and I feel fully involved in their care.'

We looked at three care records. The support plans showed how the needs of the people who used the service were to be met, including any risks to their well-being. Records also showed that when necessary the service had made deprivation of liberty safeguarding referrals.

Records and discussions with relatives of people who used the service and members of the staff team showed that the service co-operated with other service providers.

Relatives spoken with described the staff as caring and said they always appeared competent in their work. Training records and discussions with members of the staff team showed the staff team were supported to undertake relevant training to support them in their roles.

The provider had systems in place to monitor the quality and safety of the service provided at Acrefield House.

We spent time with people who used the service and observed care workers supporting them in a caring and supportive manner.

We looked at three care records these included support plans, risk assessments, daily records and information about visits to or by health and social care professionals. The support plans showed how the needs of the people who used the service were to be met, including any risks to their well-being.

We spoke with two care workers who told us they had received training in safeguarding and described how they would ensure the welfare of vulnerable people was protected through the whistle blowing and safeguarding procedures.

We looked at two staff files and found there were effective recruitment and selection processes in place.

Displayed on the notice board in the hallway there were two copies of the complaint procedure. One in a written format and another that used pictorial prompts to support understanding of the procedure. There was also information displayed about local advocacy services, CQC and Wirral department of adult social service.