Archived: Angela House

Angela House is a care home registered to provide care and accommodation for up to six adults with a learning disability or an autistic spectrum disorder. At the time of this inspection there were three adults living at the service. The accommodation comprises a communal lounge, kitchen diner and communal bathrooms and toilets. Bedrooms do not have en-suite facilities.

People’s experience of using this service:

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 reasons outlined below:

People were not always supported to have maximum choice and control of their lives.

Staff were not always supporting people in a kind or caring manner. We witnessed abuse taking place. These concerns are currently being investigated by the local authority safeguarding team.

Risks to people's health and wellbeing were not always being assessed, mitigated or reviewed appropriately. This impacted on people’s safety and dignity.

Staff were not always supporting people in the least restrictive and safest way possible.

People were at risk of harm because staff were not always following guidelines and recommendations provided by healthcare professionals.

Incidents were not being referred to safeguarding authorities as required to ensure a thorough investigation was completed and people were protected from harm.

The environment was poorly adapted and failed to meet people’s needs appropriately.

Opportunities to observe, review and adjust care practice were being missed.

The provider's systems for assessing and reviewing the quality of the service were not always effective. Improvements to the service and how it was managed were overdue.

The previous inspection rating was displayed in line with CQC requirements.

Rating at last inspection and update:

The last rating for this service was requires improvement (report published 8 August 2018). 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 to the specific issues we identified in relation to the safe storage of medicines, sharp knives and COSHH (Control of Substances Hazardous to health). However, we found repeated breaches of the regulations in relation to risk management and medicines management.

Why we inspected:

This inspection was part of a scheduled plan based on our last rating of the service and aimed to follow up on some concerns we had found at our previous inspection.

Enforcement:

We have identified repeated breaches of regulations in relation to safe care and treatment. We found further breaches related to person-centred care, dignity and respect, safeguarding, premises and equipment, good governance and failure to notify. Please see the action we have told the provider to take at the end of the full version of the report. 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 made a recommendation in relation to home improvement and relocation plans.

Follow up:

We will contact the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

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.

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

This comprehensive inspection was conducted on 15 and 21 March, 5 April and 14 May 2018. The first day of the inspection was unannounced and we advised the manager of our plan to return on the second day. We visited the provider’s main office on 5 April 2018 in order to check staff recruitment files and also met with senior management staff at the main office on 14 May 2018, as they wished to discuss matters that had arisen about the service. During the inspection we received information of concern from an external source which alleged concerns regarding to the safety and welfare of people who used the service. There were specific allegations regarding the provider’s management of people’s finances. This information was also sent to the local authority, who met with the provider to discuss these allegations. The provider informed us that they asked the local authority to investigate these allegations through safeguarding procedures, so that an independent judgement could be reached. These safeguarding investigations were in progress at the time we concluded this inspection.

An immediate concern was also raised by the external source about the safety of a specialist bed and mattress allocated to a person living at the care home. This was addressed by a visit from a physiotherapist and occupational therapist employed by the local learning disability partnership. Following their visit, we received written confirmation from the professionals to confirm that the bed and mattress safely met the person’s needs. The external source has subsequently raised other issues to the local authority about the suitability of the bed and mattress.

At our previous comprehensive inspection on 30 January, 6 February and 16 March 2017 the service had an overall rating of Requires Improvement. We had rated effective, caring and responsive as Good, and safe and well-led were rated as Requires Improvement. A breach of legal requirements had been found in relation to staffing levels. Following the inspection the provider wrote to us to state what action they would take to meet the breach of legal requirement.

We undertook an unannounced focussed inspection on 13 October 2017 in order to check how the provider had met its action plan and report on our findings in relation to specific aspects of safe and well-led. We had also received information of concern from an external source prior to the inspection and these concerns were looked into as part of the inspection. Following the inspection visit we had received other information of concern from other external sources and returned unannounced to the service on 21 November 2017 to conduct a second day of this unannounced focussed inspection and look into the additional concerns which had been brought to our attention. We had found that although the provider had met the breach of legal requirement in relation to staffing levels, two new breaches of legal requirements were identified in relation to the safe management of medicines and the robustness of the provider’s quality monitoring. Following the inspection the provider sent us an action plan to state how they would meet the breaches of regulation.

The service did not have a registered manager in post at the time 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 manager had applied to the Care Quality Commission for registration.

At this inspection we found that the provider had met the breach of regulation in regards to the safe management of medicines. New medicine cabinets had been installed in people’s bedrooms and the main office and medicines were no longer at risk of product deterioration and potential harm to people who used the service. Although systems were in place to safely receive, administer and store medicines, we found two medicines that were no longer required in a locked box in the fridge.

The provider had met the second breach of regulation in regards to the provider’s quality monitoring system, in relation to concerns we had identified at the service that had not been fully addressed by the provider. At this inspection we found that the provider had taken clear actions to support members of the staff team, listen to their views and promote their participation with developing and implementing objectives to improve the quality of the service.

At the time of this inspection the provider was in the process of making improvements to the premises. The provider wished to minimise any disruption to the daily lives of people who used the service and had already made arrangements for one person to use alternative night-time accommodation for a short period. We found specific issues in relation to the safety of the environment, for example we found that the provider had not carried out a risk assessment for kitchen knives that were potentially accessible to people who used the service and items were being stored under the stairs that were flammable and potential obstacles if there was a fire at the home.

Staff had received safeguarding training and knew how to protect people who used the service from abuse. Records showed that staff were safely recruited, and they received appropriate training and supervision for their roles and responsibilities. Our discussions with staff and review of the staffing rotas evidenced that there were ordinarily sufficient staff deployed to meet people’s needs.

The care and support plans for people who used the service showed that their social care and health care needs were assessed, monitored and reviewed. People were supported to attend health care appointments and we noted that a health care professional had commented favourably about the way members of the staff team had supported people to follow a specialised communication project. People were provided with encouragement, and assistance where necessary, to eat nutritious and appetising meals and snacks.

We observed that staff supported people who used the service in a caring, respectful and compassionate way. We saw positive interactions and staff spoke with pride about people’s interests and achievements. Staff provided daily care and support in a way that sought people’s consent and promoted their freedom to go out every day if they wished to. Staff understood about best interests decisions and the importance of working in partnership with relatives and professionals when people who used the service did not have the capacity to make key decisions, for example about hospital treatments. People were supported to access advocacy support and the provider’s complaints policy and procedure was accessible to people and their representatives.

The provider had a clear vision in regards to its commitment to enabling people who used the service to experience positive care and support to enrich their lives. Although the provider had liaised with staff to jointly develop ways to improve the service, we continued to receive some mixed views from staff about how the service was managed and how this impacted on the quality of care and support for people living at Angela House. The provider demonstrated a transparent approach in relation to the investigation of concerns and complaints.

We have recommended that the provider seeks guidance from professional pharmacy guidelines about systems for the safe disposal of no longer required medicines.

We found one breach of regulation in relation to the absence of effective practices to consistently identify and remedy issues in regards to the safety of the premises.

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

At our previous comprehensive inspection on 30 January, 6 February and 16 March 2017 the service had an overall rating of Requires Improvement. We had rated Safe and Well-led as Requires Improvement and Effective, Caring and Responsive were rated as Good. This report only covers our findings in relation to specific aspects of Safe and Well-led. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Angela House on our website at www.cqc.org.uk.

Angela House is registered to provide care and accommodation for up to a six adults with a learning disability or autistic spectrum disorder. At the time of this inspection there were five people living at the service, each with their own bedroom. The accommodation comprises a communal lounge, kitchen diner, a sensory room, a small rear courtyard, and communal bathrooms and toilets. The bedrooms do not have ensuite facilities. The house is located in a central part of Hammersmith close to a wide range of amenities, public transport and a large park.

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. At the time of the inspection the service was being managed by an experienced manager who had applied to the CQC for registered manager status.

At the previous inspection we had found that staffing levels did not demonstrate that sufficient staff were consistently deployed to ensure that people received their care and support in a timely manner. At this inspection we found that the staffing levels were now satisfactory. The staffing levels were planned in accordance with people’s needs and kept under review.

The systems for storing medicines needed to be improved. Although the provider was aware that the temperature of the room used for the storage of medicines was not suitable for this purpose, no actions had been taken to address the problem. Concerns about how the service decanted medicines to the relatives of a person who regularly took breaks away from the service with their relatives were shared with us by the relatives. Although the relatives were offered an alternative system that would have been safer, the relatives were not consulted with or provided with sufficient training about the new medicines system so that they could make an informed decision.

Although the health and safety records we checked were up to date, the cleanliness of the premises needed to be addressed. The structural damage at the service had resulted in the growth of mould in communal areas and we were informed after the inspection that this mould had spread to the bedroom of a person who uses the service.

Staff understood how to protect people from the risk of abuse and confirmed that they had received safeguarding training. Individual risk assessments had been developed in order to reduce identified risks to people’s safety and welfare.

We received mixed feedback from relatives. It was evident that one person’s relatives had concerns about how the service met their family member’s personal care, health care and social needs and they were understandably frustrated that the provider had not implemented the improvements they sought. Another relative acknowledged that there were issues that impacted on Angela House and other care services, for example the difficulties with recruiting and retaining staff of a high calibre. This relative commented on areas that needed improvement such as the maintenance and refurbishment of the premises; however they were presently pleased with the quality of care and support provided to their family member. They felt that their concerns and queries were satisfactorily responded to by the provider.

The new manager was experienced and had received favourable feedback from health and social care professionals in regards to their approach and commitment to improving the service. At the previous inspection we had noted that staff had treated people with kindness and were caring, which we observed during the inspection. However, we had been made aware of an incident when people were not supported with compassion and afforded the privacy they required.

The issues of concern we identified at the inspection indicated that the provider’s own quality monitoring and audits did not pick up on areas that needed improvement. For example an obsolete inspection report with a former rating was being displayed on a notice board on the first day of the inspection although the provider is required by legislation to ensure that the current rating is prominently displayed. We had also observed that a cupboard with hazardous domestic cleaning items was not locked as it did not have a complete lock attached.

We found two breaches of regulation in relation to the safe storage of medicines and the need for the service to receive more robust monitoring. You can see what action we have told the provider to take at the back of the full version of the report.

Angela House is registered to provide care and accommodation for up to a six adults with a learning disability or autistic spectrum disorder. At the previous inspection the accommodation was organised so that four people had a single bedroom and two people shared a bedroom. At the time of this inspection there were five people living at the service, each with their own bedroom. The accommodation comprises a communal lounge, kitchen diner, a sensory room, a small rear courtyard, and communal bathrooms and toilets. The bedrooms do not have ensuite facilities. The house is located in a central part of Hammersmith close to a wide range of amenities, public transport and a large park.

The service had a registered manager, who had worked at Angela House for nearly 25 years. 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. At the time of the inspection the registered manager was on an authorised period of absence and had not been working at the service since May 2016. The service was being managed by an interim manager, who was an established manager from another local service operated by the provider.

Staffing levels did not demonstrate that sufficient staff were consistently deployed to ensure that people received their care and support in a timely manner. Observations during the inspection, discussions with different individuals and information sent to CQC signified that there was a distinct level of concern about the difficulties permanent staff encountered. This was due to the regular use of agency staff in an environment where people need consistency of care to meet their complex needs.

Staff were familiar with the provider’s safeguarding policy and procedure, and understood how to protect people from the risk of abuse. Individual assessments were in place to promote people’s independence and mitigate identified risks to their safety and welfare. Staff had been recruited in a detailed manner which ensured, that as far as possible, they were suitable to work with people who use the service. Records showed that staff had received medicines training and staff followed the provider’s policy to safely manage people’s prescribed medicines.

People were supported by staff, who had appropriate training to meet their needs. Newly appointed staff received induction training and their performance was formally monitored, in order to ensure they were suitable to permanently remain at the service. People’s legal rights were protected as staff had a satisfactory understanding of how the Mental Capacity Act 2005 (MCA) impacted on their role and responsibilities.

People were supported to make choices about their food and drinks, and their nutritional needs were monitored. Staff supported people to visit health care professionals, including GPs, psychologists, speech and language therapists and dietitians.

We observed that people had positive relationships with staff, who demonstrated their understanding of people’s individual and complex needs. Staff understood people’s likes and dislikes, and could explain people’s life histories. People were spoken with and treated by staff in a respectful and kind manner and their privacy and dignity were promoted. For example, people were asked by staff if they were happy to show us their bedrooms and their wishes were respected. People were supported to eat a healthy diet that reflected their preferences and took into account any medical needs. The service had good links with local health care providers and professionals and people’s individual files showed that their health care needs were regularly assessed and updated, with reference to the guidance and instructions from relevant professionals.

Staff supported people in a kind and compassionate way. They knew people well and understood their individual preferences. People’s dignity and privacy was promoted by a caring staff team.

Individual care and support plans had been developed to identify people’s needs and wishes, and explain how staff proposed to meet these needs. These care and support plans were regularly reviewed, involving people, their relatives where possible, and health and social care professionals. Relatives confirmed that they attended meetings and were asked to give their views. People participated in social activities at home and in the community, although this aspect of people’s support did not appear as active as it was at the time of the previous inspection. There was an established system in place for informing people and relatives about how to make a complaint.

The interim manager was experienced and was described by external health and social care professionals as having a caring and knowledgeable approach. They were supported by an area manager, who was familiar with the service and knew the people using the service. The management team confirmed that there had been difficulties at the service with staff recruitment and retention, and environmental problems that had caused disruption to people and staff. We noted that staff had not been receiving individual supervision, and received information from other sources that staff did not feel supported by the management.

We found one breach of regulation in relation to not enough staff being consistently deployed. You can see what action we have told the provider to take at the back of the full version of the report.

On the day of our visit we spoke to four members of staff and looked at the files of four of the people living at the home. We spent time in the house observing the care provided to people. The house had a homely atmosphere and we saw that people were well looked after by staff who understood their needs. Staff were respectful and kind in the way they cared for people and took pride in supporting people to be as comfortable as possible.

We saw that some people needed considerable support with their personal and health care as well as support in managing their learning disability. We saw that care and support was provided safely because risks were identified and was action was taken to minimise these.

We saw that records about people was well organised and kept securely. Medicines were administered properly and stored safely. The provider had carried out the required checks on staff to ensure they were suitable to care for people living at the home.