Archived: Cheshire House

We found the following examples of good practice.

¿ Social stories, which included photographs of members of staff, were used to support people to understand changes around social distancing rules, the COVID-19 testing procedures and why PPE was required.

¿ People had been supported to change their usual routines. Alternative activities had been introduced, for example having a ‘pop up’ café in the home as people missed going out to eat and supporting a person to arrange their photographs into computer presentations.

¿ Clear policies and procedures were in place covering all aspects of COVID-19 support, including if people or staff became COVID-19 positive.

¿ Additional staff training for COVID-19 and infection control had been completed. Good contact with the local authority infection control team had been established.

¿ Video conferencing had been used to complete an assessment for a new admission, with documents being shared via the video link. Transition visits had been arranged, with additional precautions in place to reduce the risks of a COVID-19 infection.

Further information is in the detailed findings below.

Cheshire house is a care home providing nursing care for up to eight people with a mental health need and / or a learning disability. Each person has their own self-contained flat and there was a small communal lounge and garden. People received one to one support depending on their assessed need and they shared the support of two waking night staff. At the time of our inspection there were seven people living at the home. The service supported people with complex care needs and associated behavioural issues.

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. It is slightly larger than current best practice guidance. However, people have their own individual flats and dedicated 1:1 staff support. 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 and what we found

The service had improved their rating at the last inspection in 2017 to Outstanding. People and professionals were extremely positive about the service. Improvements in people’s quality of life were evident throughout the inspection.

There was an open and welcoming atmosphere at Cheshire House. People and staff were keen to explain and share their experiences about the service.

Staff were exceptionally kind and caring. They knew people, their needs and how to support them very well, which contributed to the reduction in incidents at the service. People were actively encouraged to share their views and thoughts about their care, support and the goals they wanted to achieve. Various methods of communication were used to support them to voice their opinions.

People were supported and actively encouraged to increase their independence whilst being aware of their own responsibilities in achieving their goals and being safe in the wider community. Positive risk taking was promoted in a supportive and managed way to enable people to move towards their goals in a step by step manner.

People were supported to plan their own weekly activities. A wide range of different activities were in place, including supporting people to access short holidays for the first time in many years and to be involved in local community groups. This promoted people’s confidence, wellbeing and independence.

The provider had adapted parts of the home to meet people’s needs. One person had moved to a ground floor flat with their own entrance in order to reduce their anxieties around meeting other people living at the home. This had greatly reduced the number of incidents involving this person.

The management team had developed an ethos within the staff team of involving people in their care and supporting them to achieve their goals. They had a clear oversight of the service and had developed the staff team to be part of the quality monitoring and care planning through keyworkers, champion roles and workshops to discuss and agree people’s support.

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 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 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

The last rating for this service was Good (published 1 June 2017).

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.

The service is registered as a care home providing nursing care for up to eight people with a learning disability and /or associated mental health need. Each person has their own self-contained flat and receives one to one support depending on their assessed need. At the time of our inspection there were five people living at the home. The service supported people with complex care needs and associated behavioural issues.

The service had a registered manager in place. 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 also a registered mental health nurse. They were supported by a registered learning disability nurse.

The service was previously inspected in March 2016 where we found three breaches of the Health and Social Care Act 2008 in relation to assessing and mitigating risks, obtaining people’s consent for their care and treatment and staff training. At this inspection we found improvements had been made in all three areas.

People we spoke with and professionals involved with the service were complimentary about the care and support provided by Cheshire House. People said they felt safe and that the staff knew their needs a well. The staff we spoke with showed they had a good understanding of people’s needs. There were sufficient staff on duty to meet people’s needs.

Care plans, risk assessments and positive behavioural plans were in place. Clear guidance was provided for staff to support people and mitigate the identified risks. The service worked closely with the community learning disability team (CLDT) to support people manager their behaviours. The care plans promoted people’s independence where appropriate and were evaluated regularly. Staff knew the guidance in place to support each person safely.

Incidents were analysed and de-briefs were held with the staff team, the provider’s behavioural specialist and the CLDT to learn from each incident. The behavioural support plans were updated as required following an incident.

Staff had received suitable training for them to undertake their role. This included specialist training in areas such as mental health and personality disorder. Staff had completed training in safeguarding vulnerable adults and explained the types of abuse and the action they would take if the witnessed or suspected any abuse had taken place. New staff received a comprehensive induction to the service and people’s needs.

Staff received regular supervisions from the team leaders. The registered manager supervised the team leaders. Regular team meetings were also held. Staff told us these were open forums where they were encouraged to contribute to the discussions and raise any ideas or concerns.

Staff said they felt well supported by the registered manager and behavioural specialist. They were positive about the changes in the management structure and the introduction of key workers. They said they were now more involved in developing people’s care and support and liked the increase in responsibilities.

A robust procedure was in place for assessing people referred to the service. The registered manager and behavioural specialist completed an initial assessment and were able to state if the person could or could not be supported by the service. Staff were also involved in visiting people before they moved to the service so they could get to know them and their needs.

During the inspection we observed and heard kind and respectful interactions between the people who used the service and the staff team. People told us they liked the staff who supported them. People were supported to plan activities each week. Staff were matched with people so they engaged in the planned activity, for example aqua aerobics, with the person they were supporting.

Medicines were administered as prescribed and stored safely. Staff had received training in the administration of medicines. We checked the quantities of medicines stored at the service corresponded with the medicines administration record. We found two ‘as required’ medicines were correct but one was not. We saw weekly audits and counts of medicines were completed which would have identified this issue. We saw any issues were actioned by the nurse.

Health action plans were in place for each person. We saw people were supported to maintain their health and wellbeing.

We found the service was working within the principles of the Mental Capacity Act (2005). Capacity assessments and best interest decisions were made where required. Applications for Deprivation of Liberty Safeguards (DoLS) were appropriately made. Staff offered people day to day choices about their care and sought their consent before providing support.

The home was seen to be clean. Cleaning schedules were in place but were not always fully completed. Infection control audits were completed to monitor the home.

Systems were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and gas supply. Regular checks were in place of fire systems and equipment.

Surveys were completed to gain feedback about the service from people, their families and staff.

A complaints procedure was in place. People we spoke with said the staff and registered manager dealt with any issues they raised verbally without needing to use the formal complaints process. This was confirmed by the staff and registered manager.

We noted there were a number of quality audits in the service; these included medicines, care records, accidents and incidents and health and safety checks. The Operations Manager also completed a monthly visit and audit. We saw actions were identified from the audit and were then completed.

This was the first inspection of this service since it’s registration with the Care Quality Commission in August 2015.

The service is registered as a care home providing nursing care for up to eight people with a learning disability and /or associated mental health need. Each person has their own self-contained flat and receives one to one support depending on their assessed need. At the time of our inspection there were three people living at the home.

There was a registered manager in post at the time of this 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.

Since opening in August 2015, the home had received referrals for people with complex care needs and associated behavioural issues. As a result we had been made aware of a number of incidents occurring between the people who live at Cheshire House. We therefore carried out observations and reviewed records to look at how the home managed incidents and kept people safe.

Staff we spoke with were confident in describing the different kinds of abuse and the signs and symptoms that would suggest a person they supported might be at risk of abuse. They knew what action to take to safeguard people from harm.

Records of medicine administered were complete and there were clear instructions to guide staff in the safe administration of ‘as needed’ (PRN) medicine.

A system was in place to identify and assess the risks associated with providing safe care and support. We found more work was needed to ensure there were risk assessments in place to enable people to achieve their current goals as well as to support them with associated risks through behaviours. We saw risks had been discussed with the people who used the service and action agreed to keep people safe from harm.

We saw that the philosophy of the care and support delivered at the home were based on best practice guidance, such as person centred care planning and positive intervention. However we found not all of the care plans were up to date and improvements were needed to ensure people’s current needs were met.

Staff we spoke with understood the needs of the people they supported. We observed that people were supported to carry out household tasks and supported to access the local community which prevented social isolation and promoted their independence.

New staff received a comprehensive induction along with a regular support and mentoring from more senior staff following their appointment. Staff fully understood their caring responsibilities and they demonstrated respect for the rights of the people they supported. We observed positive interactions between people being supported and staff although due to the nature and layout of the service our observations were limited. Because the service was a new service, supporting only three people at the time of inspection, it was difficult for us to ascertain how caring the staff were towards the people they supported. We will check this again at the next inspection.

Records showed that other healthcare professionals such as general practitioners (GPs), dentists, opticians, psychologists and psychiatrists were involved in people’s care.

Staff told us they felt supported, management were approachable and they felt like a valued part of the team. We were unable to ascertain how much people using the service and their relatives or advocates were consulted and involved in assessments, care planning and the development of the service because the service was relatively new and this information was not reflected in care plans. We will check this again at the next inspection.

We found staff received mandatory induction training, however staff had not completed specialist training about positive intervention and positive behaviour support in line with company policy .

We asked the registered manager how people were involved in making choices about their care and support. The registered manager told us that prior to moving in to the home, people (and when appropriate their family members and associated health professionals), were invited to visit the home and spend time there. The manager told us people could visit as many times as they wanted, spend a day, have a meal or stay overnight. They said an assessment would be carried out to determine the suitability and compatibility of each person living there. We saw one assessment contained conflicting information about the suitability of one person living at the home and another did not contain enough information to ensure staff managed risk safely.

We found that the provider had not clearly assessed the risks to the health and safety of service users of receiving the care or treatment in order to ensure staff had the information they needed to mitigate such risks. This was a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found information in relation to restrictions placed on people and why particular decisions had been reached were not always clear and was a breach of Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found there were not enough suitably qualified or trained staff to meet the needs of the people who used the service. This was a breach of Regulation 18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found the provider had not notified us of all incidents which was a breach of Regulation 18 Care Quality Commission (Registration) Regulations 2009.

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