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Inspection carried out on 4 March 2019

During a routine inspection

About the service: The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 12 people. Ten people were using the service. This is 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 were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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; promotion of 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 told us they were well cared for; they said staff were kind and caring.

People told us they were safe living at Crows Nest. Staff had a good understanding of safeguarding and the whistle blowing procedure; they knew how to raise concerns.

There were sufficient staff to ensure people received the support they wanted. The provider followed safe recruitment practices.

Health and safety checks and risk assessments were carried out to ensure people were safe and to maintain a safe environment. Medicines were managed safely. Accidents had been and appropriate action was taken.

Staff received good support and had access to the training they needed. 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 supported this practice. People were supported to have enough to eat and drink and to access health care services when needed.

People's needs were assessed to identify how they want their support provided; this was used as the basis for developing personalised care plans.

People were engaged in a wide range of activities; some people accessed the local community independently.

People gave us only positive feedback about the registered manager. There were regular opportunities for people and staff to give feedback. Management completed checks to help ensure people received safe care.

More information is in the Detailed Findings section below. For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.

Rating at last inspection: Good (the last report was published on 1 September 2016).

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

Follow up: We will continue to monitor this service and inspect in line with our re-inspection schedule for services rated good.

Inspection carried out on 29 June 2016

During a routine inspection

Crows Nest provides personal care and accommodation to up to 12 people with a learning disability. It is located in Newbiggin by the Sea close to the promenade. There were 10 people living at the service at the time of the inspection.

The service was inspected on 14 and 21 August 2014 and we found concerns with infection control and the safety and suitability of the premises. We inspected again on 30 April and 11 May 2015 and these regulations had been met. A new breach was found in regulation 11 (consent) and recommendations were made with regards to best practice in relation to the management of medicines and finances.

This inspection took place on 29 June 2016 and 07 July 2016 and was carried out by one inspector.

We were supported during the inspection by the provider who was also the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. We were also supported by a deputy manager.

People told us they felt safe. There were safeguarding policies and procedures in place and staff were knowledgeable about the signs of abuse or neglect and knew what to do in the event of concerns. All staff had received training in safeguarding vulnerable adults.

We looked at staff rotas which confirmed there were suitable numbers of staff on duty. Staff told us that they had no concerns about staffing and that they had time to care. Staff cared for people in a relaxed unhurried manner. Safe recruitment procedures were followed which helped to protect people from potential abuse.

The service was clean and there had been an increase in the level of cleaning carried out since the last inspection. Deep cleans were now carried out on a regular basis in addition to routine cleaning. This had been carried out twice in the last six months. Staff had received training in the prevention, control and spread of infection and one staff member acted as infection control champion which meant they attended regular meetings at the hospital and cascaded new information back to the team.

Safety checks on the premises were carried out on a regular basis. Gas, and electrical safety certificates were in place, and a legionella risk assessment had been carried out. Assessments of the individual risks to people were carried out. These included risks to physical and psychological health, and risks associated with activities in the community. These were up to date and regularly reviewed. A record of accidents and incidents was maintained.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. The registered manager had submitted DoLS applications to the

local authority for authorisation. Assessments of mental capacity had been carried out and decisions taken in the best interests of people had been recorded although some of these lacked detail. The manager said they would add further information.

Training had been provided in a range of topics and there were plans in place to address gaps in training. Staff received regular supervision and appraisals and told us they felt well supported.

People were supported with eating and drinking. Menus were in place and people were consulted weekly about any changes they would like to make. People were able to choose what they wanted to eat and were encouraged to choose a varied and healthy diet. Nutritional assessments were carried out and people at risk received specialist dietetic support.

The health needs of people were met. Pictorial information was provided about individual health needs and people were supported

Inspection carried out on 30 April and 11 May 2015

During a routine inspection

The unannounced inspection took place on 30 April and this was followed by an announced day on 11 May 2015. We last inspected Crows Nest on 14 and 21 August 2014. At that inspection we found the service was not meeting all the regulations that we inspected in relation to infection control, safety and suitability of the premises and assessing and monitoring the quality of the service. At this inspection we checked on progress the provider had made in relation to action plans they had sent us following our inspection in August 2014 and found they were now meeting these regulations.

Crows Nest provides residential and personal care for up to 12 people with a learning disability. At the time of our inspection there were 11 people living at the home.

Crows Nest does not require a registered manager to be in post under its registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. In this service the provider is a ‘registered person’ who is in day to day charge, and who has legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection in August 2014 we found concerns with infection control and the safety and suitability of the premises. At this inspection we found the provider had implemented changes to the service to ensure all areas of concern that we had found, were addressed.

We found some issues with the storage and recording of medicines. We have made a recommendation that the provider follows best practice guidelines in relation to the management of medicines.

People were safe because the provider and staff team understood their role and responsibilities to keep people safe from harm. They knew how to raise any safeguarding concerns. Accidents and incidents affecting people were monitored and appropriate action taken to reduce the likelihood of a reoccurrence.

People’s finances were checked and found to be correct, although we have made a recommendation that the provider follows best practice guidelines in relation to managing people’s personal finances.

People were supported to take appropriate risks and promote their independence. Risks were assessed and individual plans put in plans to protect people from harm. The service had emergency procedures in place and we contacted the local fire service who agreed to visit the service, meet the deputy manager and ensure all fire procedures were in place.

There were sufficient skilled and experienced staff to meet people’s needs. Staff underwent employment checks before working with people to assess their suitability; however we found that the provider had not been as robust with procedures as they should have been and we have made a recommendation that the provider follows best practice guidelines in relation to the specialist needs of people living at the service.

Staff had received supervision and felt supported and appraisals were about to be undertaken.

People consented to their care and support before it was delivered and we saw examples of this in practice.

The provider and deputy manager were not fully aware of the implications of the Supreme Court judgement which had redefined the definition of a deprivation of liberty in March 2014. The service had not assessed whether people required a deprivation of liberty safeguards application to be made to the local authority.

People were supported to eat and drink and maintain a healthy diet, with choices of food they preferred.

Arrangements were made for people to see their GP and other healthcare professionals when they needed to do so. People had been referred for specialist support if that was required, for example, to the speech and language team.

People living at the service and staff had positive and caring relationships. People were involved in making decisions about how they wanted to be looked after and how they spent their time.

People told us they liked living at the service. They said staff treated them with respect and we saw people’s dignity was maintained. Staff knew how to access advocacy services if the need arose.

People’s individual needs had been assessed and their support planned and delivered in accordance with their wishes. People were involved in their support to ensure it was effective and were actively involved in a range of activities and encouraged to follow interests and develop new skills.

People’s choices and decisions were respected and they knew how to make a complaint if they were unhappy with the service.

The staff appeared to have an open an honest culture with staff being able to ask for support when required, either at the regular team meetings or individually. Staff told us they felt supported by the provider and the deputy manager. One staff member said, “We are like a big family.”

The staff within the service had good links with the local community and the deputy manager had made plans to further develop the service by attending the local area provider forums.

People were encouraged to make their views known and the service supported this by holding ‘home meetings’ and completing surveys.

Audits and checks were regularly made by the provider and deputy manager, although some of these lacked substance and required improvement.

We found one breach in relation to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the need for consent. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 14 and 21 August 2014

During a routine inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection carried out on 14 and 21 August 2014. The previous inspection was carried out on 8 and 9 May 2013. There were no breaches of legal requirements identified on that occasion.

The Crow’s Nest is a care home registered to provide accommodation for up to 12 people with learning disabilities. There were 11 people living at the home when we visited. It is registered to provide accommodation for people who require personal care. The provider, Ms Jo Ball, is also the registered manager and had been in post since the home was registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found problems with the cleanliness and hygiene at the home. We observed that people’s bedrooms and communal areas were not always clean. Effective systems were not fully in place to reduce the risk and spread of infection. The deputy manager told us there was no system of regular cleaning in place.

The maintenance of the home was inadequate. There was equipment and general items lying around the home including next to the stairs. We were concerned that this was a trip hazard and could impede people’s safe evacuation out of the home in the event of an emergency. The outside garden areas had not been well maintained and were strewn with rubbish and debris. Chemicals were not always stored safely and the walls in the laundry room were affected by damp.

Although the service had a registered manager in post, we saw the leadership of the service was essentially carried out by the deputy manager. We were told that the deputy manager was responsible for the day to day management. This meant the person who was legally responsible and registered for the day to day running of the service was not always available when decisions, for example, with regard to the financial budget, or other issues in relation to the effective running of the service had to be made.

A number of checks were carried out to monitor the quality and safety of the service. However, these were not always effective in identifying any issues such as the condition of the premises and infection control concerns.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Proper policies and procedures were in place. The relevant staff were aware of when an application should be made and how to submit one. Staff had received training in safeguarding adults.

We found that people’s health care needs were assessed. People were consulted about their care and support. Records confirmed people's preferences. Care and support was planned and provided in accordance with their needs.

People told us they liked the food and were given opportunities to contribute to menu planning. Anyone who required special diets were supported by staff and referred to the speech and language team as necessary.

Staff received appropriate training and had all completed national qualifications in care.

We saw people were afforded choices about their routines and lifestyle. They were treated with respect and staff interactions with people were warm and kind.

People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

At this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to cleanliness and infection control, safety and suitability of the premises and assessing and monitoring the quality of service provision. You can see what action we have asked the provider to take at the back of the full version of this report.

Inspection carried out on 8, 9 May 2013

During a routine inspection

People told us they could choose how to spend their time and could come and go as they pleased. They said the staff were very caring and were always willing to help. They felt their privacy and dignity were respected. Comments included, "I have a key to my bedroom door and the staff don't go in without my permission", "No one is allowed to see my care plan without my permission" and "Only me can look in my file because it's my personal file. Everybody in this house has one".

People were complimentary about the staff and said they really enjoyed living in the home. They said "It's like a family here", "It's really good, I like it here", "It's friendly here" and "The staff are really good". We found each person had a plan of care which aimed to meet their individual needs.

We found there were effective systems in place to reduce the risk and spread of infection.

We found the home was adequately maintained and a programme was in place to ensure the premises were safe and comfortable for the people who used the service.

We found there were enough qualified, skilled and experienced staff to meet people's needs.

People told us they were consulted about the day to day running of the home and any changes that were made. We found there were effective systems in place to assess and monitor the quality of service that people received.

Inspection carried out on 30 November and 3 December 2012

During a routine inspection

We spoke with eight people and one relative to find out their opinions of the service.

People told us that consent was gained before care and treatment was carried out. We found that before people received any care or treatment, they were asked for their consent and the provider acted in accordance with their wishes.

People were complimentary about living at the home and the care and support that was provided. One person told us, �It�s a good place to live�it�s like a family.� We found that people experienced care that met their needs; however arrangements were not in place to deal with foreseeable emergencies.

People and the relative we spoke with told us that the home was clean. However, we found that effective systems were not in place to reduce the risk and spread of infection.

People told us that they �loved� their home. They informed us that they had been involved in choosing how their rooms should be decorated. However, we found that the provider had not taken steps to provide care in an environment that was adequately maintained.

People told us that they thought staff knew what they were doing. One person told us, �They�re well trained.� We concluded that staff received appropriate professional development.

We found that effective systems were not in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.