Amber House

About the service

Amber House is a residential care home providing personal care for up to 13 people with a learning disability and autistic people in 1 adapted building. At the time of our inspection there were 11 people using the service.

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

Right Support: People were supported by a staff team that were committed to providing them with a good quality of life and to lead fulfilling lives. Personalised support plans gave clear information for staff to follow in keeping people safe, whilst enabling people to be as independent as possible. People were fully involved in managing personal risks and in taking decisions about how to keep safe. Staff were skilled in recognising signs when people experienced emotional distress and knew how to support people to keep them safe.

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.

Right Care: People received kind and compassionate care. Staff protected and respected people's privacy and dignity. They understood and responded to their individual needs. Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff were safely recruited and were knowledgeable about people's needs and wishes. Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensured people using the service led confident, inclusive and empowered lives. People were empowered to achieve their personal aspirations and positive outcomes from their care with staff support and guidance. Staff knew and understood people well and were responsive, supporting their wishes to live a quality life of their choosing. Staff respected people's rights, including the right to make unwise, informed choices and positive risk taking. People and, where appropriate, their relatives, were at the centre of their care and their voice was used to guide and inform how care and support should be provided.

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

Rating at last inspection and update

The last rating for this service was good (published 21 June 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service and when the service was last inspected.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This was a focused inspection and the report only covers our findings in relation to the Key Questions safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Accommodation is provided over two floors, in single bedrooms with en suite facilities. There are a range of separate lounges and a large dining area situated on the ground floor. Enclosed gardens to the side and rear of the service are easily accessible.

This comprehensive inspection took place on 25 April and the 8 May 2018 and was unannounced. At the last inspection on 17 and 18 August 2017 the service was found to be non-compliant with regulations; 9, person –centred care, 11, consent, 12, safe care and treatment, 15, premises and equipment, 17, good governance and 18, staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because care plans were insufficiently detailed to enable staff to meet people's needs, there were restrictions in people's lives that had not been agreed as in their best interest and people did not always have risks to their safety mitigated. It was also because elements of the environment were unsafe, quality assurance systems and oversight of people's needs were ineffective and staffing recruitment checks were insufficiently robust.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and the timescales this would be achieved to improve the key questions, is the service safe, effective, responsive and well-led? We received a comprehensive action plan and regular updates, which demonstrated the progress made with the improvement programme. At this inspection we looked at the previous breaches of regulations and the action plan to check that improvements had been made and sustained over a period of time. We found significant improvements had been made in all areas.

The care service has been developed and designed in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

In our last report of 17 and 18 of August 2017 we reported that a management company had been contracted by the provider to support the necessary changes required. The management company purchased the service since then and became the nominated individual.

The new provider, registered manager and staff had worked hard to make improvements. People, relatives, staff and professionals provided only positive feedback about the service and the improvements made. The leadership and management had improved, with both working alongside staff and taking an active role in the running of the service. Everyone spoke highly of the management team and said they were approachable and supportive.

Quality assurance systems had been fully implemented and maintained since the last inspection and we saw action had been taken when issues had been identified. The provider had worked hard at implementing many positive changes and was committed to ensuring improvements were sustained and developed further, to ensure people received high quality care.

A robust recruitment process was in place, which ensured staff had the necessary skills and experience and were suitable to work with people who used the service. Staff received the training and support they needed to carry out their roles and meet people’s needs. The provider monitored staffing levels regularly, to ensure staffing levels were sufficient and staff deployment was effective.

Staff knew how to safeguard people from the risk of harm and abuse. They had completed safeguarding training and knew how to raise concerns and who to speak to, about them. The provider operated effective infection control and prevention within the service. Systems were in place to ensure people received their medicines safely. This included key staff receiving medicines training and regular competency assessments.

People’s mental capacity was appropriately assessed and their rights were protected. 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. We found improvements in records when people were assessed as lacking capacity to make their own decisions. Staff were clear about the need to obtain consent prior to carrying out care tasks.

Staff worked closely with health and social care professionals to ensure people were supported to maintain good health. People received a well-balanced diet that offered variety and choice. People told us they enjoyed the meal provided and their nutritional needs were met. People were supported to participate in a range of activities of their choosing within both the service and the wider community.

Health and social care professionals were complimentary about the new leadership and the dramatic improvements made within the service. People's support plans were person-centred, reflected their needs and provided staff with detailed information.

Complaints were appropriately addressed. Although no one was in need of end of life care at the time of the inspection, systems were in place for when this time would come.

The management team promoted an open and inclusive management style where people and their relatives were invited to share their views and to comment on the service through surveys and meetings.

Extensive improvements and refurbishment had been made to the environment to ensure it was suitable to meet people’s needs.

Accommodation is provided over two floors, in single bedrooms with en suite facilities. There is a large sitting room set out into two separate areas, a small sitting area and a dining/activities area. Two further lounges are situated on the ground floor. Enclosed gardens to the side and rear of the building are easily accessible. There is also a supported living house called Redbourne House. We undertook this inspection on 17 and 18 August 2017. The last inspection was carried out on 29 and 30 March and 3 April 2017 where the service was found to be non-compliant with the regulations 8, 9, 10, 11, 12, 13, 15, 16, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) as well as regulation 18 of the registration regulations. Due to concerns found during the inspection, the overall rating for the service was 'Inadequate' and the service was 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.

Following the inspection in March and April 2017, we met with the provider and have requested an interim action plan. We also requested, and have received, weekly updates to assure us actions have been taken to address the concerns.

After the focused inspection March and April 2017, the provider contracted the support of a management company to help them make the required improvements and achieve compliance with the regulations. We met with the consultant who represented the management company at this inspection. We refer to them as, ‘the consultant’ throughout this report.

During this inspection we found the provider’s quality assurance systems continued to be ineffective. The governance systems operated by the provider failed to cover all aspects of care delivery and did not identify areas of the service that required improvement. The provider did not have oversight of the service as required and was not consulted regarding people’s care and support.

People who used the service did not always receive their medicines as prescribed. Instructions to staff about when medicines should be administered were not clear.

Staff had not always completed the necessary training to deliver the care and support the people who used the service required.

People’s care plans did not always contain suitable guidance to ensure staff could meet their needs effectively and consistently.

The provider’s recruitment practices were not robust. Some staff files did not contain relevant recruitment information and thorough checks were not completed before agency staff worked with the people who used the service.

Elements of the environment did not meet people’s needs; we found a window that did not have a restrictor, radiator covers were not in place and wooden garden furniture was water damaged with split and pliable wood.

We found that people had restrictions in their lives that had not been agreed as in their best interests.

The registered manager did not have access to some people’s care records and failed to ensure they have oversight of their care. This meant there could be delays in any care or treatment they required.

We saw that improvements had been made with regards to some of the risks we identified at our previous inspection, but found further evidence that the provider was not mitigating risks as required. For example, legionella checks were not being carried out which put people who used the service at unnecessary risk. We also found items of food, which indicated on the packet that they could not be frozen in the freezer and items that were past their used by or best before dates in fridges.

Staff, who received adequate support and mentorship were deployed in suitable numbers to meet people’s needs. Staff had completed safeguarding training and were aware of their responsibilities to report any potential abuse and episodes of poor care they became aware of.

People were supported to eat a diet of their choosing and encouraged to make healthy choices.

People were treated with dignity and respect by staff; they were enabled to make choices in their daily lives. We saw people taking part in different activities throughout the inspection.

The service had a registered manager who fulfilled their regulatory obligations to inform the Commission of notifiable events that occurred with the service.

Accommodation is provided over two floors, in single bedrooms with en suite facilities. There is a large sitting room set out into two separate areas, a small sitting area and a dining/activities area. Two further lounges are situated on the ground floor. Enclosed gardens to the side and rear of the building are easily accessible.

We undertook this inspection on 29 and 30 March and 3 April 2017. The last inspection was carried out on 1 February 2016 where the service was found to be compliant with the regulations looked at with the exception of well-led. This was because the manager in post had not yet registered with the CQC.

The service now had a registered manager in post as required by a condition of their registration. 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.

Due to concerns found during the inspection, 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.

Following the inspection, we met with the registered provider and have requested an interim action plan. We also requested, and have received, weekly updates to assure us actions have been taken to address the concerns. We found multiple concerns and are considering our regulatory response. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what action we told the provider to take at the back of the full version of the report.

We found concerns with how the service was governed. The CQC had not always received notifications of incidents which affected the welfare of people who used the service.

There was no effective quality monitoring system in place and audits completed had not been effective in identifying shortfalls within the service.

We found accidents had been logged, which highlighted specific issues but lacked analysis to ensure lessons were learned to prevent reoccurrence.

We found there was no staffing matrix tool used to determine staffing levels required for the residential, respite and day care services. This led to inadequate staffing levels within the service, people’s care needs being overlooked and had led to people put at risk while out in the community.

Some people were at risk of not receiving their medicines as prescribed due to errors in recording.

There was a lack of robust risk assessment and management; staff had not always followed policies and procedures, guidance from health professionals and outcomes from risk assessments.

Some areas of the environment were potentially unsafe yet were constantly accessible to people, for example the laundry, where cleaning products were openly stored. These issues had placed people who used the service at risk of harm and injury.

Not all staff had received safeguarding training. Training provided to staff on restrictive physical interventions included the use of pain-inflicted techniques, which was not appropriate in this setting.

We found there was an inconsistent application of mental capacity legislation. Some people had assessments to determine their capacity to consent to specific restrictions such as behaviour management interventions but others did not. Best interest decision making was not always completed.

There were concerns with the management of infection prevention and control as some areas of the service required deep cleaning. Poor infection control procedures were observed which included soiled washing stored in baskets on the floor alongside clean laundry stored in open baskets; this created the potential for cross-contamination.

We saw from records that not all staff had received training to enable them to support people who used the service safely and to an appropriate standard.

Staff had not been receiving regular supervision in line with the registered provider’s supervision policy.

People told us that the approach of some members of staff was kind and caring and they felt able to raise issues with them. However, others told us they had raised concerns with the registered manager about care and support, but their issues had not been addressed.

Not all interactions between staff and people who used the service were seen to be positive. For example, we overheard one member of staff ask someone if they wanted to use the toilet before going out; this was overheard by all of their peers and other people in the vicinity and did not promote the person’s dignity. Another person, whose behaviours compromised their dignity, was not supported to engage in these behaviours in private, so was seen by their peers and others in a state of undress.

We found people’s nutritional needs were met. There was a varied menu which provided people with choices and alternatives.

There was a range of activities offered by the day care facility, based within the service, for people to participate in. However, people told us that the way these were structured meant there was little flexibility available and they did not always wish to participate in group activities.

Staff were not always recruited safely, when positive disclosures were identified there were no assessments in place to mitigate any potential risks to people who used the service.

Complaints raised by relatives were not recorded and addressed in line with the registered provider’s policy and procedure.

We identified a number of fire safety issues whilst undertaking an inspection of the premises. For example, four, floor-mounted hold back devices on fire doors were not working. These issues meant that people who used the service were placed at risk and would not be protected in the event of a fire.

We saw people’s saw people's health needs were met. Staff kept a log of when people had contact with health professionals in the community. Staff followed advice about treatment plans the health professionals prescribed.

We undertook this unannounced inspection on 01 and 04 February 2016. At the last inspection on 14 and 15 July 2015, we found the registered provider was in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe care of people who used the service, staff training, providing person centred care, obtaining consent and working within the requirements of the Mental Capacity Act 2005 (MCA). A warning notice was issued due to risks associated with failing to monitor and assess the quality of service provision. The registered provider subsequently sent us an action plan that showed us how they were going to going to put things right.

At the time of this inspection there was no registered manager in post and the acting manager was awaiting an interview with the CQC for their suitability and capabilities to be assessed as a registered manager for the service. A registered manager is a person who has registered with the 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.

During this inspection we found improvements had been made in all domains. We have changed the rating in the three key domains which were previously rated as Requires Improvement to Good. We have changed the rating for the Well-led domain from Inadequate to Requires Improvement. This domain cannot be rated higher than Requires Improvement, as the rules for rating this as good requires there to be a registered manager in post and we want to monitor the improvements to make sure they are sustained over a period of time.

We found people were protected from the risk of abuse or harm. Staff were aware of the need to report potential issues of abuse and policies and procedures were available to guide them when making referrals to the local safeguarding team. Risk assessments were available for people concerning the management of behaviours that might challenge the service and we saw these had been developed and improved since our last inspection of the service.

There was evidence that staff with the right skills had been safely recruited in sufficient numbers. We saw that training had been developed to ensure staff had the appropriate skills and knowledge to meet people's needs. We were told the service had not yet achieved its target of providing a regular programme of supervision and appraisals for all staff, but that arrangements were in place to address this issue.

We found people’s health and wellbeing was appropriately supported and that people had access to a range of medical professionals and that all had been registered with a local dentist since our last inspection. The local community learning disability team told us the service worked well and involved them when this was required. We found people’s nutritional needs were met and that a choice of meals was provided. People’s dietary intake and weight were monitored where this was needed.

We observed people were treated with dignity and respect and that support was provided in a planned and person centred way. We saw that staff interacted with people in a sensitive and encouraging way and demonstrated a caring and compassionate approach.

We found that staff supported people to make their own decisions and that best interest meetings were held to discuss options when people lacked capacity to do this themselves. Where people were deprived of their liberty staff had ensured this was done in the least restrictive way and in line with current legislation. We saw that arrangements were in place to ensure training was provided for staff who had not completed training on the Mental Capacity Act 2005 and safeguarding people from harm.

We saw that staff consulted people and provided explanations before carrying out interventions to ensure their consent was obtained and that information about people was stored securely to ensure their confidentiality was maintained.

We found improvements had been made in the way the service was managed. Quality monitoring systems were in place to ensure the service was safe, effective, caring, responsive and well-led. We saw this included audits and checks of people’s care, incidents and accidents, staff training needs, together with action plans to address shortfalls that were highlighted.

We did not speak to any of the people who used the service during this inspection.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan and in a way that was intended to ensure people's safety and welfare. People told us they were well cared for.

Medicines were handled appropriately, safely administered and kept safely.

People we spoke with told us they liked living at the home. Comments included, 'My bedroom is nice.' However people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises. This was because window restrictors were not fitted at some first floor windows, some of the flooring created a trip hazard and fire alarms had not been tested with adequate frequency.

There was a complaints system available but the complaints procedure may not have been in a suitable format for all the people accommodated to understand. Records of complaints were not available at the time of the inspection. People told us they were satisfied with the care and could talk to the staff.

The person who used the service had complex needs and we used mainly observation and other non-verbal methods to help us understand their experiences.

We saw that when staff helped the person they spoke calmly and provided clear information about alternatives and choices. Staff were sensitive to the person's needs and provided appropriate reassurance and guidance.

We found that staff had received training in safeguarding people from abuse and in managing behaviour that challenged services. Guidance and support were provided for staff in supporting people with behavioural issues so that they were kept safe.

We saw evidence that staff received adequate training which helped them to care for the people with learning disabilities or autistic spectrum disorder so that their needs were met.

The provider had developed arrangements for quality assurance of the service through surveys and audits, although some aspects of these arrangements were still to commence.