Beech Tree House

Beech Tree House is a residential care home providing personal care for up to eight adults with learning disabilities and/or autism. The service is provided over two floors. Each person has their own bedroom and en-suite, with shared areas such a lounge, dining room, bathroom, quite room, sensory room, and activities room. People had access to a garden area at the rear of the property.

Services for people with learning disabilities and or autism are supported

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to eight people. Eight people were using the service at the time of our visit. This is larger than current best practice guidance. Environmental factors and the way the service was arranged sometimes impacted the ability to provide truly person-centred care.

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

The service did not always establish or implement robust systems to protect people from the risk of abuse. We found concerns in relation to the management of people’s finances and people were not always protected from the risk of abuse. The registered manager had reported recent safeguarding allegations to the local safeguarding authority as required and taken action to prevent reoccurrences. Hazards and safe measures were not always clearly identified in people’s care records in response to incidents and staff did not always fully understand risks to people. The general fire evacuation plan was not up-to-date or accurate. Water safety systems were not routinely implemented and control regimes were not effective in controlling the presence of Legionella bacteria. Other health and safety checks and compliance certificates were in place to promote safety.

Medicines were not always managed safely. We found issues with medicines records and stock rotation which placed people at increased risk of not receiving their medicines as prescribed. Infection prevention and control policies and procedures were not always fully implemented by the service, which placed people at increased risk of infection. Improvements had been made to the cleanliness of the environment. Recruitment checks were completed to make sure staff were suitable, however, risk assessments surrounding checks of new staff were not always implemented. Staffing levels had improved to meet people’s needs.

Governance systems did not always identify or manage risk effectively. For example, provider medicines and financial audits did not identify the concerns we found. The provider’s policies and procedures were not always robust or implemented by the service. Improvements had been made to the culture of the service. Relatives and staff consistently reported the new registered manager had made a positive impact upon people’s quality of life. Relatives reported the service was more open and they felt comfortable raising concerns with the provider.

Staff training and supervision had improved, however, staff were not always competent to meet people’s needs safely. The principles of the Mental Capacity Act were not fully understood or appropriately applied by the service. This meant people did not always receive appropriate support in their best interests. Assessment of people’s needs were not comprehensive to ensure the environment and compatibility of people using the service was suitable. Noise levels had an impact on people’s wellbeing. We found fresh fruit and vegetables were not available to people on day one of our inspection, which was immediately addressed. The registered manager had made improvements to the menu and monitoring of people’s nutritional intake. People were supported to access a range of healthcare professionals to meet their needs.

In general, we observed staff interactions with people were positive and engaging. We raised concerns with staff referring to people as “good”, which was not respectful which the management team agreed to address with staff. Relatives told us, “Staff appear helpful and kind. Happy with attitude of staff and management” and “[their family member felt] safe, secure and understood.” Staff had received specific communication training and we observed staff use people’s preferred methods to involve them in day-to-day choices. Relatives had the opportunity to contribute to people’s care planning and felt more involved by the service.

The provider’s care plan system aimed to identify people’s preferences and diverse needs including protected characteristics such as religion and sexual orientation. However, information recorded in care records did not always provide clear guidance about how to meet people’s preferences. The registered manager had identified that care plans needed to be reviewed. They had started to make some improvements where they had spent time with people to get to know them and monitored staff support. Systems were in place to make sure information was adapted using people’s preferred communication tools to enhance understanding and involvement. Staff received training in methods to promote people’s skills and independence. We saw staff apply this in practice when supporting people.

The service did not always 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 following reasons. People were not always supported by staff who had the skills or confidence to use their preferred methods of communication. This meant people were not fully involved to make choices about their care and support or the way the service was run.

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 inadequate (published 24 January 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was still in breach of four regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 14, 18 and 21 November 2019. Breaches of legal requirements were found. Enforcement action we proposed was reviewed in consideration of the COVID-19 pandemic and withdrawn due to intelligence the service was making improvements. The provider completed an action plan after the last inspection to show what they would do and by when to improve person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting upon complaints, good governance, staffing and notifying CQC of certain events.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to all the Key Questions; Safe, Effective, Caring, Responsive and Well-led which contain those requirements. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Beech Tree House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified continued breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, need for consent and good governance at this inspection.

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.

Follow up

We will meet with 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 ‘Requires improvement’. However, the service will remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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 impro

Beech Tree House is a residential care home for up to eight adults with learning disabilities and/or autism. The service is provided over two floors. Each person has their own bedroom and en-suite, with shared areas such a lounge, dining room, bathroom, quite room, sensory room, and activities room. People had access to a garden area at the rear of the property.

The service has not been developed in line with the principles and values that underpin Registering the Right Support. It did not ensure that people who used the service could 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 did not receive planned and co-ordinated person-centred support that was appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to eight people. Eight people were using the service at the time of our visit. This is larger than current best practice guidance. 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 and what we found

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The service didn’t apply the full range of 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 following reasons, lack of choice and control, limited independence, limited inclusion, limited interaction, and meaningful activities. For example, people did not have choice in the food they ate or at what times meals were served.

People were at risk of contracting infections due to poor levels of hygiene throughout the environment and via staff practices. For example, significant amounts of faeces and urine were found in some people’s bedrooms. Staff did not wear appropriate protective equipment when cleaning body fluids up.

People were not protected from unsafe and poorly maintained premises. We found a wide range of maintenance improvements were required around the building. Some of which posed a hazard to people’s health and safety. For example, staff could not immediately access fire extinguishers as they were locked in cupboards and the key was not readily available.

People were not routinely protected from the risk of verbal and physical abuse. Incidents had occurred where people had been harmed. One person’s relative told us “I sometimes worry that when I come to the home, will [named person] still be alive? I am extremely worried about their safety…”. Although concerns had been raised with the registered manager, they had failed to take the appropriate action.

People were not supported by sufficient numbers of staff. We found the lack of staff had a detrimental impact of people’s well-being. People could not participate in activities if the staffing was short. The funding did not equate to the numbers of staff present in the service, for example one person required 15 hours of one to one support by staff each day. We did not see this happen. Each person was funded to have individual support throughout the day, however, the service only employed four staff during the day as a minimum and five as a maximum.

People were not routinely supported with their prescribed medicines by staff who had received training to do this safely. Staff did not consistently follow the providers policies when supporting people with their medicines. For example, we noted the person had not received their medicine 11 times in the month of November 2019.

People were not routinely supported to eat balanced and nutritious meals. Food items listed on past menus did not consistently contain fruit and vegetables. People were only offered one choice at each meal.

Staff were not always supported to carry out their role to the best of their ability. We were told by the registered manager new staff received an induction and completed the care certificate. We asked to see evidence of the completed care certificate, but this was not given to us. People’s relatives did not feel staff were suitably trained to carry out their roles.

The service did not routinely support people in line with the Mental Capacity Act (MCA) 2005. People had been assessed as having the capacity to consent to certain restrictions, but this was questionable. For example, consent was given for staff to carry out physical interventions. This was not time specific.

People’s relatives felt staff did not treat people in a way that was kind and compassionate. Three relatives told us they did not trust the staff. One relative felt their family member may have been discriminated against. People were not routinely provided with dignity and respect for example, over heard a member of staff speaking in a derogatory manner to a person.

Relatives told us they did not have confidence to raise concerns or complaints. One relative told us “I wouldn’t feel comfortable raising a concern, it wouldn’t be taken seriously”. Other comments included “I have raised concerns with the manager, I don’t feel the complaint was listened to. It is only in the last three weeks they are now listening to us”.

People’s relatives told us their care wasn’t reviewed regularly, one relative took it upon themselves to organise their family member’s review, as the provider was not forthcoming in doing so.

Activities were provided at the service for people, but these were not always the most relevant or age appropriate. For example, messy play, story time, or garden time in the evening in winter.

Although there was a registered manager in post, there was a lack of clear leadership and overview of the service. Staff practices were not up to date and person centred. Staff spoke positively about the support they received from the registered manager, however, we found a service that was poorly managed, and this had impacted on people’s welfare.

People were supported to healthcare appointments when needed. Care records showed that people were supported to attend routine healthcare appointments with GPs, dentists, opticians, community behaviour support teams and learning disability and mental health specialists.

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 24 October 2017). At this inspection we found the standard had not been maintained and there were multiple breaches of regulations.

Why we inspected

The inspection was prompted in part due to safeguarding concerns received about the conduct of staff and the environment. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Beech Tree House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to Regulations 9, 10, 11,12,13,14, 15, 16,17 and18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our primary objective during the period of the COVID-19 pandemic is to act proportionately and support Providers to keep people safe during a period of unprecedented pressure on the health and care system. As such we are working to limit any enforcement activity and of course avoid any unnecessary cross-infection risks by undertaking inspections during the Covid-19 pandemic. Therefore we will make sure that any action we take is proportionate, considers current risks to people's safety, as well as the potential impact of our actions upon people, care providers, registered managers and the wider system during this time. We will carry out a further inspection when we are able to do so to check that improvements have been made.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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

The home 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 service was registered with us in October 2016. This was the first inspection since registration had taken place.

Staffing levels were determined based on people’s needs. Staff recruitment was carried out safely; this was to prevent unsuitable people from working with the people at Beech Tree House. Staff were trained and received support to ensure they had the skills and knowledge to carry out their roles. They were encouraged to feedback ideas to assist with the improvement of the service, through supervision, meetings and general discussion

We found some areas of the home required thorough cleaning. Plans were immediately put in place to rectify the situation. We have made a recommendation about cleanliness and hygiene in the home.

Staff were trained to identify signs of abuse and how to report concerns. Medicines were administered by trained staff. Records showed people received their medicines in a safe and appropriate way. Where people required additional support with maintaining their health, health professionals such as psychologists and GPs were referred to.

People’s consent was sought for aspects of their care. Where people were not able to make decisions for themselves, their mental capacity was assessed and the best interest process was followed. 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. Where people required restrictions to be put in place these were authorised by the local authorities supervisory body.

People were supported with their nutritional and hydration needs. This included providing food and drink that was safe for them to consume in line with their preferences and cultural needs.

People and their relatives spoke positively about the caring nature of staff. We observed how staff supported people with their care in a dignified and sensitive way. People’s communication needs were identified and staff had the skills and knowledge to work in an inclusive way with each person.

People’s relatives told us where appropriate they were kept up to date with changes to people’s needs and their day to day lifestyle choices. Relatives told us there was an honest and open culture in the home, and they felt part of the service provision to their family members.

People were supported to remain as independent as possible; involvement in the community was encouraged. Activities were available to people to protect them from the risk of social isolation.

Care plans and risk assessments were in place to ensure staff knew how to support people appropriately and safely. Amendments were planned to be made to the structure of the care plans to ensure all information could be easily located. Maintenance checks and health and safety audits had been completed to ensure the environment was safe for people and staff.

All people were treated equally with a strong emphasis on supporting people's diverse needs, including their religion and sexual orientation. People with protected characteristics had been assisted by the service to achieve their own goals and their preferences and their lifestyles were respected.

People, relatives and staff spoke positively about the registered manager and the senior staff. Staff supported each other and worked well as a team. Quality assurance checks and feedback from people, relative’s staff and professionals was used to drive forward improvements to the service.

Staff understood the aim of the service and worked together to accomplish providing good quality and effective care.