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We are carrying out a review of quality at Tarry Hill. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 9 October 2019

During a routine inspection

About the service

Tarry Hill is a care home in the New Mills area of Derbyshire. The home is made up of five separate houses in one communal setting. The home is registered to care for up to 26 younger adults and people with learning disabilities and autistic spectrum disorder and older people. At the time of the inspection there were 18 people living there.

The service had been developed and designed before the principles and values that underpin Registering the Right Support had been published. This guidance aims to ensure 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. The service was larger than current best practice guidance.

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

The service was not safe. People were subject to excessive control and restraint. Staff and managers had not recognised and taken action in relation to safeguarding incidents and potentially abusive practices. The use of physical intervention and restraint was not assessed or planned for and staff did not have appropriate training to enable them to perform physical intervention safely. Staff had been harmed as a result of poor behaviour management. Opportunities to learn from adverse incidents had been missed.

Environmental risks were not managed safely and the environment was not clean and hygienic. Medicines were not always safely managed resulting in some people getting too much or too little medicine. There were not always enough staff to ensure people’s safety in the event of an incident. Safe recruitment practices were followed.

People’s rights under the Mental Capacity Act were not upheld. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. Staff had not received the training they needed to complete their role safely and effectively. People’s support was not always provided in accordance with national standards or good practice. The environment was adapted to meet people’s needs.

People were not always treated in a dignified way. Feedback about the approach of staff was mixed. There was a lack of consistency in the quality of support people received. Several staff expressed concern about some people’s wellbeing and told us they were unable to provide appropriate support to some people. The approach to promoting people’s independence was inconsistent. People and their relatives had been involved in developing parts of their support plans.

People did not consistently receive personalised care that met their needs. People were not always provided with opportunity for meaningful activity. There were systems to manage complaints but some relatives told us they had to chase up a response to their complaints or concerns.

Tarry Hill was not well led. The provider did not have effective oversight of the home. Consequently, there had been a failure to identify and address serious issues with the safety and quality of the service. Systems to monitor and improve the quality of the service were not effective. Where audits had identified areas for improvement, action had not been taken to address issues. The provider had not implemented learning from serious incidents. Failings in leadership and governance placed people at risk of harm. The provider was not always open and transparent and did not always meet the duty of candour.

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 Requires Improvement (published November 2018). The provider completed an action plan after the last inspection to show what they wo

Inspection carried out on 10 October 2018

During a routine inspection

This inspection visit took place on 10 October 2018 and was unannounced. It was completed by one inspector, an assistant inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Tarry Hill is set on a large communal site which includes supported living units. This home was registered before the introduction of Registering the Right Support; however, the service aims to adhere to the values set out as best practice. 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. The home is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Tarry Hill is five small homes set on one communal site. Each home was independent with their own communal spaces, kitchen and bedrooms for each person. There was a registered manager at this location. 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.’

When people had been identified as being at risk, assessments had not always been completed to provide the details and guidance required. People were not always protected from the risk of infection in relation to cleaning schedules and the use of personal protective equipment. We have made a recommendation in relation to the risk assessments and support people from other associated risks. Medicines were not always managed safely when people required as required medicine or medicine for a specific condition.

The staff were provided to meet the commissioned needs of individuals. However, when new agency staff had been employed to support people they were not given an induction or clear direction for their role in supporting people.

The provider had completed audits in relation to the ongoing improvement however these were not always effective. Notifications had not always been completed in relation to events. People had been encouraged to voice their feedback, however there was no formal process and areas identified in the past had not been addressed.

Staff had received skills to support people’s individual needs. Training was ongoing and new initiatives were being developed. People’s nutritional needs had been met and specific diets observed and supported.

Health care professionals had been regularly consulted to support people to achieve better outcomes for their health care and wellbeing. People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

The provider worked with a range of internal and external healthcare professionals. They also worked in partnership with a range of organisations.

Staff had established positive relationships with people and knew people well. Staff showed kindness and compassion when delivering care. People’s dignity had been respected.

Care plans for people reflected a lot of detail and included people’s preferences. These included their communications methods and any cultural requirements. People enjoyed activities of their choice.

Complaints had been responded to. People were protected from harm and lessons had been learnt from events to drive improvements in this area. Staff and professionals were positive about the management changes within the home. Partnerships had been developed with a range of professionals to support people’s health had wellbeing.