Archived: Individual Care Services - 11 Wembrook Close

11 Wembook Close is a residential home, providing care and accommodation for up to four people. It provides care to people living with a learning disability and other support needs including autism. At the time of our inspection visit two people lived at the home.

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

People did not receive safe care. Risks associated with people’s care were not always identified, managed or mitigated. The provider had not effectively assessed staff had the skills, knowledge or experience they needed to provide care which ensured people living at the service were safe and others’ safety was maintained. People’s care plans did not always contain detailed or accurate information to help staff support people safely. The provider had not always ensured detailed records were kept of important healthcare visits or guidance.

People were not 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 support least restrictive practices. Where restrictive practices were used the provider had not always acted in line with the Mental Capacity Act 2005.

An 'infection prevention control' audit was carried out by CQC during the inspection. We found the provider was not consistently following government guidelines. Risks related to Covid-19 were not consistently well managed.

People were not cared for in premises that were consistently safe. Fire safety deficiencies had not always been acted on in a timely way. The provider had not ensured staff consistently had the equipment needed to keep people safe.

An admission to the home had not been well-managed by the provider and meant systems to manage potential abuse were not effective.

Governance systems, and management and provider oversight of the service were inadequate. Systems and processes designed to identify areas of improvement were ineffective. The providers policies and procedures did not always provide staff with the guidance they needed. Audits and checks had not identified the concerns we found.

The management of individual and environmental risks continued to require improvement.

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. (Report published 21 February 2018).

Why we inspected

We undertook this focused inspection because emerging risks had been identified by us and other professional bodies including the Local Authority and Fire Service. We had also received information of concern from staff and members of the public prior to our inspection visit in relation to the management of risks at the home and how people’s needs were met. As a result, we undertook a focused inspection to review the key questions of Safe and Well Led only.

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 our 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 identified breaches in relation to the risks associated with people’s care and management oversight of the service. The provider had not ensured effective systems and processes were in place to monitor the quality of the service and drive improvement.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during our inspection is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider to agree our ongoing monitoring of the service and discuss how they will make changes to ensure they improve. 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 '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 six 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 no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

11 Wembrook Close provides accommodation and personal care for up to four people with a learning disability or autistic spectrum disorder. At the time of our inspection there were three people living at 11 Wembrook Close.

People in care homes receive accommodation and nursing and/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.

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.

A requirement of the service’s registration is that they have a 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was a registered manager in post, however they were not present during this inspection due to planned leave.

In December 2016 we rated this service as Requires Improvement overall because we had concerns around risk management and a lack of effective quality assurance systems. We completed a follow up inspection visit to the home in May 2017 to assure ourselves improvements had been made and rated Well Led and Effective as ‘Good’. We did not change the overall rating because we only reviewed two outcomes. Since that inspection we have reviewed and refined our assessment framework, which was published in October 2017. Under the new framework certain key areas have moved, such as support for people when behaviour challenges, which has moved from Effective to Safe. Therefore, for this inspection, we have inspected all key questions under the new framework, and also reviewed the previous key questions to make sure all areas were inspected to validate the ratings. At this inspection we found the service was ‘Good’ overall.

People were protected from harm and abuse because staff understood their responsibilities to report any concerns they had about people's health and wellbeing. However, we found one incident involving a person’s missing money had not been referred to us or the local authority as required. The provider had investigated this incident and has improved their checks to minimise this from happening again.

Staffing levels were flexible to ensure there were enough staff to provide responsive and effective care. During our inspection visit some people went out and staff were able to

spend time with the people that remained in the home so they could respond effectively to meet their needs.

Staff supported people in a kind, gentle and caring manner and treated them with dignity and respect.

Staff told us the training they received supported them in providing effective care to people. Following our visit we received a copy of the training schedule which showed some staff refresher training was required. However, the registered manager had planned to revise and update how staff received their training so it met their expectations and assured them, staff were effectively trained and skilled.

The provider used recognised risk assessment tools to identify any risks to people’s health and wellbeing. Staff knew how to support people to reduce identified risks to people.

Staff promoted people’s choices and independence which gave people a sense of worth and ownership in how their care was received.

Where there were changes in people's health and wellbeing, they were promptly referred to other healthcare professionals. Closer working with other healthcare professionals helped support and promote better outcomes for people and minimised potential impact of stress and anxiety being caused to people unnecessarily.

People received the food and drinks they preferred and staff knew who required special diets.

The deputy manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff monitored people who could not communicate verbally to ensure they were consenting to the support being offered. The provider was arranging advocacy services to ensure decisions were made in people’s best interests.

The home was clean, free of odour and staff wore personal protective equipment (PPE) at the necessary times. Regular spot checks and effective monitoring ensured standards of cleanliness were maintained.

Medicines were administered safely and people received their medicines as prescribed. Time critical medicines were given at the required times and PRN protocols ensured staff provided those medicines as and when required, safely.

The management team carried out checks to ensure the safety of the environment and the standard of care people received was maintained. However, audit systems required improvement to ensure actions led to improvements.

Further information is in the detailed findings below.

We previously carried out an announced comprehensive inspection of this service on 25 November 2016, when we found two breaches of the legal requirements. This was because the provider did not always respond appropriately and in good time to support people's changing needs, and systems and processes to identify and assess risks to the health and safety of people who use the service were not implemented consistently. As a result of the breaches and the impact this had on people who lived at 11 Wembrook Close, we rated the key questions of ‘Effective’ and 'Well-led' as ‘Requires improvement’. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for ‘Individual Care Services - 11 Wembrook Close’ on our website at www.cqc.org.uk.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to each breach. We undertook a focused inspection on the 20 April 2017 to check that they had followed their plan and to confirm they now met the legal requirements. We gave the provider 24 hours notice that we would be visiting to ensure that people and staff would be available to speak with us. At this inspection we found the requirements had been met.

There was a registered manager in post. 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 and associated Regulations about how the service is run.

The registered manager had appointed a deputy manager and was recruiting a team leader to provide leadership within the home. New staff had been recruited to ensure people received consistent care from staff they knew.

Staff felt more effective in their roles because the registered manager was committed to providing them with the training and development to support their everyday practice.

Where there were changes in people's health and wellbeing, they were promptly referred to other healthcare professionals. Advice given by external healthcare professionals was followed and recorded in people's records. Records supported the exchange of information to ensure people's mental and physical health was maintained.

People received the food and drinks they preferred and staff knew who required special diets.

The manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff monitored people who could not communicate verbally to ensure they were consenting to the support being offered.

The management team carried out regular checks to ensure the safety of the environment and the standard of care people received was maintained.

11 Wembrook Close provides care and accommodation for up to four people with a diagnosis of a learning disability or autistic spectrum disorder. Three

ladies lived at the home at the time of our visit.

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. There was no registered manager in post at the time of our inspection. The provider had appointed a new manager who was going to complete their registration with us.

People were protected from harm and abuse because staff understood their responsibilities to report any concerns they had about people's health and wellbeing. Staffing levels were flexible to ensure there were enough staff to provide effective care. During our visit each person was taken out and staff were able to spend time with people on an individual basis and respond effectively to their needs. Staff supported people in a kind and caring manner and treated them with dignity and respect. People's rights under the Mental Capacity Act were protected by the provider and staff team and their consent to care was sought.

Staff told us the training they received supported them in providing effective care to people, but some training needed to be updated to ensure their skills were kept up to date.

Care plans were individualised and person-centred. They provided staff with information about people's likes and dislikes and how to meet people's needs in a way they preferred. Risks to people’s safety and wellbeing had been assessed and planned for. However, improvements were needed to ensure people’s care records were consistently reviewed and updated to reflect changes in people's needs and the way risks were managed. A lack of detailed daily records meant we could not be sure people received the care outlined in their care plans.

Medicines were stored and managed safely and people received their medicines as prescribed. However, referrals to other healthcare professionals had not always been made promptly when a need was identified.

Recent changes in managers and high staff turnover had affected staff morale and impacted on the emotional wellbeing of people who lived in the home. Whilst staff had confidence in the new manager, they did not see them very often because they had managerial commitments in two other homes. The provider was recruiting a team leader to provide day to day leadership at Wembrook Close.

There had been a lack of oversight by the provider during the previous months to identify the issues we found during our inspection visit.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We looked at five outcomes to answer the following questions. Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

People's needs and abilities were assessed before they moved into the home and care plans were written to make sure people's needs were met. Care staff we spoke with told us they had read people's care plans so they understood what they should do to minimise risks to people's health and wellbeing. Staff kept detailed records of people's needs and whether they ate and drank well. This meant that changes in people's needs were recognised promptly.

People received their prescribed medicines when they needed them. Staff made all the necessary arrangements to ensure medicines were obtained, managed, administered and disposed of safely. Staff understood people had capacity to make their own decisions about when they would take their medicines.

Staff personnel records contained all the information required by the Health and Social Care Act 2008. The provider checked staff were suitable to work with vulnerable people and made sure they had appropriate skills and experience to support people who lived at the home. Staff told us new staff shadowed experienced staff while they got to know people. Staff told us they had to be checked by the Disclosure and Barring Service (DBS) before they worked independently.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. The manager told us they had not needed to apply to the local authorities to deprive anyone of their liberty. Staff were trained to use distraction techniques to help people avoid harm and did not have to restrain anyone against their will. The manager and staff were clear about their responsibilities under DoLs.

Is the service effective?

People's health and care needs were assessed with them, their relatives and other health professionals. Specialist dietary, mobility and equipment needs were identified in people's care plans where required. We saw staff encouraged people to eat a regular, healthy diet and to drink plenty of fluids. Staff regularly checked that equipment was in good working order and knew how to obtain replacements and repairs when necessary.

Staff recorded when people saw their GP, their dentist and the specialist health teams. We found people followed the advice from other health professionals, because staff helped them to recognise the benefits of doing so.

Staff attended mandatory training and specialist training that was relevant to people's needs. Staff told us they attended refresher training.

Is the service caring?

People were supported by kind and attentive staff. We saw care workers encouraged people to be as independent as possible and to make their own decisions. One person was happy to show us their room. Staff had helped arrange their personal possessions and put photos on display. The person showed pleasure in staff's interest in their latest photos. Another person told us, 'I have friends next door. We go out together sometimes.'

We saw care plans which helped staff understand how to care for people who could not verbally communicate. In one care plan we read, 'If X is silent, it doesn't mean X agrees' and 'Give X time to consider, X will be stressed if rushed.' The manager had created a table of the non-verbal communication the person made, what that usually meant and how staff should respond. We saw staff responded to the person as described in their care plans.

We saw staff were observant and knew how to support people in the way they preferred. At breakfast time, we saw staff cut up one person's food small enough for them to eat independently and another person was offered soft foods because they were easier to swallow.

Is the service responsive?

The manager regularly reviewed people's care plans and updated them when people's needs changed. Staff told us they read people's care plans when people first moved into the home. Staff told us they knew people's needs because of the detailed daily records they kept.

The care plans we looked at described people's preferences, likes and dislikes. People told us staff supported them to spend time in their preferred way. One person told us they got up, showered, had breakfast and went out when and where they wanted to.

People were supported when they moved between service providers. For one person who had recently moved into the home, the manager had asked for support and advice from the person's dietician, district nurse, pharmacist and occupational therapist, to ensure a smooth transfer.

Is the service well-led?

The manager told us people who lived at were not always able to express themselves verbally, so they obtained feedback from people by observing how they responded to staff's interactions with them. The manager sometimes worked alongside staff so they were able to observe staff in practice and make suggestions for improving the quality of care, according to people's reactions.

The manager explained they obtained feedback through spontaneous one to one discussions with people. The manager asked people what they thought about the food, the activities and the staff.

The manager told us all staff were involved in maintaining the quality of care. Staff told us about their responsibilities for checking and monitoring the quality of various elements of the service. We saw staff regularly checked people's skin condition, their nutritional intake and their personal monies. This meant that the manager involved the whole staff team in the quality assurance system.

We spoke with the manager and two support workers about their roles in providing care and support to people. We looked at records which stated how people liked and needed to be cared for. We were told that people were included in planning their care and were happy with the support they received. One person commented, 'I would say if I was unhappy."

We were told that people led busy and active lifestyles. This was confirmed by the records we looked at. One person told us, "I do a lot of things for myself."

We observed support workers assisting people with their daily routines and saw that people were treated with dignity and respect.

The support workers we spoke with demonstrated an understanding of people's needs and clearly knew them well. We saw that care plans and care records were reviewed on a regular basis so that they remained reflective of people's individual needs.

We looked at training records and talked to two support workers about the training they had received to enable them to meet people's needs. We were told, 'We have a lot of training' and 'It is all very useful.'

We found that there was a system of measuring the quality of the service provided to people so that improvements could be made, based on people's comments and suggestions.