Archived: The Shrubbery

The Shrubbery is a care home for up to 15 men. It is one adapted building arranged across three floors. Each bedroom has either en-suite or a private access bathroom. There are shared facilities including lounges and a games room, as well as kitchen, utilities spaces and food stores. There are two offices within the building. The Shrubbery is also registered to deliver personal care to people who live in the community in their own houses or flats. At the time of the inspection they were not delivering personal care.

The service was registered before Registering the Right Support was developed. The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The guidance ensures 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. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them. The provider had not applied the principles and values of RRS.

People’s experience of using this service

People received support that reflected the level of risk they posed due to their offending histories. Risks linked with their medicines, or to areas other than offending, had not been clearly identified or addressed. Although staff were able to describe the steps they took to mitigate these risks, they were not captured in risk assessments or care plans.

People told us, and staff agreed, their experience of care was affected by high use of agency staff at the home. Permanent staff had been recruited in a way that ensured they were suitable to work in a care setting. Staff did not receive the training they needed to perform their roles, although they did receive regular supervision.

People told us, and records confirmed, their opportunities for activities and engagement outside the home were limited. We saw people had been supported to identify goals, but there were no detailed plans in place about how to support them to achieve their goals. We have made a recommendation about care planning.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support as people were not supported to develop their independence and had limited choices in their day to day lives.

People were not supported to have maximum choice and control of their lives and 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. People had not had their capacity to consent to their care assessed when there was reason to believe they may lack capacity to understand all aspects of their care.

The governance systems in place had failed to identify and address the issues we found during the inspection.

People told us they felt safe. Staff took action to ensure people’s safety if allegations of abuse were made, however, they had not always followed local safeguarding adults procedures. This was addressed during the inspection.

People told us, and we saw, staff knew people well and supported them in a kind and sensitive way. Staff behaviour reflected the ethos of the provider that no one should be disadvantaged by their past behaviours.

People were supported to access specialist services, and to have their health needs met. People were supported to have their nutrition and hydration needs met, although people were not always happy with the menu options.

People were supported to have their dignity upheld. People’s protected characteristics were respected and people felt safe to disclose their sexuality and gender identity. People knew how to make complaints and the provider investigated these thoroughly.

The provider had a clear values base. People and staff were actively engaged by the provider's systems.

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 August 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to risk assessment and medicines management, staff training and the governance of the service.

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

Follow up

We will request an action plan from 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.

The Shrubbery is registered to provide accommodation with personal care for up to 15 people. There were nine people living at the service on the day of our inspection.

The Shrubbery supported people who had previously committed offences. Some people had lived at the service for up to three years although many people had lived at the service for less than one year. People had varying care and support needs. Some required more support than others but most people were quite independent and required only prompts and encouragement. Although most people were capable of going out alone, some people had restrictions in place that meant they could only go out when escorted by a member of staff.

The service was provided in a large renovated property with private gardens at the back. Each person had their own bedroom with en-suite shower and shared two communal lounges and a dining room. Close to shops and community facilities, including public transport, people could get to places they needed easily.

There was a registered manager based at the service. 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.

Our last inspection report of this service was published on 08 July 2016 and related to an inspection that had taken place on 01 and 02 March 2016. At the inspection in March 2016, we found two breaches; one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 11, Need for consent and one breach of the Care Quality Commission (Registration) Regulations 2009, Regulation 18, Notification of other incidents. People were restricted from entering or leaving the premises freely as the door was locked and only staff had a key fob. The provider and registered manager had failed to notify CQC of important events at the service that they are required to notify by law.

We asked the provider to take action to meet the regulations. The provider sent us a report of the actions they were taking to comply with Regulations 11 and 18 on 19 July 2016. They told us they had already taken the action specified in the plan and were meeting the regulations.

At this inspection, we found that the provider had implemented new ways of working to address the breaches from the previous inspection which had resulted in improvements to the service provided. All people living at the service had been issued with their own key fob so they had full and free access in and out of the premises. Monitoring systems had been reviewed, ensuring one member of staff took responsibility for completing notifications to CQC. This change had resulted in improvements and notifications being made when necessary.

Although no people living at the service had been assessed as lacking capacity to make any of their own decisions, the registered manager and staff had a good understanding of the Mental Capacity Act 2005 and how they may be required to support people to make decisions in the future. People who did not require a staff escort when leaving the premises now had their own key fob so they could freely enter and leave when they wished.

The management of risk was robust with systems in place to assess the risk to individuals and by individuals. People were involved in their risk assessments as well as outside agencies when relevant. People had a comprehensive assessment before moving into The Shrubbery which resulted in the development of a care plan. People were involved in the planning of their support. A risk meeting was held regularly with the registered manager and senior managers to assess referrals to ensure the service only accepted people they were able to support.

All aspects of medicines administration were managed well. Robust monitoring and auditing to support the safe management of medicines were in place. People received their medicines in a safe way and as prescribed.

Accidents and incidents were recorded and managed well. Regular monitoring helped to make improvements to minimise the risk of similar incidents occurring.

The appropriate servicing and maintenance necessary to maintain the premises were carried out regularly. There was room for some improvement in the décor and environment.

Safe recruitment practices were used. New staff went through a thorough application and vetting process to make sure they were suitable to work with the people living in the service. There were enough staff employed to meet the assessed needs of people. Although agency staff were used to make sure the numbers of staff were appropriate, the registered manager was actively recruiting new staff.

Staff had received the training they required to support the needs of people living in the service. Staff had access to the provider’s online system that allowed them to book the training they required directly, then signed off by the registered manager. Staff could apply or ask for additional training to meet specific needs. Staff received regular one to one supervision with their line manager and also had an annual appraisal to support their personal development.

People were supported to maintain their health and well-being and were registered with a local GP. People were complimentary about the food and confirmed they had choices.

Many staff had worked at the service for a number of years so knew the service well and were confident in their role. New staff felt the benefit of this and felt well supported through their induction.

Staff were friendly and approachable and spoke about people with respect. Staff clearly knew people, their histories and their needs well. Confidentiality was taken seriously and staff closed doors and windows during meetings and discussions.

People who were able to move on to live more independently were actively encouraged to do so.

Complaints had been dealt with appropriately and responded to quickly.

There was a range of age groups amongst people living in the service so people had differing needs when it came to providing meaningful activity. The registered manager and staff were aware of this and tried to accommodate each person’s requirements.

People were asked their views of the service in various ways, by residents meetings and questionnaires. The provider sought people’s views through a national forum for people using their services across the country with a representative of The Shrubbery supported to attend.

The staff had positive comments to make about the support they received from both the registered manager and the provider organisation. They were confident they were listened to when they had suggestions to make or had concerns to raise.

The provider had effective systems in place to monitor the quality and safety of the service and to make improvements when necessary.

The accommodation was set in a detached property over three floors as well as a separate annex and an independent flat. At the time of our visit, there were five people who lived in the home.

The home had 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 2008 and associated Regulations about how the service is run.

The home was safe. Risk assessments were in place for every person living in the home and covered a wide range of potential risks. The assessments were very thorough, identifying risk and how to mitigate it. They were constantly being reviewed and updated. Some people were not allowed to leave the building without a daily risk assessment being completed.

Environmental risk assessments were in place and safety certificates for gas and electricity were up to date. There were fire evacuation procedures in place although people did not have personal evacuation plans. Staff were able to describe how they would support people to evacuate in an the event of an emergency.

The provider had a safeguarding policy and procedure in place and staff had received training in safeguarding vulnerable adults. This policy made reference to the local authority’s safeguarding protocols but there was not a copy of this protocol in the home. Despite this staff were able to confidently tell us what their responsibilities were in relation to keeping people safe. We have made a recommendation about this.

Accidents and incidents had been responded to appropriately and the registered manager had put in place procedures following one specific incident that ensured protection for people living in the home.

Staff rotas showed that there were enough staff on duty to meet people’s needs and in line with the providers staffing policy.

The provider had a recruitment policy in place and records showed that recruitment practices were safe. References had been gathered, Disclosure and Barring checks (DBS) had been completed and gaps in employment history had been explored before staff commenced working.

The provider had a medicines policy in place which the staff were following. Medicines were stored correctly and medication administration records (MARs) were completed correctly. Medicine audits were carried out on a daily and weekly basis.

The home were not providing care in line with the Mental Capacity Act 2005 (MCA) or taking into account Deprivation of Liberty Safeguards (DoLS). People that had no legal restrictions in place were not able to leave the home unless staff allowed them to. The registered provider and manager had not considered that these people would need a DoLS in place. Staff and the registered manager did not have a clear understanding of how the Mental Capacity Act and the need to consider people’s consent to care and treatment fed into the support they provided.

The provider had a training schedule in place for the whole of 2016. The registered manager did not have a training matrix in place and had no overall view of what training might be out of date. We were provided with additional information after the inspection but it was still not clear whether all training was up to date. We have made a recommendation about this.

Staff completed residential inductions to the trust, received regular supervision and annual appraisals. They were supported in their roles.

People were supported to have access to routine health appointments such as doctors and physiotherapy appointments.

People were supported and encouraged to maintain a healthy and nutritious diet. The kitchen was well stocked and people were given a choice of meals. There was access to healthy snacks with a large fruit bowl in the dining room, and access to drinks throughout the day.

We saw staff engaging with people in a kind and compassionate way. People told us that the staff were kind and helpful to them.

People were supported to increase their independent living skills as much as possible. For example, staff organised for people to attend financial budgeting classes. They were also supported to resolve debt related issues.

Records showed that people had been actively involved in the drawing up and reviewing of their care plans.

Staff knew about the importance of confidentiality and to ensure that private conversations were held were other people could not hear. Care records and other management records were kept in locked office that only people authorised could have access to.

People’s privacy and dignity was protected and people’s religious and cultural views were taken into account. People also had access to independent advocates if they needed this support.

Pre admission assessments were very thorough and health care professionals were particularly impressed with this process. These clearly fed in to care plans that were drawn up in conjunction with people, taking into account their likes and dislikes and assessed needs. These documents and risk assessments were regularly reviewed.

People were supported to take part in meaningful activities if they wanted to. People were able to go out on organised trips and the home arranged trips that people had specifically requested.

People had regular access to the surrounding community and were involved in helping at local charities such as the food bank.

The provider had a complaints policy and procedure in place which gave information on how people could make a complaint if they needed. People told us they knew how to complain and staff supported them to do so if necessary.

The home had transition plans in place to support people to move one when it was felt they were ready to do so.

The registered manager was aware of their responsibilities however there was a lack of clarity between the home and head office about reporting responsibilities to the Care Quality Commission. Some incidents had not been notified to the CQC.

There were systems and processes in place to ensure the monitoring of quality in the home. Improvements had been made to medicines management as a result of monitoring.

Staff spoke of an open culture and everyone said they felt supported in their role. The registered manager also felt supported by the provider.

They kept up to date with best practice by attending local forums and accessing training and support from local providers. Staff had received additional training to support one person with a specific diagnosis.

The visions and values of the trust were based on Christian principles, about seeing the person as a whole and giving people a second chance. We observed staff echoing these principles in the care and attention they gave people.

Communication between staff and the registered manager was good, with shift plans being completed as well as verbal handovers.

We saw that people were supported and encouraged to lead independent lives within individual agreed boundaries and constraints. People were offered choices and were able to contribute to their agreed support plans.

Support plans and risk assessments were comprehensive and were subject to regular review and discussion. This gave people the opportunity to take responsibility for their own lives.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

All the interactions we saw between staff, management and people who lived in the home were positive. We saw that people felt free to express their opinions and were listened to and provided with all the support they needed.

The recruitment procedures at the service were sufficiently robust to ensure the safety and wellbeing of people living there.

Staff received training and support appropriate to the needs of the people who lived in the home.

There was an effective system to regularly assess and monitor the quality of service that people received.