Archived: Adjuvo Care Essex Limited - Halstead

Adjuvo Essex Care limited – Halstead is a residential care home providing personal and nursing care to 12 people with a learning disability and autism.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 12 people. Six people were using the service. This is larger than current best practice guidance.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support because a lack of skilled, trained and supported staff meant people did not receive planned and co-ordinated person-centred support that was appropriate and inclusive for them. Therefore people were not supported to have maximum choice and control of their lives

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

Staff told us there were insufficient staff in the service.

The service failed to provide adequate and meaningful activities for people.

The provider failed to learn lessons to ensure risks associated with individuals were identified, planned for and monitored effectively.

The service was not well led and management failed to have oversight of the service to drive improvement.

The service failed to encourage staff to maintain and develop their knowledge and skills. Systems for managing staff training was ineffective.

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 5 March 2019) for the second time. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made.

Why we inspected

The inspection was prompted in part by notification of a specific incident. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

Following our last inspection we were informed by the provider of the decision taken to close the service, at that time a closure date had not been given. As part of our monitoring we carried out a focused inspection to review the Key Questions Safe and Well Led only.

We found shortfalls in the oversight, management, staff training and support and staffing levels which all impacted on the service’s ability to support people safely and effectively. This put people’s wellbeing at risk. Please see the safe and wellbeing sections of this report.

The service had been developed and designed in line with the values that underpin the CQC Registering the Right Support policy 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.

People’s experience of using this service:

Staff understood the risks to people and the measures in place to keep them safe, however safeguarding concerns were not always raised to the appropriate authorities and investigated. People’s medicines were not always managed safely.

Measures were in place to reduce the risks associated with the spread of infection.

Sufficient numbers of staff were employed to meet people’s needs and ensure they had maximum choice and control in their lives. This included supporting people to access a wide range of activities in the community that reflected their specific needs and interests.

The environment was not always well maintained and repairs were not actioned in a timely manner.

The training processes in place did not always ensure staff had the right skills and experience, and were suitable to work with people who used the service.

Staff were not always caring and did not always promote people’s dignity and independence

People received personalised care responsive to their needs, but did not always have access to health care services in a timely manner. People had access to food and drink based on their individual choice and preferences.

Staff did not always understand their role and lacked confidence in the manager. There was a poor culture within the service. Staff and relatives did not feel the service was well led. There was a lack of oversight by the manager which meant issues, such as safeguarding matters, medicines errors and issues were not always identified and managed.

Rating at last inspection: Requires improvement (Report published 09 October 2017)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: Our previous inspection in August 2017 (published October 2017) identified improvements were needed in relation to the overall management of the service and systems in place to account for how funding for people had been allocated and spent. The service was rated requires improvement. This was because there had been a lack of oversight of the service by the provider and the manager to ensure the service delivered was of a good quality, and safe. They did not have systems in place to identify what was working well and what needed to improve.

During this inspection we found the required improvements had not been made. We will continue to monitor all intelligence received about this service to ensure that the next planned inspection is scheduled accordingly.

Following the inspection visits, the provider has provided evidence on the action they have taken to mitigate immediate concerns, such as completing a Personal Emergency Evacuation Plan for one person and fire safety works, which has lowered the risk to people

Futures – Halstead provides accommodation and personal care for up to 12 people with a learning disability and autism. On the day of our inspection there were eight people living at the service.

At our previous inspection in December 2016, we identified continued, serious concerns regarding the management and leadership of the service and the quality of their care delivery. People were being put at risk of physical and emotional harm and there was insufficient governance in place to make improvements within acceptable timescales. Staff had not received appropriate training to understand the complex needs of people using the service. Peoples complex behaviours were not managed safely, and forms of restraint were being used which placed people at risk of harm. There was insufficient monitoring and reporting of incidents which meant that poor practices had become embedded into the service. In response, we took action to restrict admissions to the service, placed conditions on the provider’s registration and placed the service in special measures.

At this inspection, we found action had been taken to improve the quality and safety for people in a number of areas. However, we also identified areas that further work was needed to increase the service's overall rating and ensure that people are provided with good quality, safe care at all times. There continued to be insufficient staff available to meet people’s assessed needs at all times. Whilst the appointment of a service manager had resulted in some improved internal quality and safety monitoring, the provider continued not to operate effective oversight and governance of the service. There continued to be limited quality assurance in place to identify potential shortfalls in the overall quality of the service and the planning of resources to ensure continuous improvement of the service.

There was 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.

This service was in transition as the current registered manager was leaving and the service manager who had been in post since December 2016 was now responsible for the day to day management of the service. They had not submitted any application to register with the Care Quality Commission (CQC) but said they intended to do so following our inspection.

Since the last inspection, we found the culture of the service had improved. There was improved visible leadership with a positive focus on people who used the service. Staff were positive about the changes made and had been provided with improved opportunities to contribute to the development of the service. Team meetings and one to one supervision meetings were now provided on a regular basis to enable staff to have their views heard.

There were improved systems in place to assess and manage risks to people and reviewed monthly or sooner if something changed. Risk Assessments were detailed and personalised with guidance for staff in meeting people’s assessed needs. Accidents and incidents were logged with the information analysed and action plans were generated in response to promote people’s safety.

Any restrictive practice used to keep people and others safe had been appropriately assessed in people’s best interests. There was improved training provided to staff in the use of de-escalation techniques when people became distressed and presented with behaviour that put themselves and others at risk. Appropriate assessments had been carried out with detailed guidance for staff as to the least restrictive option, which upheld people’s rights to having their dignity respected.

There continued to be insufficient staff available at all times to meet people’s assessed needs with continued issues with high staff sickness absence. We found improved systems for safe and effective recruitment and training of staff.

There were systems in place to manage people’s medicines in a safe way. However, we recommend that the provider reviews its procedures in relation to the safe storage of medicines to ensure people’s medicines are stored safely at all times and ensure that they are compliant with best-practice guidance for storage of medicines in care homes.

There was improved staff training provided to staff. Whilst some staff had received comprehensive training in managing complex behaviours, which may put people and others at risk, not all staff had received this vital training.

A choice of food and drink was available that reflected peoples nutritional needs, and took into account their preferences and any health requirements. People’s dietary needs had been identified as part of their care plan. People were supported to maintain their health and had access to wide range of healthcare professionals. However, healthcare plans in use had not always been updated and did not adequately reflect a record of people’s health, outcome of appointments and fully establish what health professionals were involved in supporting people’s healthcare.

Staff had developed positive relationships with people and were attentive to people’s needs. People’s privacy and dignity was respected and care plans guided staff in how to promote their dignity and independence. People were supported to keep in contact with their family and friends who were made welcome at the service. However, people continued to have limited access to sufficient staff available at all times and resources to enable them to live their lives fully according to their assessed needs and as they would wish to do so.

Since our last inspection, the service manager had implemented a new, improved system of care planning. These were comprehensive in detail and personalised to guide staff in meeting people’s care and treatment needs.

At our last inspection, we found there was no access for people to internet connection, which would have enabled them to access information online. This would have provided for people a better quality of life and for those who would use this as a tool for communication and or relaxation. At this inspection, we found action had been taken to rectify this. We saw that people now had access to the internet and we observed this clearly had benefits to people’s quality of life.

There were ineffective systems in place in accordance with the provider’s statement of purpose to account for how funding provided for individuals in relation to meals, activities, transport and holidays had been allocated and spent. People’s personal inventories had not always been updated to include all their personal possessions.

During this inspection, we identified a number of continued breaches 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 this report.

The service provides accommodation and personal care for up to twelve people living with learning disabilities and autism. At the time of our inspection, there were ten people using the service.

The home has 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 & Social Care Act and associated regulations about how the service is run.

Our inspection identified serious concerns regarding the management and leadership of the service and the quality of their care delivery. People were being put at risk of physical and emotional harm and there was insufficient governance in place to make improvements within acceptable timescales.

The service was not safe. Staff did not receive appropriate training to understand the complex needs of people using the service. Behaviour which may have impacted negatively upon people was not managed correctly, and forms of restraint were being used which placed people at risk of harm. There was insufficient monitoring and reporting of incidents which meant that poor practices had become embedded into the service.

People had care and support plans in place but these were not always updated or reviewed with involvement from the person or their relatives. Risk assessments were robust and detailed but not always followed correctly in practice. People had their dietary and healthcare needs assessed although some improvement was required to ensure that the full range of people’s needs were being met. People had been supported to develop daily living skills and enjoy activities in and out of the service, although this was not always consistent.

Staff were not supported through regular supervision or appraisal and did not have any opportunities to contribute to the development of the service. Staff were being recruited to the service without the correct checks and balances which left people at risk of receiving care from staff who were not suitable. Staffing numbers were not always adequate to safely meet people’s needs, and impacted upon the quality of care they received. Staff only received basic training which was unfit for the nature of the roles they were employed to perform. There was no formal induction process being followed. While staff were dedicated and caring, there was a lack of consistency which impacted on people’s routines and ability to pursue activities.

The leadership and management at provider level was absent which meant that the registered manager was performing his role beyond the scope of his remit. This had led to a decline in the standards of the service and the registered manager did not have sufficient time to make improvements. There was little quality assurance in place to identify potential shortfalls in the quality of the service, and take remedial action. Some complaints were dealt with but others were not recorded or resolved, and some relatives and staff felt that their concerns were not listened to. There were inconsistencies in the maintenance, design and decoration of the service which had an impact on the safely and effectiveness of the environment for people.

This inspection identified that there had been a number of breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014 and the overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service provides care and support for up to ten people with complex needs who have a learning disability and autistic spectrum disorder.

The service 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.

Staff were trained in safeguarding people from abuse and systems were in place to protect people from all forms of abuse including financial. Staff understood their responsibilities to report any safeguarding concerns they may have although most were not clear how to report concerns to external bodies such as the local authority safeguarding team.

Risks to people and staff were assessed and action taken to minimise these risks, although sometimes information was not shared effectively to ensure people were protected. People were encouraged to remain as independent as possible and risks related to this were assessed.

Staffing levels meant that people’s needs were met. Recruitment procedures were designed to ensure that staff were suitable for this type of work and checks were carried out before people started work to make sure they were safe to work in this setting. Some recruitment processes had not been robust.

Training was provided for staff to help them carry out their roles and increase their knowledge of the healthcare conditions of the people they were supporting and caring for. Staff were supported by the managers informally although formal supervision and appraisal had not been regular.

People gave their consent before care and treatment was provided. Staff had not been provided with training in the Mental Capacity Act (MCA) 2015 and Deprivation of Liberty Safeguards (DoLS) but demonstrated an awareness of people’s capacity to consent. The MCA and DoLS ensure that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. Where people’s liberty needs to be restricted for their own safety, this must done in accordance with legal requirements. People’s capacity to give consent had been assessed and decisions had been taken in line with their best interests. DoLS applications had been appropriately submitted to the local authority.

People were supported with their eating and drinking needs and they were involved in shopping and cooking. Staff helped people to maintain good health by supporting them with their day to day physical and mental healthcare needs. The service worked well in partnership with other healthcare services, such as the Intensive Support Team, to ensure people’s healthcare needs were met.

Staff were caring and treated people respectfully making sure their dignity was maintained. Staff were positive about the job they did and enjoyed the relationships they had built with the people they were supporting and caring for.

People, and their relatives, were involved in planning and reviewing their care and were encouraged to provide feedback on the service. Care was subject to on-going review and care plans identified people’s particular preferences and choices. People were supported to play an active part in their local community and follow their own interests and hobbies.

Formal and informal complaints were responded to appropriately although records were not clearly logged.

Staff understood their roles and were well supported by the management of the service. The service had an open culture and people felt comfortable giving feedback and helping to direct the way the service was run. Staff were positive about their work and about the support and guidance they received from the manager.

Quality assurance systems were in place and audits were carried out to monitor the quality and safety of the service. Audits had not been regular but a new system had been put in place by the manager.

We spoke with one person who used the service and communicated with the other three people who used the service through gestures and body language. We looked at two people's care records. We spoke with one of the providers, the registered manager and two members of staff. We viewed the staff rota, training records and quality monitoring systems. We also inspected the premises including the garden. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a member of staff greeted us, noted our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The staff rota which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff and within the staffing structure to meet people's needs.

We reviewed staffing records regarding The Mental Capacity Act (MCA) 2005 in relation to Deprivation of Liberty Safeguards (DoLS) and saw this training was up to date. The CQC monitors the operation of the DoLS which applies to care homes. Appropriate applications had been submitted correctly and proper policies and procedures were in place. The registered manager and staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

There were systems in place to audit care plans which ensured there were effective systems in place for the delivery of care. The service had worked with people who the service and their families to develop their care plan to ensure that they supported the person to enjoy a variety of activities and their choices were respected.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that staff had signed records to show that care plans had been reviewed monthly and updated appropriately. This meant that staff were provided with up to date information about how people's needs were to be met.

We discussed the concerns regarding the safety of a specific bathroom in the service which had been brought to our attention with the provider and registered manager. They spoke to us about how this area was built and how it was operated. We also inspected the bathroom to understand how the staff supported people to have a bath and the safety aspects of having risk assessments in place.

Is the service caring?

We saw that the staff interacted with people who used the service in a caring, respectful and professional manner. We saw that the staff conversed with a person who used the service both verbally and using sign language to determine if they were hungry. We noted that people who used the service had been horse riding while other people had been taken out for lunch.

Is the service responsive?

The service had an effective complaints procedure in place which included a pictorial system to support people. We examined the care records of two people who used the service and noted that risk assessments were reviewed and updated in response to events. This ensured people received safe and appropriate care. One person told us. 'The staff helped me to write my care plan.'

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. On the day of the inspection, the staff we spoke with felt they were well supported by the registered manager.

This is a summary of what we found;

Is the service safe?

We saw that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS), which were updated every year. This meant that staff were provided with the information that they needed to recognise, and report concerns so that people were protected from abuse as far as possible.

People were provided with their medication in a safe manner and at the prescribed times. We saw that medication was stored safely and administered as per instuction.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with respect. One person said, "I get on well with all of them." Another person said, "They are all very kind and they work so hard." People using the service, their relatives and other professionals involved with Futures completed satisfaction questionnaires. Where shortfalls or concerns were raised we saw these were addressed by the provider.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. People told us that they knew how to make a complaint if they were unhappy. We saw that where people had raised concerns appropriate action had been taken to address them. People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed.

Is the service well led?

There were structures in place for clinical governance and quality assurance. We saw a planned approach to quality audits and evidence that action was taken as a result of these to improve the service provided.

Staff told us they felt well supported and encouraged to provide standards of care they could be proud of. They had received the training they required to deliver safe and effective care. There were systems in place for the appraisal of staff and personal development planning.

Is the service effective?

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We issued a warning notice dated 20 September 2013 which explained that the provider was failing to comply with Regulation 10 (1) (a) (b) and (2) (ii) of the Health and Social Care Act 2008. We told the provider they needed to be compliant by 07November 2013.

We carried out an inspection on 02 January 2014 to follow up on our warning notice. We found that the provider had taken action regarding assessing and monitoring the quality of the service provision. We will continue to regulate the service to ensure that this is maintained.

We issued a warning notice dated 20 September 2013 which explained that the provider was failing to comply with Regulation 9 (1) (a) and (b) (i) (ii) and (iii) of the Health and Social Care Act 2008. We told the provider they needed to be compliant by the 07 November 2013.

We carried out an inspection on the 13 November 2013 to follow up upon our warning notice. We found that the provider had taken action regarding how people who used the service received care that was safe and protected them. We will continue to regulate the service to ensure that this is maintained.

We spoke with one relative and three members of staff as part of this inspection. There were two people living at the service but due to their complex needs we were unable to speak with them directly or one to one? A relative of one person told us, that their relative was 'Much more relaxed and has made good progress here particularly with meals.'

The ground floor of the service has been refurbished to provide five single space living accommodations all with en-suite. They have been decorated in different styles.