Archived: Windsor Drive Dawlish

1 – 4 Windsor Drive is a residential care home providing personal care for up to 12 people with learning disabilities such as autism, and physical disabilities. At the time of this inspection there were nine people living at the service. Accommodation is provided in four linked semi-detached bungalows situated on the outskirts of Dawlish within easy walking distance of local amenities.

The service was registered prior to the guidance 'Registering the Right Support was published. However, the service has been developed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This 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 received planned and co-ordinated person-centred support that was appropriate and inclusive for them. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

The service is registered for the support of up to 12 people. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the design of the bungalows which gave the impression of a four small bungalows on a residential housing development with no outward signs that it was a care home. There was a strong focus on treating each person as an individual, and supporting people to participate in their local community.

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

Since the last inspection many changes and improvements had been made in all areas of the service. A new registered manager was appointed who has supported and inspired the staff team to bring about positive changes. Staff told us they felt valued and they were enthusiastic and proud of their achievements. Comments from staff included, “There is more continuity with staff members and a passion for what they do because they are valued within their role. The standard of the care is brilliant as the people here now genuinely care”. A relative told us, “We as [person’s] family are really happy to see the improvements which make [person’s] life so much more enjoyable.

People were supported by an exceptionally caring staff team. The staff team demonstrated passion and determination to help people overcome barriers and lead more active and fulfilling lives. In the past year people had been supported to achieve positive changes in their lives, such as overcoming agoraphobia, obtaining pets, and making plans to achieve their hopes and dreams in the near future. A person who used computer technology to enable them to communicate told us, “I am excited about (living) here and I like all staff member(s)”.

People were safe. There were sufficient staff with the skills and knowledge to give people the support they needed, at the right times. Care had been taken when recruiting new staff to ensure they were entirely suitable for the job. The number of permanently employed staff had increased, and the level of agency staff had decreased. This meant people received support from a consistent staff team they knew and trusted.

Measures were taken to minimise risks to people’s safety. Risks to people’s health and safety were assessed and staff knew how to support people to remain healthy and safe. Medicines were stored and administered safely. Staff understood how to keep people safe from infection. The accommodation and equipment were well maintained, checked and serviced.

Staff understood the support each person needed. Care plans had been improved in the last year to provide greater detail about all aspects of the support each person needed. Staff understood each person’s individual style of communication and they were working to improve this through projects, training and communication ‘Champions’.

Staff had worked with a range of professionals to improve peoples’ health and comfort. Peoples’ social needs were met through a better understanding of the things people enjoyed doing. Staff supported people to go out, participate in clubs and activities, and keep in touch with friends and family. People were encouraged to retain and gain independence, for example by involvement in meal planning, shopping and meal preparation where possible.

The service was well-led. There were checks and measures in place to ensure all aspects of the service were running smoothly. The provider, registered manager and staff team reviewed the service regularly and consulted with people who used the service, friends and family to consider any improvements needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 19 December 2018).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

• People were supported by staff who were kind and affectionate and knew people’s needs well. Every person was calm during our inspection, some people told us they were happy, other people made sounds or facial expressions that indicated they were happy.

• People lived in a service that was homely, with freshly cooked food and a range of drinks on offer. People’s rooms were comfortable and reflected people’s character. The communal areas needed some redecoration and there were plans for wider refurbishment.

• Care staff felt supported and were receiving supervision. They were also supported through the provision of relevant training so they could effectively meet people’s needs.

• The service was linked in with health professionals who had regard for the service. Professionals we spoke with said their advice around meeting people’s health needs was followed.

• Where people did not have capacity to make decisions, they 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.

• Care records and risk assessments were not always up to date with recent information and had conflicting information about people’s care needs and how to manage risks. Care staff knew people well enough to support them with distressed or self-injurious behaviours but the records did not reflect this.

• The provider had recently recruited a new manager as the longstanding registered manager was leaving. People were sad to see them go and some support had been provided around the changes taking place in the service for people.

• There were enough staff to meet people’s basic needs but people could have accessed the facilities in the local community more. We saw some people going out but not everyone had the same opportunities as others because of transport difficulties.

• Staff knew what potential abuse might look like and how to report it. Medicines were managed safely. Building checks were completed regularly.

• We found one breach in relation to legal requirements in good governance. More information is available in the detailed findings below.

Rating at last inspection: Requires Improvement, the last report was published on 18 July 2018.

About the service: 1-4 Windsor drive (referred to in this report as the service) is a residential care home in a rural setting that was providing accommodation and personal care to 11 people with support needs around physical and learning disabilities and people with autism at the time of the inspection.

Why we inspected: This was a planned, scheduled inspection based on the previous rating.

Enforcement: The provider is required to send us an action plan addressing the concerns we found at this inspection regarding the breach of regulation we found, within the timeframe we specify.

Follow up: We will meet with the provider after an action plan has been sent to us to discuss the improvements they are going to make.

Following our inspection in December 2016 we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Caring, Responsive and Well-led to at least a ‘good’. We found that although action had been taken this was not sufficient to improve the ratings at the service or to meet the requirements set by the breaches of regulation.

1-4 Windsor Drive 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. 1-4 Windsor Drive is registered to accommodate up to 12 people with learning disabilities and complex needs across four separate bungalows, each of which has separate adapted facilities. At the time of this inspection in March 2018 there were eight people living at the service, spread across all four bungalows.

The service was not 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. We found these were not shared by the service.

The service 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.’

During our previous inspection in December 2016 we identified four breaches of regulation, relating to people not receiving care which always met their needs, people’s lack of opportunities to spend time outside the service, staff failing to demonstrate respect towards some people, insufficient staffing numbers to meet people’s needs and ineffective systems in place to monitor and improve the service. During this inspection we found three of these areas still required improvements and three regulations were still in breach. We also identified two further breaches of regulation and new concerns.

People who lived in 1-4 Windsor Drive were not always safe. Although we saw a number of good examples of risks to people being identified, reported and well managed, we also identified instances where risks had not been adequately assessed or mitigated. For example, staff did not have any information relating to the acceptable blood sugar levels for one person living with diabetes. Although staff were regularly checking the person’s levels they did not know what these should be, how they presented should their levels be too low or too high or what they should do in these instances. We also found risks relating to one person’s meals containing items identified as being high risk for them by a specialist speech and language therapist. This placed this person at risk of choking.

All the people living in the service required help to take their medicines. Prior to our inspection a medicine error had taken place and the registered manager had assured us they had reviewed systems for medicine management in order to ensure risks of reoccurrence were minimised. We found, however, when reviewing people’s medicines, that the systems in place to record and review medicines did not make it possible for the staff or registered manager to ensure people were taking their medicines as required. We found a number of inconsistencies between the number of tablets people had in stock compared to the numbers recorded. This meant it was not possible to tell whether people had been taking their medicines as prescribed by their doctor.

We identified some concerns relating to the five principles of the Mental Capacity Act 2005 (MCA) which include that any action taken on a person’s behalf must be in their best interests and regard must be had as to whether an act or decision is the least restrictive of a person’s rights and freedoms. We found one person’s privacy was potentially being violated by staff who used a viewing hole in their bedroom door to look in on them when there was no clear reason for doing so. We also found one person’s money had been used to purchase some equipment which was going to be used to equip the service’s sensory room. Although the person was likely to benefit from this, all other people living in the service would be able to use this and this had not been discussed with the person or taken into account when making the decision.

People did not have access to sufficient opportunities to leave the service, to socialise or take part in activities that met their individual needs and interests. One person shared their experience with their relative and said, “I’ve lived a quiet life for seven years and I’ve had enough and want to get out and about more”. People, staff and relatives confirmed people did not regularly take part in activities outside of the home and told us this was down to shortages of staffing numbers and access to vehicles. Although some staff told us they felt supported to carry out their work, others told us they did not feel this way. We found staff supervisions were not being carried out regularly. The registered manager told us they were working towards improving this.

People had access to sufficient amounts of food and drinks to meet their health needs by staff who knew how best to encourage them and support them. However, we found risks relating to the foods being eaten by one person and found that people were not being encouraged to take part in the preparation of food. Staff did not work towards involving people in the running of the home by joining in with daily tasks where they could. Improvements were required in relation to providing people with accessible information in order to best communicate their care plans, assessments and personal information to them.

Although we observed some very positive interactions between staff and people, and it was clear staff knew people very well, we witnessed an incident which did not demonstrate respect towards one person. One member of staff did not demonstrate respect of one person’s dignity or privacy by opening and leaving open, the person’s bedroom door, when they were in a state of undress.

The systems in place to assess and monitor the quality and safety of the service had not been effective in identifying some of the concerns we found during this inspection. Although concerns had been raised during the previous inspection, inadequate efforts had been made to improve in those areas.

We found records for people were not always accurate and were sometimes not personalised. For example, people were put on fluid output charts whether this was required or not. People’s care plans were highly detailed however, and contained lots of clear guidance and information for staff on how to best support people.

People’s bedrooms were personalised to reflect their preferences and their personalities.

Staff were provided with training to meet people’s needs. Training topics included supporting people with epilepsy, autism and mental health needs, medicine administration, food hygiene, first aid, fire awareness and more. Staff knew how to recognise signs of potential abuse and knew how to report any concerns they may have. Recruitment practices at the service ensured that, as far as possible, only suitable staff were employed.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people’s individual needs not being met, people’s rights under the MCA not being protected, people not always being safe from risks relating to their health and to medicines, staff numbers not being adequate to meet people’s needs and staff not being supported, and ineffective quality assurance systems. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 19 and 21 December 2016 and was unannounced. The service was previously inspected in June 2014 and was found to meet the regulations inspected at that time.

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

Prior to the inspection we had received information about the welfare of one person supported by the service. Concerns were raised with us that this person’s complex care needs were not being met. We reviewed this person’s care. We saw the service was working with staff from the local authority to ensure this person was safe. However, we did find that improvements were required in the number of staff available to respond promptly and consistently people’s support needs.

Staffing levels did not promote opportunity or choice for people to engage with staff or participate in activities outside of the home. In addition, while some people’s care and support needs were clearly identified in their care plans and risks to their health and safety were being well managed, this was not the case for everyone. Systems in place to assess quality and risk had not been effective in identifying these issues.

The registered manager and staff told us they felt there were insufficient staff available to meet people’s care needs. Staff were identified to work in each of the bungalows but at times there was insufficient staff in the bungalows to support people with their personal care, such as going to the toilet. Staff told us they asked staff from one of the other bungalows to help them at these times. Staff told us that they were anxious there was not always enough staff available to support people in the way they wished to be supported. Relatives told us they felt there was not enough opportunity for people to go out of the service as there was not enough staff on duty. Following the inspection, the registered manager confirmed that staffing levels had been increased.

Not all care plans provided staff with accurate guidance about people’s current care needs and how risks to their health and safety should be managed. Two of the three care plans we looked at provided staff with clear guidance about people’s care and their preferences. However, the third care plan did not accurately reflect the person’s care needs. Staff were not guided about how to support the person with their personal hygiene, how to encourage the person to become involved in activities or how to support them at times of anxiety and distress. Information held in the care plans stated whether people had the capacity to consent to the support identified in these plans. However, there were no records of formal capacity assessments having been undertaken for those who staff thought lacked capacity.

During our observations we saw kind and friendly interactions between staff and some people. However, we observed staff favouring those people who were able to communicate with them and those with limited communication abilities received less attention from staff. While staff were not being outwardly unkind to people, they ignored people who, due to their disabilities, were not able to seek staff company and interaction.

Relatives and advocates told us they found the staff caring and kind. Staff were described as “excellent” and “absolutely amazing”. Staff talked of people fondly when they told us about people’s support needs. One member of staff said, “When he smiles, it fills my heart.”

Staff received a variety of training to ensure they understood people’s care and support needs. This training included safeguarding adults from abuse. Risks to people’s well-being due to poor mobility or medical conditions such as epilepsy were well recorded. Staff were provided with clear information about how to support people safety and minimise these risks. Specialist advice was sought when appropriate from healthcare professionals such as the community nursing team, occupational therapists and medical consultants at the local hospital. The community nurses we spoke with were confident people’s healthcare care needs were being well met. People’s medicines were managed safely and people received their medicines as prescribed.

Although staff, relatives and advocates had some concerns over the staffing arrangements at the service they told us they felt the service was well managed. One relative described the service as “excellent in the way it’s run” and an advocate said of the registered manager, “I really rate [name], she has standards.” Relatives and advocates told us they had no complaints and felt they could talk to the registered manager if they did. Staff told us they enjoyed working at the service and were well supported. They said the registered manager was approachable and always had time for them. One staff member said, “It’s a nice place to work, I like it here”.

We made a recommendation and identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 where improvements were required.

You can see what action we told the provider to take at the back of the full version of the report.

' 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. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People's needs were assessed with care and treatment planned and delivered in line with their individual plans to ensure people's safety and welfare. For example we saw that there were detailed mental health assessments in place which detailed the person's condition, symptoms and behaviours. These were reviewed and shared with Social Services with any concerns regarding changes in mental health. This meant the service was able to make sure that they met people's needs.

Risk assessments had been developed around areas of risk and those showed evidence of review and update. A scoring system was used to make an assessment and a plan completed which gave staff clear guidance on how to manage the risk. These were then cross-referenced to care plans outlining how risk could be managed so that the level of risk was reduced.

Records showed that care plans and risk assessments were reviewed monthly and updated as necessary in recognition of the changing needs of the people they described. This ensured that people received good quality support that was responsive to each person's changing needs.

One family member told us "I have every confidence in the quality of care received, we have an excellent relationship with the home and all other health professionals involved." They added "If I did have any concerns I could approach any of them and be assured my concerns would be dealt with professionally."

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people's human rights. The manager said they had not needed to submit a Deprivation of Liberty Safeguards application to-date. However, the manager was aware when an application should be made and knew where to go if an application was required.

Is the service effective?

People were encouraged to remain independent. Care plans identified what people were able to do for themselves, rather than only focusing on what a person could not do. For example, such as picking out their own clothes. One relative told us "The staff go above and beyond what's expected of them. They really know what's important". They added that staff treated them like an "old friend".

Relatives told us "Communication from the home is very good, they keep me informed." They added "It's important for us to feel involved and we are always kept up to date with any changes."

Is the service caring?

Relatives told us that they had visited the service before their family member had come to stay. One person told us "Social Services suggested I visited and I really had thought there wasn't anywhere good enough." They added "We are now very happy and feel content with the decision we made. They are settled and very well cared for."

One relative said "I just can't praise the home enough. The staff are absolutely excellent, every one one of them".

Due to people's conditions we were not able to discuss their experience in detail. A relative told us "All staff are very good here, they are polite and would do anything for you"'. They added "Staff really know the people that live here and know their personalities"

Staff were seen to explain to people about what they were doing when providing care. For example when helping a person to stand, the staff member explained why they needed to help them, how they were going to do it and if it was alright for them to do it.

One relative told us "Staff are very sensitive to people's needs, they are all wonderful." They added "Staff go above what is expected and do those little extra things that show just how much they care."

An external therapist visiting the home said they were "very impressed" with the standard of care. They added that staff "told people exactly what was going to happen" and were "gentle".

Is the service responsive?

There was evidence that advocacy was used for some people. We spoke with an advocate who had represented some of the residents for a number of years. They told us "I have seen enormous improvements with some people since moving here, you can tell people are happy."

Close links were evident with other professions such as GP, hospital and dentist. It was evident that the home regularly sought the support of relevant professional advice. This showed that staff were given information to enable them to provide care that met people's specific needs.

People's care was planned and delivered in a way that protected people from unlawful discrimination. Reasonable adjustments had been made to meet individual needs. For example the home was adapted to meet disability access needs and specialist equipment was available.

One staff member said "It's really important to build a relationship with people, you become able to learn and understand their own style of communication." They added "I have learnt to recognise certain noises or behaviour as their way of telling me just what they want."

One staff member told us "I had felt the need to learn more about autism to support people's needs." By approaching the manager and discussing further training a course was agreed and attended within a few months. The staff member felt confident with the new skills and went on to share experience with other staff.

Is the service well led?

The Registered Manager demonstrated a good awareness of the needs of the people that lived in the home and looked at good practice guidance in order to improve care provided.

Staff told us that they felt supported to carry out their role. They felt that the manager was approachable, professional and supportive. We saw evidence of staff meetings hosted by the manager. This showed that staff were provided with support in a number of different ways, through supervision, staff meetings and by the manager having an open door policy.

Staff reported that they had regular supervision meetings with the manager. Staff members said they "Felt free to discuss anything and any suggestions on improvements were always considered."

The manager told us they operated an 'open door' policy and were frequently within the home and worked alongside staff when required.

One staff member told us "The training is always good, it makes you think about the things you do". Another said "The manager is very approachable if I need to discuss anything and I could use my supervision time if needed". This demonstrated that people could be confident that the manager would identify and respond to any safeguarding matters promptly and correctly.

People who lived in the home had limited verbal communication and therefore were not able to tell us about their experiences. We spent time observing interactions between people and the care workers who were supporting them. We observed interaction between staff and people living in the home that was respectful, positive and encouraging. Relatives, health professionals and an advocate were positive about the care and support provided. Comments included 'the staff are brilliant and we're always welcomed' and 'people always look smart, well cared for and happy.

We found that care workers were receiving appropriate training and professional development so they could carry out their job role effectively. Care workers knew how to report concerns to ensure people were protected from the risk of harm.

Records were accurate, kept up-to-date and stored securely.