Archived: Tree Top View

Tree Top View is a residential care home providing personal care to five people at the time of the inspection. The service can support up to six people between the ages of 18-65 with learning disabilities and autism. There are six ensuite bedrooms with shared communal space. There is a separate building adjacent to the main house that contains a small gym, an education room, laundry facilities and staff offices.

The service has been developed and designed 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 receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

People received an exceptional standard of person-centred care and support which enabled them to experience positive outcomes. This was because the service applied the principles and values of Registering the Right Support and other best practice guidance including Positive Behaviour Support (PBS). PBS is an approach used to understand the behaviour of an individual. It is based on an assessment of the social and physical environment in which the behaviour happens, includes the views of the individual and everyone involved, and uses this understanding to develop support that improves the quality of live for the person and others who are involved with them. These principles ensured that people who used the service could live as full a life as possible and achieve the best possible outcomes that include control, choice, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

We received extremely positive feedback about the service people received, comments centred around how well the service was led, social inclusion and person-centred care. Relatives told us, “Tree Top View supports each [person] on an individual basis, and with person centred planning. The managers and experienced dedicated senior support staff build up a programme of activities that suits preferences as well as needs. Loved ones are fully supported by the service and parents are included throughout the personalised journey to discover the needs and likes of each resident, the result of which provides a safe, happy and stimulating environment for residents to live, learn and enjoy life in” and “Staff are kind, caring and have the right attitude.”

Staff truly embraced a holistic approach to supporting people in a person-centred way by undertaking thorough assessments of their needs and taking time to understand their preferences, keeping them at the heart of all assessments. Staff received training by the organisation which was person-centred for their needs as well as of those they supported. Staff told us they were supported and the registered manager went over and above to ensure they were safe and happy at work.

The service was exceptionally managed by a team of skilled and co-ordinated staff. The registered manager invested in staff’s professional growth to ensure in their absence the service continued to sustain outstanding outcomes for people. Stakeholders consistently told us about the positive changes to the culture and staffing since the registered manager took over. The registered manager was innovative around staffing and recruitment and they had undertaken a piece of work around agency staff consistency including agreed terms with agency providers for temporary to permanent employment, this ensured candidates were right for the job.

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. The senior management team were asked to participate in a steering group with local commissioners to share best practice around restrictive practices. Professionals told us staff were respected for their knowledge and commitment to PBS.

People had achieved significant and life changing positive outcomes since the last inspection. Staff genuinely cared for people and their relatives. There was a clear inclusive culture. Staff were passionate about making a difference to people’s lives and helping them to achieve their goals and challenge their abilities.

People were protected from abuse and avoidable harm. Staff understood about positive risk taking, reporting risk. People’s medicines were managed in a safe and person-centred way. The environment was clean and refurbishment plans had been approved to improve some areas of the environment.

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 16 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The home did not have a registered manager at the time of our inspection as the previous manager had recently left the home. The previous deputy manager had been appointed to the position of manager of the home, and at the time of the inspection, he was progressing with his application to be registered with the Commission. 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.

We spoke with staff about their understanding of safeguarding procedures. Staff we spoke with were knowledgeable about how to recognise different types of abuse. They were also aware of how to report potential safeguarding issues both internally and to external agencies such as the local authority and Care Quality Commission (CQC). Records showed that staff had been recruited safely and they received an appropriate induction.

Staff received regular supervision and their practice was observed regularly to ensure that they were providing safe care. Staff told us they felt well supported by management at the service. Staff competence to administer medicines safely was assessed regularly, and medicines were found to be stored and administered safely. Staff had completed training that enabled them to improve their knowledge in order to deliver care and support safely.

People were supported with their healthcare needs and were referred to healthcare professionals when appropriate.

Staff understood the main principles of the Mental Capacity Act 2005 (MCA) and supported people to make everyday decisions about their care. Where people lacked the capacity to make decisions about their care, their relatives were consulted.

We observed staff displayed caring and meaningful interactions with people and people were treated with respect. We observed people’s dignity and privacy were actively promoted by the staff supporting them.

People living in the home were supported to access activities and pass times of their choice. There was a clear management structure in place and staff were happy with the level of support they received.

We saw evidence that regular audits were completed by the registered manager and the service provider. These checks were effective in ensuring that appropriate levels of care and safety were maintained.

We saw there were sufficient numbers of suitably qualified staff deployed within the home, to meet people’s needs and promote people’s safety. However, the home did not have a full complement of permanent care and support staff, and relied on the use of bank staff. Taking into account the nature of the assessed needs of the people who used the service, this high use of bank staff had the potential to lead to inconsistencies of approach occurring in the way care and support was offered, which could have the knock of effect of people who used the service feeling anxious and distressed. This could lead to changes in behaviour and mood. We have made a recommendation about this.

' 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?

We saw that all permanent members of staff had up to date adults safeguarding training. This was also the case for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training.

Because of their needs and associated risks all the people who lived at Oxen Barn were on one to one or two to one staffing. We spoke to the registered manager who had been in close contact with each placing authority to ensure that recent changes to DoLS legislation were being adhered to. We saw evidence of this within peoples care files.

Is the service effective?

There were a number of 'success stories' that showed how people had progressed behaviourally and physically since they began living at Oxen Barn. One example included one individual who had lost a significant amount of weight due to a better diet and exercise regime being introduced by the home.

Is the service caring?

We spoke to two families regarding their loved ones care. Both were happy that they were treated with dignity and respect. One relative told us, 'I can't say how please I am with (Name) being at Oxen Barn. I don't think you can beat this place in terms of the care, staff and activities. I visited tens of places looking for the perfect one, you couldn't beat it'.

Relatives were involved in helping to plan the care and support needed and this was reviewed at regular intervals, with any changes in circumstances being well recorded. Evidence was available to show a wide range of external professionals were involved in the care and treatment received by those living at the home, including GP's, social workers, psychologists, speech and language and consultants. Risk assessments were in place across a wide range of areas and were seen to be regularly updated.

Is the service responsive?

Each person's room was personalised to their own needs and requirements. We saw that one person's room had been decorated to resemble their own room within their family home whilst they were undergoing a transition period which was aiming to have them stay at Oxen Bar permanently. Another person had a curtain between their living area and en-suite facility as they did not like having doors in their room. There were many other examples of this throughout the home.

Is the service well-led?

We saw evidence that regular team meetings took place and the staff we spoke to confirmed that meetings happened and that they had a chance to raise any issues or ideas they may have. One member of staff told us, 'Team meetings happen every other Thursday. In-between there is a management meeting where managers and seniors meet up'.

People did not just use words to communicate their needs; they used some signing as well as their preferred communication styles. The home had introduced people to a pictorial system 'Boardmaker' symbols. We observed staff responding respectfully and sensitively to the nonverbal communication and actions of people as well as using Boardmaker symbols.

Assessment of people's need was thorough and person centred, with focus on their individual circumstances and immediate to longer-term needs. Care and support plans placed an emphasis on people's right to be self-determining in how they lived their lives and took risks.

Peoples' capacity to make their wishes known when they did not use words was recorded and appropriate communication methods were used. Where people posed a risk to themselves staff were trained to respond to people's distressed behaviours and reactions.

The right of people to take informed risks had been acknowledged and risk assessments ensured a balance of safety and effectiveness. People were cared for by staff who were well trained and available in appropriate numbers.