Riverview

We found the following examples of good practice.

Procedures were in place to ensure the risk of any visitors to the service introducing infection were minimised. This included taking peoples temperature, supplying personal protective equipment (PPE) and using an external door to ensure people washed their hands before entering the building.

The nature of the building and staffing levels ensured people were encouraged to socially distance. For example, if a person wanted to use the communal kitchen the staff member supporting them would first ensure nobody else was using it.

Procedures were in place to admit people to the home safely, including adherence to an isolation period and cohorting a staff team to work exclusively with that person.

Staff were wearing PPE appropriately and efforts had been made to support people to cope with staff wearing masks. One person had initially found this difficult, desensitisation techniques such as leaving masks around the environment had been used and were successful in helping this person adjust and accept staff wearing masks.

Programmes for regular testing for staff and people were in place. Where people declined to be tested, information was provided, and the offer of a test made again each time they were due. Peoples temperatures were being taken twice daily.

People were supported to access the community and adjustments were made to minimise the risks of them doing so. For example, one person liked to walk to the seafront and buy a drink, instead they were supported to take a drink with them to enjoy so they did not need to go into a shop. Another person was supported to buy a takeaway and eat it on the sea front instead of their usual pub meal.

People were supported to maintain contact with loved ones using a variety of technology, and visiting was assessed on an individual basis.

There were comprehensive policies and operating procedures in place. The provider issued regular health and safety updates. For example, during the hot weather guidance around keeping cool and using fans was issued.

The service was a large home, bigger than most domestic style properties. Riverview is registered to provide accommodation and personal care for up to nine young adults with learning disabilities, and at the time of our inspection there were nine people living there. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the layout of the service. This consisted of six self-contained flats and two rooms.

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 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 service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, 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.

The Secretary of State has asked the Care Quality Commission (CQC) to conduct a thematic review and to make recommendations about the use of restrictive interventions in settings that provide care for people with or who might have mental health problems, learning disabilities and/or autism. Thematic reviews look in-depth at specific issues concerning quality of care across the health and social care sectors. They expand our understanding of both good and poor practice and of the potential drivers of improvement.

As part of thematic review, we carried out a survey with the registered manager at this inspection. This considered whether the service used any restrictive intervention practices (restraint, seclusion and segregation) when supporting people. In 2017 Riverview won a national best practice award for using innovative ways to reduce physical intervention and increase positive outcomes for people. The service used a PBS (positive behaviour support) approach which recognised the impact the environment and negativity had on people’s behaviour, and enabled staff to build a bespoke personalised environment for the individuals they were supporting. This had greatly reduced the stress and anxiety levels of people living at Riverview. Incidences of behaviour that challenges had reduced, and PRN (as and when required) medication had been required on just one occasion in the previous 12 months. A thorough analysis and investigation was completed if things went wrong, and any learning used to further reduce the risk of harm to people.

Without exception, people were supported to achieve their goals. The staff and management team were creative, committed and determined to support people to live independent lives and challenge the barriers to people with autism. The service promoted positive outcomes for people through positive risk taking. As a consequence, people were engaging with their families and local community, and achieving goals which had previously been unthinkable for them.

People were valued and placed at the centre of the service. Staff promoted their privacy and dignity, enabling them to make choices and have as much control and independence as possible. The service used a variety of methods to facilitate this including supporting people with communication, assistive technology, providing information in an accessible format, a consistent staff team who knew people extremely well and one to one ‘Your Voice ‘meetings.

The management team and staff genuinely cared for the people they were supporting. They advocated for them at every opportunity. They were there for them and their families when they were in hospital or at the end of their lives. They ensured people were able to maintain contact with their families, even when they were hundreds of miles away, using Skype so that they could see them.

Staff knew people extremely well and were skilled at responding to their needs. Training was of a high quality and gave staff the skills and knowledge they needed to support people safely and effectively. Their learning was continually reviewed and reflected on, so that they could understand how it linked with their practice. The management team were supported by the provider to continue their own professional development, using their learning to improve their leadership skills and develop the staff team.

The service was exceptionally well led. The providers ethos was strongly promoted and modelled by the management team. They demonstrated a commitment to valuing people as individuals, supporting them to meet their full potential and achieve their individual aspirations. The management team demonstrated an open and transparent management style and were fully engaged with people and staff at the service. Robust quality assurance systems ensured the continued quality and safety of the service and continued to drive improvement. This ultimately improved the outcomes for people living at Riverview.

Since the last inspection, they had continued to move forward and develop what was an already outstanding service.

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 outstanding (published 3 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor the service until we return to visit in line with our re-inspection programme. If any concerning information is received, we may inspect sooner.

Riverview is registered to provide care and accommodation for up to 10 people. On the day of the inspection eight people were living at the service. Riverview provides care for adults with a learning disability. The service particularly specialises in providing care for people with Autistic Spectrum Disorders.

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.

The service provided outstanding care and support to people enabling them to live fulfilled and meaningful lives. People were unable to tell us verbally about their experiences of the home, however, the difference the service was making to people’s lives was visible. People who had previously been restricted were now being supported in a different way, which gave them more freedom and an enhanced quality of life. We heard many examples of how people’s lives had changed for the better and about how many new opportunities they now had.

The home environment was tailored to individual needs and to help people to be as independent as possible. People who wanted or needed their own separate space were provided with facilities, which catered to their needs and were totally separate to the communal parts of the home. People who wanted the company of others were able to spend time in the communal areas with the right balance of staff support to keep them safe, whilst also allowing for a homely and relaxed environment.

Relatives and other agencies were without exception, extremely positive about the service and the care people received. Relatives told us about how people had moved from services where they had not been able to go out and had needed medicines to keep them calm and safe. We were told that since moving to Riverview people’s lives had changed and due to the care and the skills of the staff team people had progressed, experienced new opportunities and had more independence. Comments included, “ They used to be in a sparse room, now they have personal belongings, they never went out, now they go into town to the local coffee shop and people know them”, and “ The change has been dramatic, [….] eyes used to look sad, now they are smiling and bright, it is wonderful”.

Other agencies were very positive about the staff team and leadership of the service. We were told that staff embraced ideas and worked hard to ensure people were able to do the things they wanted. The overall view of other agencies we spoke with was that despite the complex needs of people they supported the service had managed to deliver excellent quality personalised care within a residential setting.

There was an extremely positive culture within the service. The management team provided strong leadership and led by example. The registered manager had clear visions, values and enthusiasm about how they wished the service to be provided and these values were shared with the whole staff team. Staff had clearly adopted the same ethos and enthusiasm and this showed in the way they cared for people. Individualised care was central to the home’s philosophy and people were placed at the heart of the service. Staff demonstrated they understood and practiced this by talking to us about how they met people’s support needs. Staff spoke with commitment and used words like, “Individual” and “Independence” when they talked about people they supported.

Staff were highly motivated and inspired to offer kind and compassionate care and support. All the staff said they enjoyed their work and loved seeing people progress. We saw a number of examples of progress people had made since moving into the home. We saw how personalised care and a positive approach to managing behaviour had resulted in people having increased opportunities and enhanced well-being. Relatives said, “We never would have thought it was possible, they go out now and we even enjoy a meal together, that had never happened before”.

People were supported to express their views and have their voice heard. Staff were creative and used innovative methods to help people express their views and understand what was happening around them. One person had a personal timer to help them understand what was happening now and later. This helped reduce their anxiety and have control over their routines and lifestyle. Your voice meetings were held with people and information was available in a range of formats about issues relating to people’s care and the service. Pictures had been taken of builders working in the service and a contract drawn up with people so they could have their say on how they wanted these workers to behave when they were working in their home.

There were sufficient numbers of skilled staff to meet people’s needs and to keep them safe. Staffing levels were regularly reviewed and planned in line with people’s daily routines to help ensure they were able to do the things they needed and wanted. The provider had clear and effective recruitment procedures in place and carried out checks when they employed staff to help ensure people were safe. Relatives said they believed and trusted that people were safe, “Comments included, “The staff are so good at being consistent, before [….] came here, it was awful, they were very distressed, we worried for their safety, now we can sleep at night”. People were protected by staff who knew how to recognise signs of possible abuse. Staff said reported signs of abuse or poor practice would be taken seriously and investigated thoroughly.

Staff were well trained and said training was relevant to their role and kept updated. The registered manager was passionate about developing the skills of the staff team, and had a commitment to people and their relatives about what the service had said they would deliver. A relative said, “Everything they told us they would do, they have done, we have not experienced this in other services”.

People had their medicines managed safely, and received their medicines in a way they chose and preferred. Staff undertook training and understood the importance of the safe administration of medicines. Staff said they undertook regular competency checks to test their knowledge and to help ensure their skills were up to date and in line with best practice.

Management and staff understood their role with regards to the Mental Capacity Act (2005) and the associated Deprivation of Liberty Safeguards (DoLS). Applications had been made and advice sought when necessary to help safeguard people and protect their human rights. When people were unable to consent to their care or support, or were unable to make decisions, discussions took place with relatives, other agencies and staff in the home to help ensure decisions were made in their best interest.

Staff worked really hard to enable people tocommunicate what they wanted and to reduce the need for behaviours that limited their opportunities. Behaviour management plans were in place for people to help staff understand the behaviour people may present, to recognise the triggers and signs and to safely manage the behaviours if they occurred. Staff had a good understanding of people’s behaviours and the guidelines in place to prevent behaviours from escalating. Staff said the number of incidents had significantly reduced for some people and they felt this was due to staff knowledge, training and consistency of care provided.

People’s health and dietary needs were well met. People were supported to maintain good health and when required had access to a range of healthcare services. Annual health checks were arranged and ‘hospital passports’ were in place to support any admissions to hospital. Hospital passports contained important information about the person to help ensure their needs were appropriately met if they should require an admission to hospital or another healthcare facility. People’s health needs were monitored closely and any concerns or changes were dealt with promptly.

People’s privacy was respected and staff provided dignified and compassionate end of life care. Extracts from thank-you cards sent to the staff included, ‘Thank-you for the love, care and unending support, you made […] comfortable, visited on your days off. You are a fantastic, caring and selfless group of people’. We also read feedback sent to the home by the local Hospice which included, ‘Very impressed by the care and compassion shown by the team’.

The service was very responsive to people’s specific and diverse needs. Other agencies told us they were always impressed with the creative and personalised care provided to people. Support plans were extremely clear and detailed, providing staff with step- by- step guidelines about people’s needs, preferences and daily routines. All the staff we spoke with had a very good knowledge of the needs of people they supported.

All the people who lived at Riverview were supported to lead a full and active lifestyle. We saw a number of examples of how people’s opportunities had increased in the time they had lived in the home. A relative said, “ It’s amazing, they do so much now” and “ The staff have been so innovative, [….] had no concept of time, the staff thought of ways of helping [….] understand here, now and next, they have so much more control now over the things they are doing”.

Systems were in place to deal promptly and appropriately with any complaints or concerns raised about the service. The provider promoted the ethos of honesty, learning from mistakes and admitted when things had gone wrong. This reflected the requirements of the Duty of Candour. The Duty of Candour i

Below is a summary of what we found. The summary is based on our observations, on records we looked at and on the views of people we spoke with. If you want to see the evidence that supports our summary please read the full report.

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?

There were systems in place to ensure all staff had received safeguarding training and were aware of reporting processes. There were systems in place to ensure risks to people's safety and welfare were identified and risk assessments were put in place to minimise such risks. There were systems in place to ensure appropriate procedures were in place in the event of a foreseeable emergency. Relatives we spoke with told us 'I feel they can meet my relative's needs', 'If there was a problem they would be straight to A&E' and 'I have no concerns with my relative's care. I feel they're very well looked after.'

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes.

There was a relevant policy in place and the Registered Manager had experience in making and submitting applications. The Registered Manager was aware of upcoming changes to the legislation and had taken steps to anticipate these and gain further knowledge and advice.

Is the service effective?

People's family members we spoke with told us staff understood the needs of their relatives. It was clear from our observations and from speaking with relatives that staff had a good understanding of people's care and support needs and that they knew them well. We saw that staff knew how to respond to people's behaviours and bring out the best in them. Relatives told us 'They are doing everything they can to make my relative happy', 'The staff know my relative well. They try to help them be mobile and independent.' And 'All the staff are very aware of my relative's disabilities and have found ways of communicating with them. They are clued in to what they prefer.'

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed understanding, patience and gave encouragement when supporting people. We saw that people were able to do things at their own pace and were not rushed. People's routines and preferences were respected and personalised activities were organised for people to participate in. Relatives we spoke with said 'They ask my relative what they want to do, if they refuse that is respected. They don't push anything on them', 'The staff are excellent and very calm with my relative.' And 'The staff are very caring.'

Is the service responsive?

Records showed that people's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. There were highly detailed records of people's preferred routines and how staff were to respect these. We saw records of the home responding to people's changing needs and seeking advice and guidance from relevant healthcare professionals.

Is the service well-led?

Quality assurance processes were in place in the home. Relatives we spoke with told us they had been regularly asked for feedback and their opinions had been sought. We saw that several audits and internal inspections had been carried out and that any issues identified had been acted upon. Staff told us they were regularly asked for their feedback and felt their opinions were listened to and used to improve the home.

We visited the service on 19 and 28 November 2013. After our first visit on 19 November we received concerning information. This related to the admission of an individual without risk assessments. This meant that people were at risk. At our second visit we found that the person had been admitted without risk assessments having been fully completed but they had since been completed.

We saw that care workers respected people's privacy. Care plans contained useful information that helped care workers look at the individual in a person centred way. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We saw information that showed there were effective recruitment procedures in place. For example, each file contained two references. We found that care workers had not received regular supervision and appraisals.

We found no evidence of an effective quality assurance system at Riverview. We saw some information that related to an action plan for Tower House, but could not be assured that the information related to Riverview.