Archived: Precious Homes Hertfordshire

About the service

Precious Homes Hertfordshire is a service providing supported living for people living with a learning disability, autism, mental health needs and sensory impairments. The service can support up to 15 people. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided. At the time of the inspection 10 people were being supported with personal care.

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

Right Support

The provider had failed to ensure people’s care plans reflect up to date information and detailing long-term aspirations.

People were supported by staff who had not had adequate inductions, training and skills to support them.

The management team did not ensure people’s medicines were managed in a safe way.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care

People were not always supported by a service that had effective systems in place to report and respond to accidents and incidents. Staff did not always understand how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse, however staff actions did not always show they understood this.

Some people said they did not feel safe with the support they received.

Right Culture

People did not always have assessments in place, to identify risks people faced and how staff should manage these. When risks to people were identified actions to mitigate these were not resolved in a timely manner which put people at risk of harm. Staff were not always knowledgeable about the content of these risk assessments.

People were not supported by staff who understood best practice in relation to supporting people.

The service had a number of changes in management. Relatives and people stated they did not feel the service was well managed. Staff acknowledged there had been changes in management and gave mixed views about how they felt supported.

People's quality of support was not enhanced by the quality assurance system the provider had in place. Actions were not documented, and it was unclear if actions were completed. This had an impact on people's care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published June 2022). At this inspection we found the provider remained in breach of regulations. This service has been in Special Measures since June 2022. During this inspection the provider did not demonstrate that improvements had been made. Therefore, this service remains in Special Measures.

Why we inspected

We received concerns in relation to safeguarding people, medicines management and meeting people’s health and support needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and remains inadequate.

We found was evidence during this inspection that people were at risk of harm from this concern. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Precious Homes Hertfordshire on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to keeping people safe, medicines management and a lack of good leadership and governance systems at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

About the service

Precious Homes Hertfordshire is a service providing personal care to ten people living with a learning disability, autism, mental health needs and sensory impairments at the time of the inspection. The service can support up to 15 people. At the time of the inspection 10 people were being supported with personal care.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

Right Support

The service did not always support people to have the maximum possible choice, control and independence.

The provider failed to ensure staff supported people to take part in activities and pursue their interests in their local area.

People were not always supported to have access to health services in timely manner. Where people were involved in health services, actions identified were not always completed. This meant people did not always receive care that was safe and met their support needs. For example, people were not supported safely with managing their epilepsy.

Systems were not robust to ensure people were supported safely with their medicines. We found examples where people did not receive their medicines when they needed them which resulted in harm. There were other examples where staff did not adhere to PRN (medicines required as and when) protocols.

Right Care

People were not supported by a service that had robust safeguarding systems in place to report and respond to safeguarding incidents We found instances where there were safeguarding concerns, and these were not identified by the staff team or management. Leadership was not effective and did not identify that people were put at risk or subject to potential abuse. Where risks and potential abuse was highlighted to the management team, they failed to implement immediate systems to ensure people were safe.

People did not always receive kind and compassionate care. Not all staff protected and respected people’s privacy and dignity or responded to people individual needs.

The provider failed to ensure staff were appropriately skilled to meet people’s needs and keep them safe.

People had limited opportunities to pursue interests that were tailored to them. The service did not give people opportunities to try new things that enhanced and enriched their lives. People did not receive support that looked at their long-term aspiration.

Right culture

The provider failed to ensure staff received appropriate training and support to understand people’s individual needs and provide enabling support to people. The support people received was not in line with current best practice guidelines. We found evidence of a closed culture in operation.

Staff turnover was high, which meant people did not always receive consistent care from staff who knew them well.

The provider failed to develop effective governance and quality assurance system to assess the quality and safety of the support people received. There was a lack of effective audits and actions being taken when things went wrong. Actions were not always documented, and it was unclear if actions were completed but the provider. This meant improvements were not always made to improve the care people received.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

Rating at last inspection and update

The last rating for this service was requires improvement (published 27 October 2021). 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 the provider remained in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, supporting people with health needs and the overall management of the service. A decision was made for us to inspect and examine those risks.

The inspection was prompted in part by notification of a specific incident, following which a person using the service died. This incident is subject to a safeguarding investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of epilepsy. This inspection examined those risks. We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to keeping people safe with medicines, safe manual handling, supporting to maintain people’s health, providing person centred support, the leadership and governance systems at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by one inspector.

Service and service type

This service provides care and support to people living in a 'supported living' setting, so that they can live as independently as possible. People's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people's personal care and support.

The service had a manager who was going through the process of being registered with the Care Quality Commission. This means the provider was legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service and three relatives about their experience of the care provided. We spoke with nine members of staff including the manager, deputy manager, senior care workers, care workers and the consultant.

We reviewed a range of records. This included two people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with two professionals who regularly visit the service.

Precious Homes Hertfordshire is a service providing personal care to six people living with a learning disability, autism, mental health needs and sensory impairments at the time of the inspection. People have their own separate flats and shared communal areas within the main building. The service can support up to 15 people and is a large detached two storey building.

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

Staff were not using personal protective equipment (PPE) effectively and safely. The provider had access to COVID-19 testing for people using the service and staff, however not all staff were regularly testing. The provider had developed a risk assessment to mitigate these risks, however the staff were not adhering to this.

The provider and management team had not identified the infection prevention control risks to the people living at the service through the quality assurance checks. This put people at increased risk of spreading COVID-19.

Medicines were given to people when they needed them, however discrepancies in the medicine documentation were not always identified. Staff had competency assessments; however, the competency assessments were not always completed by a person skilled to assess competency.

People felt safe with the care they received, and staff were knowledgeable about when to report concerns to safeguard people. Risk assessments highlighted people's individual needs, and professionals were referred to when staff needed input for people. Where things went wrong, this was shared with staff and lessons were learnt and changes implemented.

People felt they were able to express how they wanted to be supported and staff were skilled and

knowledgeable about their role. Staff and relatives felt there had been an increase in the use of agency staff over the last year. There were enough staff to support people at the time of the inspection. The service had recently undergone a change in management, the overall feedback was positive.

The provider ensured that staff went through a recruitment process and all relevant employment checks were completed. People and relatives felt staff were kind and people were happy living at Precious Homes Hertfordshire.

The manager had systems in place to manage complaints. People and relative said they felt

listened to when they raise any concerns. The manager had implemented new ways of working which had been acknowledged by the staff team as a positive thing.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People were able to have choice and control of their day to day decisions and the care plan reflected this. The management team have started to ensure that the core values and ethos of the company was shared with the staff team and embedded in the support they provided.

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 18 September 2019).

Why we inspected

We received concerns in relation to safeguarding concerns raised. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained the same. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

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.

Precious Homes Hertfordshire is a service providing personal care to fifteen people living with a learning disability, autism, mental health needs and sensory impairments at the time of the inspection. People have their own separate flats and shared communal areas within the main building. The service can support up to fifteen people and is a large detached two storey building.

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

People using the service received planned and co-ordinated person-centred support that is appropriate and inclusive for them. The registered manager and staff at Precious Homes Hertfordshire should be congratulated on providing a service that is both stimulating and diverse to people who have a range of complex and challenging needs. The atmosphere throughout this inspection was found to be inclusive, welcoming and professional.

Some people who lived at the home were able to communicate verbally but for people who were unable to speak with us we observed staff support them with a range of communication aids. These included sign language and interpreting people’s body language with regards to meeting their needs and wishes.

People showed they were happy living at Precious Homes Hertfordshire and that they felt safe and comfortable with the staff team. One person said, “This my home and I like that they support my independence and let me take some risks that means I can go out and about, but they always check in on me to see that I am safe.”

Staff were kind and caring and knew each person well. Staff felt they received good support and enjoyed working at the service. Staff had a range of expertise and skills to support people in the way they wanted. Staff received training, supervision, guidance and support so that they could do their job well. Staff respected people’s privacy and dignity and encouraged people’s independence.

Systems were in place to manage risks and keep people safe from avoidable harm. Medication was well managed. Staff followed good practice guidelines to prevent the spread of infection. The staff looked for ways to continually make improvements, worked well with external professionals and ensured that people were part of their local community. People were supported to be as active as possible.

Staff supported people 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.

Audits were carried out to monitor the service and address any improvements required. The registered manager notified the CQC of incidents that they were legally obliged to.

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 24 November 2016).

Why we inspected

This was a planned inspection based on the rating at the last inspection.

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 service did not have 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. However, the manager of the service was at the time of our inspection in the process of registering to become the registered manager.

There were excellent systems in place to keep people safe from harm. Staff had undertaken risk assessments which were regularly reviewed to minimise potential harm to people using the service.

There were appropriate numbers of staff employed to meet people’s needs and provide a safe and effective service. Staff we spoke with were aware of people’s needs, and provided people with person centred care. Staff were well supported to deliver a good service and felt supported by each other and their management team.

The provider had a robust recruitment process in place which ensured that staff were qualified and suitable to work in the home. Staff had undertaken appropriate training and had received regular supervision and an annual appraisal, which enabled them to meet people’s needs. Medicines were administered safely by staff who had received training. Staff cared for people in a friendly and caring manner and knew how to communicate effectively with people. Staff supported people well and spent time with them.

People were supported to make decisions for themselves and encouraged to be as independent as possible. Where people were not able to make decisions for themselves, the provider had a system in place to ensure that, best interest decisions were made on their behalf which involved advocates and other professionals. People’s choices were respected and we saw evidence that people, relatives and/or other professionals were involved in planning the support people required. People were supported to eat and drink well and to access healthcare services when required.

The provider had a system in place to ensure that complaints were recorded and responded to in a timely manner as well as an effective system to monitor the quality of the service they provided.

The summary is based on what we found at the inspection by looking at records and what people told us about their experiences of the service. We spoke with seven people using the service, three relatives, eight support workers, three external health and social care professionals and three management representatives.

The inspection was undertaken by one inspector over two days and included visiting people receiving support in their own flats, contacting people by telephone and looking at records and systems at the provider's offices.

Is the service safe?

People told us they felt safe. Safeguarding vulnerable adults from abuse procedures were robust and staff understood how to safeguard people they cared for. Systems were in place to make sure that managers and staff learnt from events such as accidents, incidents, complaints and whistleblowing investigations. This reduced the risks to people and helped the service to continually improve.

The service had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). DoLS are put into place to ensure that people's human rights are protected should their liberty be restricted in any way. Staff had been trained to understand when an application should be made and knew how to submit one.

The service protected people against the risks associated with the unsafe use and management of medicines.

Staff knew about risk management plans and showed us examples where they had followed them. People were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.

People who used the service told us they were treated with dignity and respect. Comments included, 'I am always asked about what choices I want to make and I am always encouraged to make my own decisions.'

The service had sufficient staff to deliver care and support to adequately meet people's needs. This meant the service had taken all reasonable steps to ensure people were protected from risk of harm. Sufficient, suitable staff were recruited appropriately to work with vulnerable people.

Is the service effective?

This service was found to be effective because we saw people were supported in a way that suited their personal needs and maintained their quality of life. People and their relatives told us they had been included in all decisions relating to the care they had received.

It was clear from our observations and from speaking with people and support workers they had a good understanding of people's care and support needs and they knew them well.

People's health and care needs were assessed and their care plans and assessments were reviewed weekly. This showed people were having care delivered effectively in accordance with their assessed needs.

Is the service caring?

We found the service was caring. People were supported by support workers who were understanding and sensitive to their needs. We were told by people and their relatives that support workers met their care needs in a way that was appropriate for them.

All of the people we spoke with were complimentary about the care provided by the service. People we spoke with gave examples of support workers going out of their way to meet their needs. For example, one person told us, 'I never imagined I would have the ability to live in my own flat. My support workers have helped my confidence so much.'

Is the service responsive?

We found the service was responsive because the service had appropriate systems in place for gathering, recording and evaluating information about the quality and safety of the overall service.

Systems were in place to make sure the provider learnt from events such as accidents and incidents and this meant that risks were minimised. The service took account of complaints and comments to improve the service. We saw the complaints procedure which guided people on who to contact if they wanted to make a complaint. People we spoke with told us they knew how to make a complaint and they felt the service would be responsive if they raised a concern. People were assured the service acted upon complaints, which were investigated and action taken as necessary.

We found people's personal care records were accurate and fit for purpose.

Is the service well-led?

We found the service was well led. Support workers and people who used the service told us they found the new manager very approachable. Comments included, "Our manager is very approachable" and 'I am very well supported, our manager is always available for advice and support.'

Support workers told us they were clear about their roles and responsibilities. They demonstrated a good understanding of the ethos of the service. This helped to ensure people received a good quality service at all times.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

We found that the service was meeting all areas.

If you wish to see the evidence supporting our summary please read the full report.

You can see our judgements on the front page of this report.

Is the service caring?

We found that the people were cared for in their own homes and that care was planned in conjunction with the person who had as full as input into their care as their condition allowed. The staff were caring and kind. We observed interaction between staff and the people they cared for and saw that a relationship had developed between them. There was sufficient staff on duty to ensure that the staff had sufficient time to spend with the people to ensure their care was person centred and delivered in a manner that promoted their dignity.

Is the service responsive?

We were told by the people who used the service that staff endeavour to meet their needs in a safe manner. Some people who were using the service were preparing for a more independent life in the community. We were told that the staff encouraged them to develop skills to prepare for a more independent manner of living. The staff encouraged and trained the person to adopt living skills that would keep them safe.

We were told that staff made arrangement to encourage and facilitate the people to have a good social life and to accommodate their friends and family.

Is the service safe?

We saw that there was sufficiently appropriately recruited staff to meet the needs and wishes of the people. We saw that staff were aware of risk management and the balance between promoting independence and keeping people safe. Staff had been trained on positive risk management where people were encouraged to take reasonable risks so that their confidence and abilities improved. Staff had been trained to recognise and respond to signs and allegations of abuse. Medication was administered as prescribed.

Is the service effective?

Discussions with people and a review of care plans of four people showed that people or their families had been involved in establishing what care they needed and how they wanted it delivered. We saw that care plans gave detailed directions to staff to ensure the care they gave was effective this included how to interpret people's body language. People had access to the local community, those who wanted to were encouraged and facilitated to have a social life in the community.

Is the service well led?

The service was managed in the best interests of the people who used the service. Staff told us that the manager was available to them should they need assistance. The manager supervised the staff while they were delivering care and if there were issues they were addressed straight away. Staff were well trained in all aspects of care delivery. The people told us that the manager was always there should they need anything. They said that the manager was easy to talk to and they were able to tell them if there was a problem.

There were systems in place to ensure the safety and welfare of the people. Care plans and risk assessments were reviewed regularly.

One person told us "I am settled here" and another said "I am having a party for my birthday".

Care plans were being updated and reviewed on a regular basis but one person did not have a care plan or appropriate risk assessments in place to manage the potential risks when they were away from the service.

We saw that the provider had made improvements in the management of medicines across the service, but there were still some concerns about the robustness of the systems at Treow House, that could have posed risks to the people there.

During our visit to Treow house we observed people who used the service appeared positive about the care and support they received from staff. During our inspection we saw that people were encouraged to be independent in all aspects of their life. For example: with personal care, shopping and domestic tasks.

We observed that staff generally engaged positively with people. One person told us, 'I had issues when I arrived here and did not like it but I have settled in well now and think that staff have supported me well.' Another person communicated that they were happy by smiling and told us they were looking forward to their holiday.

Likewise when we visited Oster house we observed positive staff engagement and people who used the service appeared happy and relaxed in their surroundings.

Prior to this inspection, we had been made aware that the local authority had some concerns about the care and welfare of people at Treow House. Although we did not observe any concerns on the day of our visit. There had been some serious incidents that involved people at the project.