Fir Trees House

About the service

Fir Trees House is a residential care home providing personal care to five people with mental health needs and/or learning disabilities and a variety of associated health and support needs at the time of the inspection. People live in one large house. The service can support up to seven people.

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

Right Support

People and relatives told us staff did not always support people to have a fulfilling and meaningful everyday life. Support was safety focused, one example being people could only access the kitchen with staff support and this was kept locked with a sign on the door reminding people to not enter without staff. Some staff spoke of health and safety concerns about people using the kitchen. Support plans did not always include guidance for staff about positive risk management to encourage skills development in line with peoples wishes. The registered manager and provider were in the process of reviewing support plans to include consideration of positive risk taking with a focus on people’s strengths and promote what they could do. Staff worked with people to plan for when they experienced periods of distress and demonstrated an awareness of individual interventions and techniques to support people with this. People had a choice about their living environment and were able to personalise their rooms.

Right Care

Staff promoted equality and diversity in their support for people. They understood people’s cultural needs and provided culturally appropriate care. Staff consistently demonstrated their awareness of people’s cultural needs this included dietary choices and terms of address. People received kind and compassionate care. We observed staff providing support in a personalised sensitive manner which demonstrated genuine regard for people. Relatives and friends spoke highly of the staff, one said, “So far they have been excellent.” Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs. The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

Right culture

People did not always lead inclusive and empowered lives. The registered manager had recently joined the service and had identified the need to ensure the ethos, values, attitudes and behaviours of the management and staff always focused on people’s needs and aspirations. They were working with people and staff to improve in this area. Relatives and friends had spoken positively about the influence of the new registered manager and expressed their hopes to be informed and involved with reviews with people. Staff placed people’s wishes, needs and rights at the heart of everything they did. People told us they were happy living at Fir Trees House and the staff knew how to support them when they were upset and were kind.

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 23 October 2018)

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support right care right culture. The inspection was prompted in part due to concerns received about safeguarding. A decision was made for us to inspect and examine those risks

We have found evidence that the provider needs to make improvements. Please see the effective and well led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

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 person centred care at this inspection.

Please see the action we have told the provider to take at the end of this 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.

Fir Trees House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Fir Trees House provides care for up to seven people with learning disabilities or mental health support needs. At the time of our inspection there were four people living at Fir Trees House.

The care service has been 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. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

There was no registered manager in post. The previous registered manager had left the service in May 2018. 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. A new manager had been appointed and supported us during the inspection. They informed us they had applied to register with the CQC and our records confirmed this was the case.

Sufficient numbers of staff were available to support people and robust recruitment processes were in place. Staff had completed safeguarding training and understood their role in protecting people from the risk of harm. Risks to people were identified and managed in a way which kept people safe whilst supporting them to take reasonable risks to promote their independence. People’s medicines were stored administered and recorded safely. Health and safety checks were completed and a contingency plan was in place to ensure people would continue to receive their support in the event of an emergency. People lived in a clean and well-maintained environment and safe infection control practices were followed.

The provider had systems in place to ensure people’s needs and compatibility to live with others were considered prior to someone moving into the service. People were supported by staff who received on-going training and supervision to support them in their role. The principles of the MCA were followed to ensure people’s rights were protected. People received support to access healthcare services. A choice of food and drinks were available to people.

People liked the staff supporting them and staff knew people well. There was a positive and relaxed atmosphere and people and staff communicated well. People's privacy and dignity was respected and people were supported to practice their religious beliefs. Visitors were made to feel welcome to the service and people were supported to maintain relationships with those who were important to them.

People and staff were involved in developing and reviewing care plans. Care plans were detailed and reflective of the support people required. However, we found that information regarding the support people wanted at the end of their life had not been discussed or incorporated into people’s care records. We have made a recommendation regarding this. People told us that staff responded to requests for support and staff understood people’s needs and personalities. People were encouraged to participate in activities both when spending time at home and within the local community. The provider had a complaints policy in place and people were aware of how to raise concerns.

People were supported by staff that understood their roles, responsibilities and the ethos of the organisation. Systems were in place to monitor the quality of the care people received and people and staff were able to voice their opinions regarding the service. Records were up to date and securely stored.

The inspection took place on 17 August 2017 and was unannounced.

There was no registered manager in post at the time of our inspection. 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.

Since our last inspection a new manager had been appointed and was present on the day of the inspection. The manager told us they were in the process of registering with the Care Quality Commission and our records confirmed this

At our previous inspections in November 2016 and May 2017 we found concerns regarding the governance of the service, risks to people not being adequately assessed and safeguarding concerns not being reported to the local authority. In addition we identified that staff training was not effective in supporting staff in their roles and people’s needs were not being responded to in a person centred manner. At our inspection in May 2017 nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. Following this inspection the provider sent an action plan detailing the action they proposed to take to ensure these breaches were met. At this inspection we found that significant improvements had been made. People were now receiving care that met their needs and no breaches of legislation were identified. We will continue to monitor the service to ensure that systems in place continue to develop and are embedded into practice.

There were sufficient staff deployed and staff worked flexibly to meet people’s individual needs. Safe recruitment practices were followed to help ensure that staff employed were suitable to work at the service. Staff received training and support that provided them with the knowledge and skills required to support people in an effective, person centred manner. Staff told us they felt supported by the management of the service and records showed they received regular supervision to monitor their performance.

Staff had received training in safeguarding people from abuse and understood their responsibilities in this area. Where safeguarding concerns were identified these were shared with the local authority and appropriately investigated. Risks to people’s safety were assessed and control measures implemented to keep people safe. Staff were aware of triggers to people’s anxiety and offered support to help people remain calm. Accidents and incidents were reported and monitored to ensure action was taken to prevent them happening again. The property had recently been refurbished and any maintenance concerns addressed. A contingency plan was in place to ensure people would continue to receive a safe service in the event of an emergency.

People received their medicines as prescribed and safe medicines practices were followed. People had access to healthcare professionals and received support to plan and attend appointments. Regular monitoring of people’s health needs was completed including measuring people’s weight. People had a choice of foods and were involved in menu design and meal preparation. People’s legal rights were protected as the principles of the Mental Capacity Act 2005 were followed.

People were supported by staff who treated them with respect and understood the importance of developing and maintaining people’s independence. We observed people were actively involved in the running of their home. People were supported to maintain relationships with those important to them. People’s religious and cultural needs were respected. Staff were knowledgeable about the people they supported and knew their likes, dislikes and interests. Care plans had been developed which were person centred and described people’s preferences, choices and how they wanted their care to be provided. People were provided with a range of activities to pursue their individual interests and hobbies. The atmosphere was positive and lively and people and staff interacted well with each other.

Audit processes were in place to monitor the quality of service being delivered. Where actions were identified these were completed in a timely manner. A comprehensive action plan had been developed to monitor the continuous improvement of the service. A complaints policy was in place and people told us they would feel confident in raising concerns. There was a positive culture and staff were clear about their responsibilities in providing person centred care.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The inspection took place on 10 May 2017 and was unannounced.

There was no 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. A manager had been in post for seven months and supported us during our inspection. A manager was in post and supported us on the day of the inspection.

At our last inspection in November 2016 we found that there had been limited improvements made in the care and support people received. However there were continued concerns regarding the governance of the service, risks to people not being adequately assessed, safeguarding concerns not being reported to the local authority, staff training not being effective in supporting them in their role and people’s needs were not being responded to in a person centred manner.

At this inspection we found that there were on-going concerns about the care and support people received. Risks to people’s safety and well-being were not always identified and addressed. Staff were not aware of how they should support people with their behaviours and there was an atmosphere of tension within the service. Staff did not demonstrate an understanding of their responsibility to safeguard people from abuse and incidents of verbal abuse had not been reported to the local authority. Accidents and incidents were not effectively monitored to mitigate the risk of them reoccurring. Medicines were not always administered safely although medicines were stored and monitored appropriately. Maintenance concerns were not addressed in a timely manner and not all areas of the service were cleaned to a satisfactory standard.

Sufficient skilled staff were not effectively deployed. Two people living at the service had been assessed as requiring one to one support for periods of the day although this was not always provided. Staff spent their time performing tasks rather than actively engaging with people. The manager had not completed a dependency tool to assess the number of staff required to meet people’s needs. Staff did not receive the training they required to complete their role. Not all staff had completed training in supporting people who may display behaviours which challenge and not all mandatory training had been completed. Staff told us they received regular supervision and felt supported by the manager. However, staff expressed concerns regarding the support they received from the provider. Recruitment checks were not fully completed to ensure that staff employed were suitable to work in the service.

People’s rights were not always protected as the framework of the Mental Capacity Act 2005 was not followed. People’s healthcare needs were not always met and guidance from professionals was not always followed. People did not receive person centred support in line with their needs. Support plans lacked detail and did not provide guidance to staff on how to support people well. There was a lack of activities provided to people and people were not supported to follow their interests.

There was a lack of positive interaction from staff and people were not always treated with kindness. Staff did not acknowledge or demonstrate understanding of the impact that repeated incidents of shouting and abusive behaviour had on people’s well-being. People were not supported to develop their independent living skills. Staff were not always respectful of people’s home. Staff were observed to use an exasperated tone with people and on one occasion a staff member was heard to swear at one person.

There was a lack of managerial oversight of the service. There was no registered manager in post and the provider had not taken adequate steps to ensure this condition of their registration was met. There was a lack of communication and collaborative working between the manager and provider to ensure that the required improvements were implemented. There was a lack of quality assurance process and audits completed lacked detail. Records were not up to date and lacked the detail required to ensure people received consistent care. Feedback received on the quality of the service was not used to ensure improvements were made.

People told us they enjoyed the meals provided and were able to make choices about their food. Visitors to the service told us they were made to feel welcome and staff were friendly. There was a complaints policy in place and people and relatives told us they would know how to raise concerns. The provider had developed a contingency plan to ensure people’s care would continue during an emergency.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

During the inspection we found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 12 November 2016 and was unannounced.

There was no 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. A manager had been in post for three months and supported us during our inspection. Records showed that the manager had begun the process of registration with the CQC.

At our last inspection in October 2015 we found breaches of the legal requirements in relation to risks to people’s safety not being adequately addressed, the requirements of the Mental Capacity Act 2005 not being followed and the lack of management oversight of the service.. The provider wrote to us to inform us of the action they planned to take to address the concerns. This comprehensive inspection was conducted to check that the action had been taken by the provider and that they were now meeting their legal requirements. We found that the provider had made improvements in some areas which had led to positive changes for people. However, the provider had failed to address a number of issues in relation to people’s safety and well-being, protecting people’s rights and the management oversight of the service.

There was a lack of management oversight of the service. Quality audits were not effective in identifying shortfalls in the service and feedback received was not always acted upon. The manager had been in post for three months. Due to vacancies within the senior management team they were not receiving effective support during their probationary period.

Risk assessments were not completed comprehensively and did not identify control measures to minimise the risks to people safety and well-being. A number of people living at Fir Tree Road displayed behaviours that challenged and records showed there were times people had felt unsafe. Where safeguarding concerns had been recorded these had not been forwarded to the local authority safeguarding team. Incident records were not analysed to identify what actions were required to minimise the risk of reoccurrence.

Staff did not receive effective training to support them in their role and had not put their training into practice in regards to safeguarding and compliance with the Mental Capacity Act 2005. Since the last inspection staffing levels had reduced which meant people were not always offered support flexibly. We have made a recommendation regarding this.

People’s legal rights were not always protected as the staff were not working in line with The MCA and DoLS legislation. Whilst some people’s care plans contained information regarding the likes and dislikes other people’s plans lacked detail and guidance for staff.

A number of activities were provided for people although staff told us they felt more could be achieved. We have made a recommendation regarding developing the opportunities available to people. A number of people living at the service were able to plan their own activities and daily routines.

Medicines were managed safely and staff understood the process involved in supporting people with their medicines. Maintenance of the premises and equipment were monitored and health and safety checks of the environment were completed. There was a contingency plan in place to ensure that people would continue to receive a service in the event the building could not be used.

Safe recruitment practices had been followed to ensure that the staff employed were of a suitable character to provide people with care and support. Staff told us they felt supported by the manager and records showed that regular supervision of staff was undertaken.

People's healthcare needs were monitored by staff and they were supported to access relevant health professionals in a timely manner when they needed to. People told us that they enjoyed the food provided and we observed people were involved in the planning and preparation of meals.

People were supported by staff who treated them with kindness. People told us they felt comfortable speaking to staff and we observed positive and caring interactions during the inspection. People were supported to develop their independent living skills and were actively involved in domestic tasks. People were supported to maintain relationships with family and other people who were important to them.

People and staff were involved in the running of the service. Regular meetings were held to gain feedback and people told us they felt listened to. There was a complaints procedure in place and clearly displayed. People told us they would feel comfortable in raising any concerns.