Mencap - East Cornwall Support Service

MENCAP – East Cornwall Support Service is a supported living service which provides personal care to people living in 11 settings in the east of Cornwall. Some of the settings had previously been registered as care homes. In supported living, people's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living and this inspection is focused on the quality of care and support people received.

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

People were comfortable with their staff and sought support without hesitation. Relatives told us people were safe and said, “[The staff] have fantastic patience”.

Staff were using PPE correctly and were following current infection prevention and control guidance to help keep people safe. All staff had been provided with additional training in relation to the Covid-19 pandemic and regular testing was underway.

Risks had been appropriately assessed and staff were provided with detailed guidance on the action they must take to ensure people’s safety. Accidents had been investigated to identify areas of improvement or learning and to prevent similar incidents from reoccurring.

The service’s recruitment practices were safe. In most settings there were enough staff employed to meet people’s support needs. One setting was short staffed. Agency and bank staff had been used to ensure safe staffing levels were always achieved. A recruitment drive was underway to address this situation.

Managers and staff had a good understanding of the Mental Capacity Act and people were supported to make meaningful decisions and choices. Restrictive care practices had been reviewed following our last inspection with appropriate input from involved health professionals. People’s care plans included clear guidance for staff on how to meet their support needs if they became upset or anxious.

Staff were sufficiently skilled to meet people’s support needs and their training had been regularly updated.

Staff told us they were well supported and confident any issue they reported to managers would be addressed. The provider had supported the registered managers learning and development. On promotion they had initially allocated the registered manager to an adjacent ‘good rated’ service to give them time to complete additional training and develop their skills.

Quality assurance systems were effective and action plans had been developed to ensure all issues identified were resolved.

The duty of candour was understood by the registered manager. Relatives told us the service communicated with them effectively and had kept them informed throughout the pandemic.

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 Requires Improvement (published 23 December 2019) when breaches of the regulations were identified.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on the 12 and 15 November 2019. Breaches of legal requirements were found. The provider completed an action plan after that inspection to show what they would do and by when to help ensure service users were protected from the risk of abuse and improper treatment and poor governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe, Effective and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all 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.

The ratings from the previous comprehensive inspection for those key questions were not looked at on this occasion or were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for MENCAP – East Cornwall Support Service on our website at www.cqc.org.uk.

MENCAP – East Cornwall Care Service is a supported living service which provides personal care to 34 people living in 11 settings in the east of Cornwall. Some of the settings had previously been registered as care homes. In supported living, people's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living and this inspection is focused on the quality of care and support people received.

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

We found that staffing levels had improved since our previous inspection. There were now enough staff employed to meet people’s support needs and all planned care shifts had been provided. Staff told us, I think it has got better, [staffing] is pretty good at the moment” and the manager said, “We are pretty good with staffing at the moment.” Relatives recognised this improvement and told us, “Staffing has got better, they have more staff.” All necessary recruitment checks had been completed to ensure staff were suitable for work in the care sector.

Medicines were managed safely and there were systems in place to protect people from financial abuse. Staff had received safeguarding training and understood their role in protecting people from all forms of abuse and avoidable harm.

Staff received regular training updates to ensure they had the skills necessary to meet people’s needs and new staff received appropriate induction training. Staff were well supported by their managers and regular supervision and support had been provided.

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. In one setting, we identified there were a number of significant restrictions in place in relation to access to food and snacks. These restrictions had not been recently reviewed and there was a lack of evidence to demonstrate they were necessary and in the person’s best interests. In another setting, one person’s care plan lacked specific guidance on how staff should provide support when they were upset and anxious. These failings meant the service was in breach of the regulations.

People got on well with their support staff who people told us were, “good fun”. Relatives were confident people were well cared for and told us, “Everybody is quite friendly” and “[My relative] has always been well looked after.” Staff ensured people’s dignity was protected and respected people’s decisions and choices.

People’s care plans were accurate and provided staff with enough guidance to enable them to meet people’s needs. Record keeping had improved and information was kept chronologically. A digital incident reporting system was now in use and all incidents that occurred had been appropriately investigated to identify where learning or any improvements that could be made. Daily records showed people had been supported to engage with a variety of activities, to develop their independent living skills and to take on responsibility for tasks and chores.

The service had again experienced significant management restructuring since our last inspection. A new manager with previous registered manager experience had been appointed to lead the service in the month prior to the inspection. Following the inspection, the new manager applied to the commission to become the service’s registered manager.

The new manager was well respected by the staff team who told us, “[The new manager] is brilliant. She gives you confidence, I am hoping we can hang on to her.”

The provider’s quality assurance processes had failed to ensure compliance with the regulations. However, prior to the inspection, the new manager had identified concerns in relation to the delivery of care in the supported living settings where the breach was identified. They had made arrangement for additional support to be provided to these settings and took prompt action in response to the feedback provided at the end of the inspection process.

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

Rating at the last inspection

The last rating for this service was Requires improvement. (Report published 05 November 2018) and there were two breaches of regulation. 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 some improvements had been made. However, the service remained in breach of regulation.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We have found evidence that the provider needs to make improvement. Please see the Effective 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.

As this is the second time the service has been rated requires improvement 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service supports people living in 11 separate houses throughout the east of Cornwall. Some of these houses had previously been registered as care homes. At the time of our inspection the service supported 57 people with learning disabilities, 34 of whom received personal care.

We carried out this announced inspection on 12 and 17 October 2018. At the previous comprehensive inspection in August 2016, the service was rated Good. An additional focused inspection was completed in October 2017 in response to concerns about staffing levels at a particular house. The focused inspection also found that the service was good as the provider had taken appropriate measures to ensure people’s needs were met. Prior to this inspection we again received information of concern in relation to staffing levels at the same house.

At this inspection we found that the service did not currently employ enough staff to provide all planned care and that agency staff were used regularly throughout the service. People told us low staffing levels had impacted on their ability to access the community and records showed people had been unable to participate in activities they enjoyed due to staffing issues. Staff told us, “Staffing levels have been testing. There were only five permanent staff when I started. A lot of agency”, “Agency staff are normally on five out of seven days” and “We are understaffed quite often…It has been pretty short at times.” Staffing records showed and managers accepted that there had been times during the summer when planned staffing levels had not been achieved.

Issues with the quality and accuracy of people’s care plans and associated records were identified throughout the service. People’s care plans did not always accurately reflect the support staff provided. Staff told us, “I know the care plans are not accurate. The information is out of date” and “The paperwork is a mess, it got to the point in July and August where I was having to copy paper work at home to use.” Summary records of incidents had not been completed accurately or logically and did not include details of all incidents that had occurred.

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 did not have a registered manager at the time of our inspection and there had been a number of leadership changes within the service since our last inspection. However, an area manager had been recently appointed and an application for their registration was submitted following our inspection.

Each house where the service provides support was led by a service manager who reported to the area manager. We found there had been a number of changes of service managers since our last inspection. In the house in which concerns had been raised about staffing levels there had been a lack of consistent leadership. Staff did not feel adequately supported and told us, “Continuity is key and this has not been there. I think there has been a horrible perfect storm to destabilise the [house] with the lack of continuity.”

The providers quality assurance system had identified these issues prior to our inspection and significant additional leadership support had been provided to the staff team. Staff reported this support had been a positive impact and told us, “The new managers are brilliant. I can go to them with anything and they will help. They are there for the staff as well which is a big thing” and “Those three ladies are doing an amazing job.” In addition, a new permanent service manager for this house had been appointed in the week prior to our inspection.

Both the new area manager and the new service manager for this house were being supported to complete significant additional training for their new roles. The provider’s regional operations manager was visiting the service regularly to provide additional support and the intention was for the additional management support to remain in place until the new managers had completed this training.

In two of the three houses we visited the service was providing appropriate supported living care. However, in one house which was previously registered as a care home we have made a recommendation. This is because people in this house were not receiving individualised care in line with the visions and values associated with this model of care.

People told us they got on well with their support staff and during our inspection we saw that staff provided support with kindness and at a relaxed pace. Staff spoke warmly of the people the supported and told us, “The guys we support are amazing”.

Staff were sufficiently skilled to meet people care needs and their training had been regularly updated. Records showed staff had received regular supervisions and annual performance appraisals.

Staff understood their role in protecting people from all forms of abuse and understood local safeguarding arrangements. The service’s recruitment procedure were safe and all necessary pre employment checks had been completed.

Staff and managers had a good understanding of the Mental Capacity Act 2005 and staff supported people to make decision and choices throughout our inspection. There were restrictions on some people’s liberty to ensure their safety and these restrictions had been appropriately authorised. However, we identified other individuals who lacked capacity in some areas and who were not free to leave their home without support from staff. We have recommended the service raise these issues with care commissioners, so if necessary authorisation from the court of protection can be sought for all possible deprivations of liberty within this service.

We found that although the service was safely staffed overall, there was a particular staff shortage in the house about which concerns had been reported. At the time of our inspection there were three staff vacancies at this house. We reviewed staff rotas and staff signing in sheets in detail and found that all planned care shifts had been provided. However, records showed that 22% of care shifts had been covered by MENCAP bank staff and 15% by agency staff. The service manager responsible for the house said, “We always make sure there is adequate staff there. No one lone works there during the day.” The registered manager recognised that it could be unsettling for people to be supported by staff who they did not know well and had worked with agency staff providers to ensure that the agency staff had previous experiences of working in the house. Records showed that during recent weeks the same members of agency staff had been used regularly. One full time staff member who had worked at the service for over a year commented, “We have agency staff who have worked here longer than I have.”

Prior to the inspection, managers had begun to address these staffing issues. An action plan had been developed and a targeted recruitment campaign had been launched. Staff told us this had resulted in the appointment of two new staff and that further interviews were planned. This demonstrated that the registered manager was responding appropriately to address and resolve the service’s current staffing issues.

We looked specifically at staffing levels at the time of an incident where a person had been exposed to significant risk. We found that staffing levels had not contributed to this incident. Records showed at the time of the incident the house had been over staffed as two managers were visiting the service to review records. Following the incident, appropriate action was taken to prevent similar events from reoccurring.

This meant that although the service has some staffing issues these had not impacted on the quality of care people received.

There were systems and procedures in place to ensure people received their medication when required. Medicines administration records (MARs) had been completed and were regularly audited. Where medicines errors occurred these were investigated and staff were provided with additional training and support. A recent incident had occurred which highlighted that the service had not made appropriate arrangements for a new medicine to be available to a person at their day centre placement. This incident was being investigated and new procedures were being introduced. These were designed to ensure that in future everyone involved in a person’s care was advised of any significant changes to their individual needs.

All staff had been recruited safely and understood their role in protecting people from abuse and avoidable harm. Risk assessments had been completed and staff had been provided with guidance on how to support people to be as independent as possible.

Relatives were confident that the service met people’s needs and told us, “I think they do the best they can for [Person name]” and “[My relative] is very happy there”. Comments from staff included, “I think people are quite happy. People get to do whatever they want to.”

Staff told us they were well supported by their managers who they described as, “brilliant”. Records showed team meetings were held regularly to ensure staff were aware of any planned changes within the organisation and staff told us, “We had one [a staff meeting] just the other day.” A number of changes had made in the service’s management structure. New managers allocated to individual addresses had been provided with informative handovers from their predecessors. One staff member who’s manager had recently changed commented, “The old manager and the new manager have been popping in together to do a hand over.”

Mencap – East Cornwall Support Service is a domiciliary service that provides care and support to people with a learning disability or a mental health condition in their own homes. It is part of the Royal Mencap Society. The service provides 24 hour supported living services to 14 people. A supported living service is one where people live in their own home and receive care and support to enable them to live independently without reliance on others. People have tenancy agreements with a landlord and receive their care and support from a domiciliary care agency. These services were funded either through Cornwall Council, direct payments or NHS funding.

There was 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.

People using the service had limited verbal communication and were not able to tell us their views about the care and support they received. However, we observed people were relaxed and comfortable with staff, and they received care and support in a way that kept them safe. People had a good relationship with staff and were comfortable with the staff that supported them.

Families, health and social care professionals told us they felt the service was safe. Comments included, “The service is really good” and “They (staff) provide safe care.”

Staff had received training in how to recognise and report abuse. All staff were clear about how to report any concerns and were confident that any allegations made would be fully investigated to help ensure people were protected. There were sufficient numbers of suitably qualified staff to meet the complex needs of people who used the service. The service was flexible and responded to people’s changing needs.

People received care from staff who knew them well, and had the knowledge and skills to meet their needs. Relatives, health and social care professionals spoke well of staff. Comments included, “The staff are absolutely stunning” and “The staff have adapted to meet the continually changing health needs of the people they support very well.”

Staff were knowledgeable about the people they cared for and knew how to recognise if people’s needs changed. Staff were aware of people’s preferences and interests, as well as their health and support needs, which enabled them to provide a personalised service. Staff were kind and compassionate and treated people with dignity and respect.

Managers and staff had a clear understanding of the Mental Capacity Act 2005 (MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. Support plans contained evidence to show people, or their relatives if appropriate, had consented to the planning and delivery of care.

Support plans were individualised and described people's needs across all areas of their lives. They were reviewed and updated regularly and accurately reflected people's current needs. There was evidence to show external health and social care professionals had been involved in care and support planning when appropriate.

Staff supported people to maintain a healthy lifestyle where this was part of their support plan. People were supported by staff with their food shopping and with the preparation and cooking of their meals.

People were supported to access the local community and they took part in activities that they enjoyed and wanted to do. Records showed that people went out most days for walks, shopping and visiting local attractions.

Staff told us there was good communication with the management of the service. Staff said of management, “They (management) are really approachable and easy to talk to” and “They (management) are really supportive.”

There was a positive culture in the service, the management team provided strong leadership and led by example. Management were visible and known to staff and all the people using the service. Staff comments included, “I have just got back from holiday and I was surprised about how I was looking forward to getting back to work. I have never had a job that I have felt like that about before” and “I love my job, I have done it for so long it is part of my life and I never want to leave.”

Relatives said they knew how to make a formal complaint if they needed to but felt that issues would be resolved informally as the management and staff were very approachable.

There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed. Where the service had identified areas that required improvement, actions had been promptly taken to improve the quality of the service provided.