Archived: House 2 Slade House

At the last inspection carried out on 6 and 14 August 2015 we found three breaches of the regulations. Staff had not received supervision and appraisal support, and the provider had failed to notify the Care Quality Commission (CQC) of incidents. The service did not have an effective system in place to assess, monitor and improve the quality and safety of the services provided. At this inspection we aimed to see what measures had been taken to ensure the quality of the service had improved and check if these measures had been effective. The provider had told us that all the corrective actions specified in their action plans would have been implemented by the end of March 2016. During our inspection on 31 August and 1September 2016 we found that not all of the recommended actions had been completed.

At the time of our inspection we noted that the service had not had a registered manager in post for the last two months. The acting manager of the service told us they were not going to become registered. 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.

During this inspection carried out in August 2016 we found risks associated with people’s behaviour, identified in risk summaries were not always followed by appropriate risk assessment and management plans. As a result, the service was unable to ensure people received care and support which kept them safe.

Staff shortages were covered by staff from another location of the same provider. Staff from the other location told us they did not always have the time to familiarise themselves with people’s risk assessments and care plans. As a result, the service failed to ensure that all staff were aware of people's needs.

Checks on fire alarms and emergency lighting had not been completed in accordance with the provider’s policy. However, the clinical manager took immediate action to conduct these checks on the day of the inspection and told us they would continue to do so regularly in the future.

Staff received regular supervisions and appraisals. However, some of the staff members did not always find supervisions meaningful and informative. Appraisal documents were incomplete and failed to identify any goals or areas for staff development.

The service had a complaints procedure in place. However, on the first day of our inspection we noticed the policy was not displayed and provided for people to know how to raise a complaint. People had been given opportunity to participate in a survey on the quality of service, but we were unable to see how their feedback affected service delivery.

The provider failed to put effective systems into effect to assess, monitor and improve the quality and safety of the service. Audits undertaken had not identified the issues relating to a lack of risk assessments, health and safety checks, and appraisal records that we found during the inspection.

Records kept by the service were not always available, accurate or complete. Staff’s morale was very low as staff felt devalued and unsupported by the service provider.

Relatives felt their family members were safe and staff knew how to identify different types of abuse as well as who to report concerns to.

People received their medicines safely and staff had been trained to administer medicines in line with the home’s policies and procedures. Staff’s competence was reviewed regularly to ensure safe administration of medicines.

There were sufficient numbers of staff on duty to meet the needs of people who use the service. The provider had an effective recruitment and selection procedure in place and carried out relevant checks in the course of the recruitment process. The checks included evidence of identity, criminal record checks, references and employment history.

Staff were suitably qualified and competent in their roles and people confirmed this. Staff received appropriate induction and a range of further training.

People were actively involved in making decisions about their care and support needs. People also decided how they wanted to spend their day. Staff demonstrated understanding of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People were supported to maintain a balanced diet and to access healthcare services when required. Staff treated people with dignity, kindness and consideration. People's privacy was respected and people were involved in making day-to-day decisions about the support they received.

Interactions between people and staff were positive. People responded well to staff and felt comfortable and relaxed in the presence of staff members. People were encouraged to take part in the activities they enjoyed and supported to be as independent as possible.

We found multiple breaches of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach of Regulation 18 CQC (Registration) Regulations 2009 You can see what action we have advised the provider to take at the end of this report.

The service required a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The manager named on this report was not the person in day to day control at the time of our inspection, but was the person on our records due to the necessary notifications not being made. There was an interim manager responsible for the day to day running of the home.

One inspector and a specialist advisor carried out this inspection supported by an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of service. We considered our inspection findings to answer the questions we always ask; is the service safe, effective, caring, responsive and well led.

This is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

During the inspection we identified the need for the service to update their registration to ensure appropriate registration to reflect the level of nursing needs required.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found the service was not always safe. There was not always enough qualified, skilled and experienced nursing staff to meet people's needs or to cover sickness and absence. These meant nurses were regularly working very long hours and doing multiple on call duties. The safety of the service was heavily dependent on an unsustainable workload on individuals.

Is the service effective?

The service was effective. We saw that each person benefited from a multi-disciplinary team that included a number of professionals to meet their physical, health and forensic needs. Clear and specialised guidance was used to inform clear support plans for the people that used the service.

People we spoke with felt respected. One person told us, 'the staff are excellent, they are full of respect for us'. Another person told us, 'staff are very respectful of me, I am not always easy to be around, but they do not judge me'. People we spoke with also felt involved. One person told us, 'I am involved with my care planning and have also interviewed new staff'.

Is the service caring?

We found the service was caring. People we spoke with felt cared for. One person told us, 'I love it here. It's really nice and quiet living here, we all have our own keyworker, but all the staff care about us'. Another person told us, 'I can't put into words what these guys [nurses and care staff] have done for me it has changed my life'. A visiting professional told us, 'the staff are totally person centred, fantastic professionals who care deeply about what they do'. We made observations throughout the day that highlighted the warmth and understanding that both nursing and care staff had for the people they support. We experienced a culture of complete acceptance and commitment to the people being supported.

Is the service responsive?

We found the service was responsive. We looked at the file of one person who had complex health needs. This person had a clear support plan in place supported by risk assessments. There were clear guidelines in place that had been written with specialist input. Staff we spoke with understood these people's needs and nurses responsible for this person's care showed an in depth understanding. Records showed that clear and accurate monitoring was being done in line with this person's support plan. This meant people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan and changing needs.

Is the service well-led?

We found the service was not always well led. We saw that the day to date monitoring of the home was robust and effective and the interim manager ran the house efficiently and effectively with the support of their team. We saw that support plans were regularly reviewed. There had been an external peer audit which identified a number of issues. We found that not all these actions had been carried out. The interim manager told us this was due to having to focus more on their nursing tasks. We also saw this issue had been raised to higher management in July 2014 and not acted upon. We also found that arrangements in place for the overall management of the home, away from the day to day running were not clear and people we spoke with above the manager gave conflicting information.

The absence of clarity in this layer of management meant that the level of nursing required at the service had not been recognised and the views of staff essential to the running of the home had not being acted upon. It also meant that despite the service requiring a registered manager, they did not have a registered manager in post. It had not been identified the interim manager had to register. This is a legal requirement of CQC.

We observed a warm rapport and many personalised social interactions between staff and the people who lived in the unit. We spoke with three out of six of these people. Comments we heard were "I prefer being here than anywhere else I have lived." "The staff are great; they know what I need." and "The staff always help me do the things I want to do."

We read care plans of a high standard, particularly for those people who had a physical illness. This was a clear example of practice impacting positively on service delivery and good patient outcomes.

We asked people if they felt safe on the unit. They told us they felt safe and well-cared for. Two of them added that they knew what to do if they had any concerns about their welfare, or that of others with whom they lived.

We did not intend to inspect the cleanliness and infection control of the building. We toured the building and noted that the level of cleanliness was inconsistent in some areas. However, staff had worked hard to maintain a clean environment, despite the minimal level of cleaning support available to them.

We spoke with the staff about the training they had received, and checked these records.

We checked the quality monitoring that had taken place. We found that, whilst a number of checks were in place, there was some evidence of lack of senior management follow-up to matters previously raised by staff on the unit.

We examined records of people, staff, training and service contracts. They were generally of a high standard but we noted some documents were out of date.