Fouracres Care Services

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Fouracres Care Services is a care home providing accommodation and personal care for up to 6 people. The care home accommodates people who have a learning disability and older people. At the time of the inspection there were 6 people living in the home.

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

Right Support

People were not supported to have maximum choice and control of their lives. Staff did not support them in the least restrictive way possible or in their best interests. The policies and systems in the service did not support this practice. There were restrictions on people’s rights and freedom. We found people were expected to be in their bedrooms by 8.00pm and stay there until 8.00am. The provider could not demonstrate any rationale for this. The kitchen was locked and people were unable to access food for the rest of the evening until 8.00am the following morning. Staff on duty at night were on call but able to sleep. It was not clear how people could alert staff if they needed support or wanted to eat or drink at night.

People could not always choose how they wanted to spend their time. People had very limited opportunities to leave the home and take part in activities in the community. There was a lack of activities to take part in within the home and no opportunity to take part in any leisure activities in the evening. People did not receive support or opportunity to live an ordinary meaningful life.

Right Care

There were some positive caring interactions where staff were kind and supportive to people.

Staff had not been provided with any training in understanding what a learning disability is and how to and interact with people with a learning disability or autistic people.

There was no written assessment of people’s care needs at night. Some people required support with continence. As there were no routine checks on people during the night it is possible that people could be left requiring support with personal care for up to 12 hours during the night. There were no call bells for people to get help from staff if they require personal care or if they were unwell. Staff relied on people shouting out to wake them up. The provider did not recognise the risks and poor quality of this practice and only took action to increase staffing when we pointed this out during this inspection.

There was no written fire evacuation procedure for night time and people were reliant on staff to leave the building in an emergency as the front door and back gate were locked. These concerns were addressed during the inspection but had not been identified as concerns by the registered provider.

Medicines were not always managed safely. People with serious medical conditions such as cancer and diabetes did not have written care plans detailing their health needs with guidance for staff to follow to ensure their health needs were met.

Right Culture

There was a lack of evidence of a positive person-centred culture which promoted people’s rights and autonomy. The service was not able to demonstrate they were meeting the underpinning principles of right support, right care, right culture.

The environment was not homely as there was a poor standard of cleanliness in some rooms and broken and damaged furniture.

Management oversight was not effective. Although systems were in place to monitor the quality of care provided by the service, we found the audits carried out by the manager and the provider were not always accurate. They did not identify all the concerns that we found during this inspection about care plans, medicines management, financial management and the environment.

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

Rating at last inspection

At the last inspection we rated this service good (published 26 February 2022).

Why we inspected

The inspection was prompted in part due to concerns received about the management of people’s personal finances. A decision was made for us to inspect and examine those concerns. We have found evidence that the provider needs to make improvements.

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. We found concerns about infection prevention and control measures as this the standard of décor and cleanliness and the condition of the furniture in the home did not meet infection prevention and control standards.

Enforcement and Recommendations

We have identified breaches in relation to providing person centred care, dignity, safe care and treatment, medicines management, safeguarding people from the risk of abuse, meeting people’s nutrition and hydration needs, safety of the environment, infection control, staffing and the overall management and governance of the home.

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

Special Measures:

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.

Fouracres Care Services (Fouracres) is a residential care home providing personal care to up to six people. At the time of our inspection there were three people using the service. People using the service were of mixed ages and living with dementia or a learning disability. Accommodation was provided in an extended semi-detached house in a residential street.

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

Improvements had been made to the providers recruitment and governance processes. Staff were safely recruited.

People were kept safe by staff who knew how to report concerns and manage risks for people they were supporting. Staff knew how to raise safeguarding concerns. There were enough numbers of staff to meet people's needs. Medicines were managed in a safe way.

Staff had received training to ensure they had the skills and knowledge to support people safely. Staff received regular supervision to support them in their role. People's dietary needs were met, and they had access to healthcare services where needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People received personalised care and support to meet their needs and wishes. People using the service, relatives and staff were given the opportunity to provide feedback on the service. Audits took place to ensure the quality of the service was maintained.

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.

Based on our review of Safe, Effective, Caring and Well-led, the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. We saw people were able to enjoy a meaningful and fulfilled lifestyle, with community involvement and contact with family and friends. Where possible people were encouraged and supported to maintain their skills and independence and their personal wishes and goals were understood and reflected in their plan of 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 requires improvement (published 15 September 2020).

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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 3 August 2020. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve staff recruitment.

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, Caring and Well-led which were previously rated as requires improvement and contained those requirements.

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 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 Fouracres Care Services on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Fouracres Care Services is a residential care home providing personal care for to up to four people. At the time of the inspection, the service was fully occupied. People using the service were of mixed ages and living with dementia or a learning disability. Accommodation was provided in an extended semi-detached house in a residential street.

The service was operating before the principles and values that underpin Registering the Right Support had been developed. However, the service would be expected to develop in line with these principles and other best practice guidance. Registering the Right Support ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service should receive planned and co-ordinated person-centred support that is

appropriate and inclusive for them.

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

There had been significant improvement since the last inspection which was reflected in the feedback we received from people’s families. They told us they felt their loved ones were safe living at Fouracres.

Improvements had been made to how medicines and risks to people’s health and well-being were managed. Care plans were more person centred and reflective of people’s current care needs.

Although improvements had been made to how staff were safely recruited, we found that not all appropriate recruitment checks were carried out, despite this being picked up in the provider’s auditing.

There was an increased oversight of quality of care at Fouracres and the provider was working closely with external parties such as a care consultancy and the local authority to implement and sustain improvements.

Refurbishment which was in progress at the last inspection had been completed which resulted in a new kitchen and additional communal areas. The home smelled fresh and clean.

There were increased infection control measures in response to the coronavirus outbreak. The provider reacted appropriately to keep people safe.

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

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

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 4 December 2019).

This service has been in Special Measures since 4 December 2019. We took enforcement action due to the significant concerns found. We imposed conditions on the providers registration. This meant the provider had to send us monthly reports on how they were addressing the issues found during the last inspection. We also imposed a condition to restrict new admissions without CQC authorisation.

During this inspection the provider demonstrated that improvements have been made although we have found evidence that the provider still needs to make further improvements. Please see the safe and well-led sections of this full report.

The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We carried out an unannounced comprehensive inspection of this service on 4 September 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when.

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 safe, responsive and well-led which contain those requirements.

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

We are making arrangements to remove the conditions imposed on the provider's registration following the September 2019 inspection.

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

Enforcement

We have identified a breach of regulation in relation to how staff are safely recruited. 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.

Fouracres Care Services is a residential care home providing personal care for to up to four people. At the time of the inspection, the service was fully occupied. People using the service were of mixed ages and living with dementia or a learning disability.

Accommodation was provided in an extended semi-detached house in a residential street. At the time of the inspection, there was construction work ongoing at the service which started in June 2019.

The service was operating before the principles and values that underpin Registering the Right Support had been developed. However, the service would be expected to develop in line with these principles and other best practice guidance. Registering the Right Support ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service should receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

People were at risk of avoidable harm as systems were not in place to ensure that medicines were managed safely.

Risks associated with people’s health and well-being were not always assessed and clear guidance was not available to staff on how to keep people safe. There was not always evidence of learning from incidents and improving the service accordingly.

Staff recruitment was not always safe or consistent.

People did not always receive individualised care according to their needs and preferences. Care plans were either not in place or reviewed regularly.

There was a lack of managerial oversight of the home. There were no effective audits of any aspect of care delivery.

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. Restrictions on people were not always put in place using the correct legal procedures. Capacity assessments and decisions in people's best interests were not always completed.

The outcomes for people using the service did not fully reflect the principles and values of Registering the Right Support for the following reasons: people were not fully included in decisions about their care and treatment and did not always receive care and support tailored to their individual needs.

Staff received the training they needed to carry out their roles, but some further training was needed around supporting people with learning disabilities.

We received positive feedback regarding how caring staff were.

People were supported to maintain good physical health and were supported to access healthcare.

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 (report published 23 March 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to care planning, staff recruitment, safety, consent to care, and good governance at this inspection.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore ‘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 six 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.

Fouracres is a care home which has been registered to accommodate a maximum of four people with mental health issues and learning disabilities. Fouracres also provides permanent, as well as long-term and short-term respite care to people. On the day of our inspection there was one person using the service.

The home had a registered manager. 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 the inspection the registered manager was not present. The registered provider and an interim manager were present.

Medicines were now safely managed. At the time of the inspection, medicines were not in use at the service, however all staff had received training, and systems were in place to commence staff competency checks when medicines were next in use at the home. Medicines audits now formed part of the overall quality assurance systems in place at the home.

Staff were now receiving regular supervisions and an annual appraisal with the interim manager. Where a new member of staff had been recruited, they had completed a comprehensive induction which had been signed as completed.

There was now increased managerial oversight of the service. Regular weekly and monthly audits were completed on all aspects of the service.

Detailed current risk assessments were in place for the person who used the service. Risk assessments in place were reviewed and updated regularly. The risk assessments explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person.

Care planning were person centred and reflected what was important to the person. Care needs were regularly reviewed and updated to meet the changing needs of people who use the service.

We saw friendly, caring and supportive interactions between staff and people and staff knew the needs and preferences of the person using the service.

People were supported to maintain good health and had access to healthcare services.

The service regularly requested feedback from people who used the service, their relatives and professionals involved with the service.

The person was encouraged and supported to access the community and engage in a wide range of activities of their choosing.

Fouracres is a care home which has been registered to accommodate a maximum of four people with mental health issues and learning disabilities. Fouracres also provides short-term respite care to people. On the day of our inspection there was one person using the service.

The home had a registered manager. 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 the inspection the registered manager was not present. The registered provider and an interim manager were present.

We found three breaches of regulations. Medicines were not always managed safely. Medicines were not stored in the correct way and the home did not have arrangements in place to store controlled drugs. The administration of medicines to people who use the service were appropriately recorded by staff. The home had a clear medicines policy in place which was accessible to staff. A medicines audit had not been carried out since 2014. Staff had not received recent medicines training.

We saw evidence of a comprehensive staff induction programme. However the induction programme had not been completed by staff prior to sign off. Staff did not receive regular documented supervision or appraisals.

No recent audits were carried out for any part of the service. The service had system in place auditing for health and safety and medicines, however, this had not been completed since August 2015.

People were supported to eat and drink. People were consulted about menu choices. However, during the inspection we found out of date dairy produce and food was not always correctly stored or labelled once opened.

Statutory notifications were not submitted to CQC when required.

Systems were not in place to ensure the quality of the service people received was assessed and monitored. Audits had not been recently carried out.

Staff were safely recruited and the necessary pre-employment checks were completed. Staff also had regular criminal records checks.

Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of types of abuse to look out for and how to raise safeguarding concerns.

A detailed current risk assessment was in place for the person using the service. The risk assessment explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person.

The home maintained adequate staffing levels to support people both in the home and the community which supported people wishes to increase their independence.

We saw friendly, caring and supportive interactions between staff and the person using the service and staff knew their needs and preferences.

The care plan was person centred, although key working sessions were not regular.

All staff had received training on the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and staff understood what to do if they had concerns as regards people’s mental capacity.

People are supported to maintain good health and have access to healthcare services. Referrals are made appropriately when concerns are noted as regards people’s health.

The provider and interim manager were accessible to people and staff who spoke positively about them and felt confident about raising concerns.

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

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

Is the service safe?

Our inspection of 27 January 2014 found that people were at risk as there were not enough staff available to meet their needs and respond in the event of an emergency to maintain their safety. On the day of our inspection one person was using the service. We saw that the person received one to one care from a member of staff. The rota showed that the manager and two members of staff were on duty throughout the day. Risk assessments were in place to ensure that person's safety and well-being was maintained when receiving care. Risk assessments provided guidance for staff on how to minimise risks to people.

The person's records including their care plans were accurate, and had been reviewed and updated at regular intervals. Care records gave an explanation of how the person's needs were to be met. This meant that care records supported staff to provide safe and appropriate care to the person who used the service. Personal records including medical records were accurate and fit for purpose.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Our inspection of 27 January 2014 found that staff had not completed all the relevant training they needed to meet people's needs safely, and the provider did not have a training matrix that showed when staff would receive this training. At this inspection we found that a training matrix outlining what training was needed had been put in place.

Staff received appropriate professional development. We spoke with one member of staff who told us they had recently received training in challenging behaviour, epilepsy, first aid, and breakaway and restraint techniques. We looked at the training records for three staff and saw that they all had received this training recently. Staff understood how to apply what they had learnt to their work with the person who used the service.

We looked at the care plan for the person who used the service. This provided information about the person's needs and gave guidance for staff about how they should be met. People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. The records of the person using the service showed that they were supported to have regular health checks with their general practitioner, psychiatrist and other care professionals.

Is the service caring?

We observed that the person's changing behaviour was responded to sensitively in a manner that enhanced their well-being. Where necessary the appropriate professionals had been consulted for advice regarding person's behaviour. Staff explained that the person using the service often found it difficult to go to the surgery or to hospital appointments as this made them anxious. Staff told us that they had spent time taking the person to the surgery and the hospital so that they overcame their anxieties about seeing health professionals. This was documented in their care plan and the care plan gave staff guidance on how they were to respond to the person's anxieties when accessing healthcare. This meant that the person was supported to meet their health needs in a way that maintained their well-being.

Is the service responsive?

Care plans identified the person's needs resulting from their cultural background. Daily notes showed that the person who used the service had taken part in activities and were supported to access their local community. For example, the person was supported to go to the park and to do their shopping.

Staff knew how the person communicated and responded to the person's requests. The person's views were recorded in one-to-one meetings, and when their care plan was reviewed. Staff explained that regular key worker discussions were used to help the person to be involved in decisions about their care. Staff listened to people and acted on their views.

Is the service well-led?

People who used the service, their representatives and staff were asked for their views about their care and treatment and these were acted on. An annual quality survey had been carried out. The manager explained that a report had been produced, and any suggestions to improve the service were addressed. Peoples' suggestions were used as the basis to improve the care provided by the home.

Staff told us they were able to make suggestions to improve the home. Staff said the manager was supportive. They felt that staff meetings provided them with a way to raise issues. Staff were supported by the manager to take an active role in improving the care of people.

We looked at one person's care plan and found that it did not show how the service would support them to develop their independent living skills. Apart from attending a work placement each week there was no other evidence his care plan that showed how the person's skills would be further developed. Staff spoken to could not tell us how they would work with the person to enable them to be more independent. We asked both staff and the manager how an emergency situation would be handled when only one member of staff was working in the service. They could not tell us how they would respond to a medical emergency.

We looked at the training records for the four staff currently working at the service. These showed that there were number of areas where all staff had not completed the relevant training. We saw that one person needed specific support in developing their independent living skills. Records showed that no staff had received this training.

The provider explained that she had carried out a survey of people, their relatives and professionals to obtain their views of the quality of the service. The quality of service provision was assessed and monitored. For example, there is now a training and supervision plan to make sure that staff receive the training and support they need. People's personal records, including their care plans, were accurate, and had been reviewed and updated at regular intervals.

Staff spent time talking with people and engaging in one to one activities with them. Staff said that sufficient staff were available to meet people's needs throughout the day. We looked at the files for the three new staff. There were no skills for care induction records to show this induction process had been completed. Staff had not received all of the training and support they needed to care for people safely.

We were told that there had not been a formal survey of people, relatives and other stakeholders about how the service could be improved. The provider could not show us how the delivery of care and management of the service were monitored, but said that there had been some consultation with relatives about care and support needs.