Archived: Tanglewood

Tanglewood is a residential care home providing personal care for up to three people with learning disabilities. At the time of our inspection three people were using the service.

The service is a detached single story building with enclosed rear garden. The accommodation is sub divided into two, the main house where two people live and an adapted annex for the third person. It is located in a rural area near St Austell, Cornwall and people were unable to access the local community without support from staff.

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

An analysis of rotas found that on nine occasion in the three weeks prior to our inspection staffing levels within the service had been unsafe. Staff recognised that people had been exposed to risk as a result of low staffing levels and told us, “The staffing honestly is a little bit scarce. We do have short periods of time where the overlap is not quite right” and “In my opinion it was not safe, it was horrendous. I managed, there was no incident, but you are just waiting for something to happen.”

Relatives told us they felt staffing levels in combination with high staff turnover had exposed people to risk. They told us “There is no continuity. It is not the nice calm orderly place that it used to be”.

Incidents had not been reviewed and analysed to identify patterns or trends. Unplanned restrictive practices were used during the inspection as staff had not followed guidance included in people’s care plans.

All necessary staff pre-employment checks had been completed to ensure people’s safety and staff understood local safeguarding procedures. Medicines were managed safely and there were systems in place to protect people from financial abuse.

All new staff received induction training and supervision had been provided. System to ensure training was regularly updated were not entirely effective and additional training updates were arranged following the inspection. The service was well maintained and action had been taken to address issues identified during our previous inspection.

There was limited evidence of best interest decision making available and there was a lack of evidence available to demonstrate the provider had acted on a recommendation issued by the commission in relation to restrictive practices following our last inspection.

People had limited choice and control of their lives. Tools developed to support people to make decisions were not being used by staff as they were concerned subsequent changes to plans as a result of staff availability my cause people additional anxiety. Staff were caring and responded promptly to people’s needs.

People did not receive person centred care as care plans were not fully understood by staff and did not always reflect peoples current support needs. Staff had been provided with guidance on how to meet people’s communication needs but this guidance had not been consistently followed.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support. Staffing levels and the availability of staff who were able to drive had limited people’s ability to access the community. Tools designed to enable people to participate in decision making around activities were not being used as staff did not know if staff would be available to support people to engage with activities they had planned. Staff told us, “[We are] very short staffed, it’s a very big issue with continuity and non-drivers. It restricts the guys from going out for activities. [Person’s name] does not do anything” and “[People] are often stuck in the house. It is only at changeovers really that they get to go out or when we have three [staff] like today.”

Relative’s were concerned that the lack of access to the community and activities was impacting on people’s behaviour. They told us, “We took [Persons name] out by ourselves because we were fed up of [our relative] being left in the service”, and “[My relative] is not occupied and is not getting the attention [they] need. [Person’s name] is becoming bored and frustrated and unfortunately this is showing in [their] behaviour.”

Complaints received had not always been fully investigated and there was a lack of evidence to demonstrate what action had been taken to address issues identified as part of the complaints process.

There was a lack of consistent leadership in the service. The registered manager had moved to another of the provider’s services prior to July 2019. No new registered manager had been appointed and no notification of the registered managers absence had been submitted to the commission. Relatives and staff reported there had been six different managers since the registered managers departure. A new deputy manager had recently been appointed but rotas showed low staffing levels had meant this manager had spent the majority of their time providing care.

The provider’ quality assurance processes were ineffective. Audits had been completed but had not resulted in action being taken to ensure compliance with the requirement of the regulations. Relatives told us they had lost confidence in the provider and were seeking alternative care placements. Their comments included, “It is not a very good picture really. It is just rather depressing thinking of the situation [My relative] is in.”

Managers accepted that the service was not meeting people’s needs and following feedback at the end of the inspection the provider has begun taking action to improve the service’s performance. Additional resources had been made available and an action plan developed to drive improvement in the service’s performance.

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 good overall but requires improvement for effective. (Report published 23 December 2017)

Why we inspected

The inspection was prompted in part due to concerns received in relation to staffing levels and the quality of support people were receiving. A decision was made to bring forward this inspection to examine those risks.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

Tanglewood is part of the Spectrum group and provides care and accommodation for up to four people who have autistic spectrum disorders. At the time of the inspection three people were living at the service.

The service requires a registered manager. At the time of the inspection 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. The manager told us they had submitted their application to become registered.

On the day of the inspection visit one person was at college. We spent time with the two other people living at Tanglewood. We spoke with them and observed staff interacting with them. We saw they were treated respectfully and with patience and kindness. Staff were aware of how to report any safeguarding concerns and were confident they would be acted on.

There was a range of risk assessments in place to ensure staff were aware of any potential identified risks and the actions they could take to minimise risks. Staff supported people in line with the information in care plans. When people tried new activities assessments were developed to support them to do this safely.

Staff were supported through a system of induction, training, supervision and staff meetings. This meant they developed the necessary skills to carry out their roles. There were opportunities for staff to raise any concerns or ideas about how the service could be developed.

People were supported to make everyday decisions such as how and where they spent their time and when they got up. Communication tools were used to assist people to make and communicate their decisions. There were some restrictive practices in place to protect people from harm. We were concerned these had not been regularly reviewed to ensure they remained necessary and the least restrictive option available, in line with the principles of the Mental Capacity Act (MCA). We have made a recommendation about this in the report.

People took part in a wide range of activities and led busy lives. They accessed the local community regularly attending social clubs, taking part in voluntary work and using local amenities. Activities were chosen to meet people’s individual interests. Staff were creative when identifying new activities. The manager worked closely with families and recognised the value of maintaining these relationships.

Care plans were detailed and contained descriptions of people’s routines. The information was regularly reviewed and up to date. Relatives told us they were involved in the care planning process.

The manager took an active role within the home. There were clear lines of accountability and responsibility within the staff team. Key workers worked closely with individuals and had a good understanding of people’s needs.

There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly both within the service and at organisational level.

Further information is in the detailed findings below.

Tanglewood is part of the Spectrum group and provides care and accommodation for up to three people who have autistic spectrum disorders. At the time of the inspection two people were living at the service.

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.

On the day of the inspection visit one person was at college. We spent time with the other person who had limited verbal communication. We spoke with them and observed staff interacting with them. We saw they were treated respectfully and with patience and kindness. Staff checked with the person frequently to find what activity they wanted to do and whether they were happy. The person preferred to carry out some tasks on their own and they were given time and space to do this accordingly. They showed us their own room and a newly converted flatlet; this demonstrated they had a sense of ownership of the premises.

There were robust recruitment systems in place to help ensure staff were fit to work in the care sector. Staff received a thorough induction when starting work with Spectrum. This was backed up by regular refresher training. Training covered general areas such as health and safety, infection control and food hygiene. Additional training in areas specific to people’s needs such as autism awareness was also provided. Safeguarding training helped ensure staff were able to recognise and report potential abuse. All were confident any concerns would be taken seriously.

There were sufficient numbers of suitably qualified staff to keep people safe. The staff team was small and most had been in their role for at least a year. They knew the people they supported well and had a good understanding of their needs. Staff told us they supported each other and communicated well as a team. There were a range of systems in place to help ensure staff were always up to date with any changes in people’s needs.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. DoLS applications had been made to the local authority as appropriate. Staff ensured people consented to their care and respected people’s wishes. People were supported to make everyday decisions such as how and where they spent their time and when they got up. Communication tools were used to assist people to make and communicate their decisions.

People took part in a wide range of activities and led busy lives. They accessed the local community regularly attending social clubs, taking part in voluntary work and using local amenities. The registered manager worked closely with families and recognised the value of maintaining these relationships.

One person had been through a difficult period in their lives. Staff had worked to support the person and demonstrated a commitment to their well-being. The person's care plan was in the process of being updated to reflect the changes. New communication tools had been developed and routines put in place to help give the person a greater sense of security.

The registered manager took an active role within the home. There were clear lines of accountability and responsibility within the management structure and tasks were delegated to help ensure the smooth and efficient running of the service. There was an emphasis on the importance of effective communication.

There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly both within the service and at organisational level.

We observed staff interacting with people who used the service in a kind and calm manner. We saw that staff showed, through their actions, conversations and during discussions with us empathy and understanding towards the people they cared for.

We examined people's care files and found the records were up to date and reviewed as the person's needs/wishes changed.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

We found that people who used the service were involved in making day to day decisions and participated in tasks at home, such as cooking, cleaning and doing their laundry. We noted that staffing levels needed to be reviewed as they did at times impact on the availability of activities that people could participate in.

People were protected from the risks of inadequate nutrition and dehydration. People were cared for in a clean, hygienic environment.

There were enough qualified, skilled and experienced staff to meet people's needs.

We observed staff interacting with people who used the service in a kind and calm manner. We saw that staff showed, through their actions, conversations and during discussions with us empathy and understanding towards the people they cared for.

We saw that people's privacy and dignity was respected by the way that staff assisted people with their personal care.

We examined people's care files and found the records were up to date and reviewed as the person's needs/wishes changed.

We found that people who used the service were involved in making day to day decisions and participated in tasks at home, such as cooking, cleaning and doing their laundry. We noted that staffing levels needed to be reviewed as they did at times impact on the availability of activities that people could participate in.

Staff said they had received sufficient training and support to enable them to carry out their roles competently.

Systems for safeguarding people from abuse were robust. Legal safeguards, which protect people unable to make decisions about their own welfare, were understood by staff and used to protect people's rights.