The Paddock

At the last inspection the service was rated overall as requires improvement. Following this we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well-led to at least good. At this inspection we found that the service had improved and the service is now rated Good.

At the last inspection, on 18 May 2017 the service had failed to ensure that behaviours that challenged or equipment used were adequately risk assessed. This was a continued breach of Regulation 12 of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. At this inspection we found that the service was now meeting this requirement. Risks to people were assessed, including risks from the use of equipment and behaviour that challenged. There was guidance for staff to enable them to minimise risks. At the last inspection we recommended that a health and safety assessment be undertaken by a qualified and competent person of current window security on the first floor to ensure people were not being placed at risk. Risks from the environment had also been assessed and actions had been taken to protect people.

At the last inspection on 18 May 2017 the service had failed to ensure medicines were managed safely. This was a continued breach of Regulation 12 of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. At this inspection we found that medicines were now managed safely and people received their medicine as prescribed and on time.

At the last inspection on 18 May 2017 we found that overall monitoring of service quality remained ineffective. This was a continued breach of Regulation 17 of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. At this inspection the checks on the quality of the service were effective and actions identified had been undertaken.

The care at the service has been developed in line with the values that underpin good practice. These values included choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

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

The service had a registered manager in place. 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.

There were sufficient numbers of staff to meet people’s needs and support people effectively. Staff had the training, skills and knowledge they needed to support people with learning disabilities. The registered manager monitored staff performance and staff had supervision meetings, team supervisions and annual appraisals. New staff had been recruited safely and pre-employment checks were carried out.

There were systems in place to keep people safe and to protect people from potential abuse. Staff had undertaken training in safeguarding and understood how to identify and report concerns. Where people did not have capacity to make decisions staff had followed guidance in line with the Mental Capacity Act 2005.

Peoples support was personalised to them and met their needs. People participated in the activities of their choosing. People’s support plans were updated when their needs changed. People and their relatives were involved in decisions about their support. People had access to food and drink when they wanted it and had a choice of what they ate and drunk. People continued to be supported to maintain their health and wellbeing and had regular access to healthcare services. When people accessed other services such as going in to hospital there was continuity of care.

People were treated with respect, kindness and compassion. People were supported to communicate their wishes and express their feelings. Staff had a good understanding of how people expressed themselves and recognised when people were upset or anxious and responded to this appropriately. Staff were aware of people’s decisions and respected their choices. People’s privacy was respected and levels of dignity were maintained.

People were supported to increase their independence and undertake activities of daily living. There was a complaints system in place if people or their relatives wished to complain. The registered manager continued to monitor the quality of service provided by seeking feedback from relatives and people who used the service.

The environment had been adapted to meet people’s individual needs and was personalised to reflect the people that lived there. The service was clean. Staff were aware of infection control and the appropriate actions had been taken to protect people.

Staff, relatives, people and health and social care professionals told us the service was well-led. The service was in a period of transition of ownership. The long standing registered manager continued to run the day to day service with support from the owner. The registered manager had a clear vision and values for the service, which staff understood and acted in accordance with. Staff and the registered manager understood their roles and responsibilities. When things went wrong lessons were learnt and improvements were made.

There was a registered manager in post. A registered manager is a person who is 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 registered manager had been in post for the last 14 years. The registered manager and the operations manager were both present at inspection.

This service was last inspected in May 2016 when we found that improvements the service had made in some areas had not been sustained in others. We issued requirement notices for action to be taken to improve arrangements for: the storage and administration of medicines, the risk assessment of behaviour and equipment used to support people, the provision of guidance to inform staff about risks associated with specific health needs, the servicing of all equipment and installations in the premises, the appraisal and training of staff, and a robust quality monitoring system that can highlight shortfalls to the registered manager. We asked the provider to tell us what actions they were going to take to address the shortfalls identified and they wrote to tell us what they had done to meet these shortfalls.

At this inspection we looked at whether these improvements had been implemented and sustained. The staff continued to provide care and support that was caring and responsive. Improvements had been implemented to ensure the service was also effective in the care and support it delivered. However, improvements to medicines had not been maintained. Risk management was inconsistent. Improvements in quality monitoring had not been fully embedded and remained ineffective in identifying shortfalls.

People were happy and settled living in the service. People's care needs were understood by staff. Care plans were designed around people’s needs and preferences. Relatives were satisfied with the standard of care and felt informed by staff about their relative’s needs. Relatives were invited to reviews and were asked to comment about the service through surveys. They commented that staff had the right attitudes and cared about the people they supported.

People were consulted about weekly food menus and enjoyed the meals they received. Staff monitored their health and they were supported to attend regular and specialist health appointments so they remained healthy. An activity programme was in place and people were asked about what they wanted to do; at times people appeared under stimulated. Staff now had the responsibility to support people with onsite activities and needed training and support to be proactive and feel confident of delivering activities suited to people’s needs.

The premises is a grade two listed building that requires an on-going programme of repair and upgrading, the communal lounge, some hallways and bedrooms have been redecorated since the last inspection and provide comfortable environments for people. Other areas such as the dining room and a smaller lounge would benefit from updating and providing a more homelike setting. All tests, checks and servicing of equipment and installations including, gas, electricity and the fire alarm had been kept updated. Staff attended fire drills so they understood how to evacuate the building safely.

There was enough staff to support people when at home and when out in the community. Recruitment checks on new staff ensured new staff were suitable for their role. Staff said they found the registered manager approachable, they felt able to raise issues individually or in a team meeting setting. Staff said they felt supported and the frequency of their supervisions had improved; a programme of staff appraisals was underway. Staff had been trained to recognise abuse. They understood their responsibilities to report and keep people safe from harm. Staff reported and acted on accidents and incidents appropriately.

New staff received an induction to their role that included completion of the Care Certificate. On-going training was also in place for the routine updating of staff knowledge and skills they needed for peoples everyday support, and for specialist areas such as epilepsy, diabetes and challenging behaviour. Policies and procedures that guide staff were kept updated and staff were made aware of any changes.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff sought people’s consent on a daily basis and understood how people with limited or no verbal communication made their choices known. DoLS applications were being made for people who lived in the home to ensure that people were not deprived of their liberty unnecessarily.

We have made one recommendation:

We have recommended a reassessment of security and safety of some first floor windows.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

This service was last inspected on 16 April 2015 when we found the service required improvement to the recruitment of staff, notifications to the Care Quality Commission in respect of Deprivation of Liberty authorisations, quality monitoring, ensuring staff induction records were in place and that the electrical installation had been serviced.

We asked the provider to tell us what actions they were going to take to address the shortfalls identified and they wrote to tell us what they had done to meet these shortfalls. At this inspection we looked at whether these improvements had been implemented and sustained; we found that action had been taken by the registered manager and measures implemented to address the shortfalls in all but one area. Due to changes in the management structure in the organisation there had been a delay in expanding, developing and taking forward an effective quality monitoring system for the assessment and monitoring of the service; progress in this area had stalled and this remains a continued breach of regulation.

There was a registered manager in post. A registered manager is a person who is 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. At the time of inspection the registered Manager was away on holiday and the deputy manager was providing cover during this period.

The ordering, receipt and disposal of medicines was well managed; we identified shortfalls however, in their storage and administration that need improving. The absence of an effective quality monitoring system meant that the registered manager was unaware servicing of moving and handling equipment was overdue, or could evidence that an inspection of the gas installation had been undertaken.

Risk assessment around use of equipment and people’s behaviour had not been assessed and implemented. Some important staff training that helped them to keep people safer was also overdue, staff monitored peoples health and well being but individualised guidance for staff around some health conditions was lacking. There was a culture of appraisal and supervision of staff but changes to the management structure within the company had delayed the annual aprrasial of staff. Recruitment procedures ensured that all relevant checks were made of new staff and that they were suitable for their role.

The service offers people a comfortable clean environment, the atmosphere is relaxed with people easy in each other and staffs’ company. Staff provide kind patient and attentive care and demonstrated a good understanding of people’s characters and individual needs. The Registered manager provides staff with strong leadership and staff found her approachable and they felt listened to. Relatives respect and value the registered manager and staff input. People experience a good quality of care.Relatives were complimentary of the service and the delivery of care they observed and experienced for their relative, similarly care professionals who provided feedback expressed no concerns overall about the service. People themselves told us they liked where they lived were happy there and had lots of friends; they were treated with kindness and respect by staff.

Staff found the registered manager approachable and felt listened to, they had opportunities to express their views through regular staff meetings. Policies and procedures that guide staff were kept updated and staff were made aware of any changes and they worked to the principles of the Mental Capacity Act 2005 in the delivery of support to people. Relatives commented positively about the service and how for some it felt like a big family because of the long service of some of the staff and the people; a number of whom had lived together for many years. Relatives said they were always made to feel welcome by staff and felt that they were kept informed about important issues in their relative’s lives. A complaints procedure was in place and relatives said they felt confident of raising concerns if they needed to.

People’s care needs were understood by staff and their care plans were personalised and designed around their needs and took account of their support preferences and things that were important to them. People enjoyed a varied programme of activities that they could choose to participate in or not. People were supported to develop independence skills and were given opportunities to express their views.

There were enough staff to attend to people’s needs; staff understood how to keep people safe from abuse and in the event of emergency situations. Accidents and incidents were appropriately managed and actions taken in respect of emerging issues.

We have made three recommendations:

We have made a recommendation about the management of air mattresses.

We have made a recommendation about how capacity and best interest decisions are made for people in hospital.

We have made a recommendation about managing behaviour that challenges.

We have made a recommendation about fire drills for staff.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Most people who used the service were not able to talk to us directly about their experiences due to their complex needs, but we observed how they spent their time and their interactions with the staff. One person told us that they 'like to paint' and another person said they enjoyed 'going to the pub on Sundays'.

We found that people were appropriately supported to make their own day-to-day decisions and were involved in how their care and support was provided. We found that care plans were individualised and contained details about people's choices and preferences.

We found that the home had arrangements in place to protect people from the risk of abuse and there were financial procedures in place to ensure people's money was kept safely.

The service had processes and procedures in place to regularly check and monitor the quality of the service that people received.

People were treated with respect and dignity. Records showed that they were supported to make decisions about their day to day lives and things that were important to them. People could choose when to get up and go to bed, what to do and what to eat each day and staff respected their choices.

People liked the staff and told us that staff were kind towards them. Staff understood people's needs and their preferred individual methods of communication. People were supported to be as independent as they could and to learn new skills.

The service had financial procedures in place to ensure people's money was protected.

There were enough staff on duty to support people safely and in the ways they preferred.

The organisation had processes and procedures in place to regularly check on the quality of the service people received and to keep them safe.

We did not speak to people who used the service as a number of people were going out to local college and resource centres for their day.

The service was safe and secure for the people who lived there. The outside space provided opportunities for social activities and a quiet area for walks and personal space.

The service was clean and tidy and there were no unpleasant odours. People who used the service had been supported to personalise their rooms, one person agreed that the non-slip floor covering in their bedroom put in by the provider had assisted in keeping their room clean and promoted their health and wellbeing. One person told us that the environment "could do with improvement in places"; however recently there had been a lot of redecoration to the inside of the service.

The service showed much commitment and compassion to the people they cared for, this was evidence by the time and flexible approach they had to meet people's individual needs. During the inspection we saw people in the home were comfortable in their environment and staff supported people to access all areas of the service freely to promote independence skills and social activity.