Archived: Adjuvo Care Essex Limited - Brightlingsea

Adjuvo Care Essex Limited - Brightlingsea is a residential care home providing accommodation and personal care for up to nine people with a learning disability. At the time of the inspection five people were living in the service.

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

People were not protected from the risk of harm. The provider had not implemented safe fire practices and documentation was not available to enable staff to support people safely in the event of a fire.

Staff did not have access to information about how to support one person living in the service. No information about risks to their safety was available and this meant staff may not know how to support them appropriately. The provider had not ensured staff had the appropriate skills and knowledge to support them in their roles.

The provider did not have robust processes in place to ensure they had oversight of the safety and quality of the service. The concerns found at inspection had not been identified by the checks and audits completed by the provider.

Relatives and staff did not feel able to raise concerns. Relatives told us communication from the provider was poor and they lacked confidence in the leadership of the service.

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 (published 20 February 2019)

Why we inspected

We received concerns in relation to people’s safety and the management of risk at the service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-Led only.

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

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Adjuvo Care Essex Limited - Brightlingsea on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to how the provider ensures people are being kept safe and in their oversight of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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.

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.

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

The service had been developed and designed in line with the values that underpin the CQC Registering the Right Support policy and other best practice guidance. These values include 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’s experience of using this service:

Staff understood the risks to people and the measures in place to keep them safe. Systems were in place to ensure people’s medicines were managed safely and to reduce the risks associated with the spread of infection.

Sufficient numbers of staff were employed to meet people’s needs and ensure they had maximum choice and control in their lives. This included supporting people to access a wide range of activities in the community that reflected their specific needs and interests.

The recruitment, induction and training processes in place ensured staff had the right skills and experience, and were suitable to work with people who used the service.

Staff were intuitively caring, and were observed treating people with dignity and respect.

People were receiving personalised care responsive to their needs, including access to health care services. The registered manager and staff worked well with other agencies to ensure people received high quality joined up care. People had access to food and drink based on their individual choice and preferences.

People’s communication needs had been assessed and were meeting the requirements of the Accessible Information Standards. This set of standards sets out the specific, approach for providers of health and social care to identify, record, share and meet the communication needs of people with a disability, impairment or sensory loss.

Staff felt supported in their roles and had confidence in the registered manager. There was an open culture of learning from mistakes, concerns, incidents and accidents and other relevant events. Staff understood how to raise concerns and felt comfortable doing so.

Rating at last inspection: Requires improvement (Report published 24 October 2017)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: Our previous inspection in August 2017 (published October 2017) identified improvements were needed in relation to the overall management of the service. The service was rated requires improvement. This was because there had been a lack of oversight of the service by the provider and the registered manager to ensure the service delivered was of a good quality, and safe. They did not have systems in place to identify what was working well and what needed to improve.

During this inspection we found the required improvements had been made. We will continue to monitor all intelligence received about this service to ensure that the next planned inspection is scheduled accordingly.

A Registered Manager was 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.

Our previous inspection undertaken on 29 and 30 December 2016 identified serious concerns regarding the management and leadership of the service and the quality of the care delivery. We asked the registered provider to make improvements to ensure staff were suitably trained and supported to respond to people’s complex needs, make the environment safe and ensure infection control risks were managed.

At this inspection, we found improvements had been made to the quality and safety of the service provided. Where staff had lacked supervision, appraisal and basic training, action had been taken to rectify this. Improvements had been made to ensure the premises were safe and the interior had been completely refurbished. However, we remained concerned about the registered persons overall management and leadership of the service. We identified that further work was needed to increase the service's overall rating and ensure that people are provided with good quality, safe care at all times.

There continued to be insufficient staff available to ensure people’s safety and provide additional care support hours, provided as part of their care packages, to access activities. The addition of people for respite care, with no additional staff, further impacted on staff’s ability to provide one to one support. Staff expressed frustration about the lack of staff and at times felt this placed them and people using the service at risk of harm. The service manager was in the process of recruiting new staff for when a new person was admitted to the service at the end of August 2017, increasing occupancy to five. However, neither the registered manager nor service manager were able to show or tell us how the staffing ratio had been calculated to ensure there was always sufficient staff available.

Consultants had been used to provide advice and guidance to staff with regards to managing people’s behaviours in a positive way. Individualised support plans had been developed providing staff with strategies for managing challenging behaviours and distress. These included step by step guidance on physical intervention and verbal de-escalation techniques to be used. Staff had received conflict management training and demonstrated how these techniques would be used. Debriefing sessions were held following incidents of challenging behaviour to discuss and agree what could be done differently to avoid incidents from reoccurring.

People’s care records and information shared with us from relatives confirmed people were receiving personalised care. Individual risks to people had been assessed and actions for staff to address these were clear and coordinated. Systems were in place, which showed staff managed people’s medicines consistently and safely.

Staff understood their responsibility to report any concerns to the manager, but were not familiar with the local safeguarding protocols and access to local authority safeguarding team. However, both the registered manager and service manager were aware of their responsibility to liaise with the police and local authority if safeguarding concerns were raised. Such incidents had been managed well. A robust recruitment and selection process was in place. This ensured prospective new staff had the right skills and were suitable to work with people using the service. A formal supervision process had been implemented and records showed these were taking place on a regular basis, where staff’s achievements, challenges and personal development were being discussed and actioned.

Staff confirmed they had received a range of training, which had given them the skills they needed to carry out their roles and keep people safe. Staff who had shown a specific interest in particular areas such as medication and first aid had been provided with additional training and had been appointed champions. These staff shared their learning and acted as role models for other staff. However, where training had been completed via eLearning; we found staff had not always fully understood the content of the course and how to put their learning into practice. For example, not all staff were able to describe how they would recognise when there was a potential deprivation of a person’s liberty. They were unable to explain the legislation and why this should be applied.

We saw good evidence that the principles of the Mental Capacity Act were being applied. Applications had been made to the local authority to lawfully deprive people of their liberty because their safety would be at risk if they left the service unescorted. These had been submitted in 2015, but had not been authorised. The registered manager was unable to show that they had made any further contact with the local authority to chase these. Neither had they considered making applications for people staying at the home for respite and by virtue depriving them of their liberty.

People received enough to eat and drink, however staff had no menu to work from and prepared whatever food was in the fridge and freezer. This ad hoc approach to meals did not always take into account people’s preferences or ensure that they had a balanced and healthy diet. People’s health needs were being assessed and monitored and where required, referrals had been made to appropriate health professionals. Staff responded promptly to people’s health needs when issues were identified, however records showed monitoring of bowl movements was inconsistent. A four day gap was identified in one person’s records, which had the potential for the person to become constipated or unwell, but this had not been identified as a risk.

Staff were kind and caring and had developed good relationships with people using the service. People were comfortable in the presence of staff. Relatives confirmed the staff were caring and looked after people very well. However, staff felt current staffing levels did not enable them to keep people safe and ensure their funded one to one care support time was provided. Feedback from relatives confirmed people had lost one to one care support hours they had originally been assessed for because they weren’t being provided. A review of the rosters indicated that people are not currently provided with all their hours a week. This risks a further reduction in funding and one to one support to access the community.

Staff and relatives spoke positively about the service manager and said they were making a positive difference and things were improving. Staff morale had improved, because they felt supported by the service manager. They described them as being helpful and approachable and were able to raise any concerns without fear of reproach. Relatives were less positive about the registered persons. They felt neither had been open and transparent when it came to issues about how people’s funding was being spent. Anomalies were identified in the amounts of money agreed by the local authority and what was actually provided for meals, social activities, transport and holidays. The registered manager had no systems in place to account for how people’s funding was allocated and spent.

To sustain the improvements that have been made in the service, further work is needed to ensure all staff, including the registered provider know, fully understand and are committed to embedding the vision and values of the service. These included honesty, integrity, respect and taking quality to its highest level. Whilst some progress had been made further work was needed to develop proper systems to assess, monitor and identify where improvements are needed to improve the safety and quality of the service.

The service provides accommodation and personal care for up to nine people living with learning disabilities and autism. At the time of our inspection, there were six people using the service.

The home has 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 & Social Care Act and associated regulations about how the service is run.

Our inspection identified serious concerns regarding the management and leadership of the service, and the quality of the care delivery. People were being placed at risk of physical and emotional harm and there was insufficient governance in place to make improvements within acceptable timescales.

The service was not safe. Staff did not receive appropriate training to understand the complex needs of people using the service. Behaviour which may have impacted negatively upon people was not managed correctly, and forms of restraint were being used which placed people at risk of harm. There was insufficient monitoring and reporting of incidents which meant that poor practices had become embedded into the service. There were risk assessments in place for people, but these did not account for the management of this type of behaviour.

People had care and support plans in place but these were not always updated or reviewed with involvement from the person or their relatives. People had their dietary and healthcare needs assessed but some relatives reported missed appointments and had been since assumed responsibility for the healthcare needs of their family member. People did not always have access to activities which were stimulating or kept them occupied. The limitations with transport and staffing hindered people’s ability to live a full and active life.

Staff were not supported through regular supervision or appraisal and did not have sufficient opportunities to contribute to the development of the service. They only received basic training which was unfit for the nature of the roles they were employed to perform. Staff did not feel able to share issues or views and did not feel supported by the management team.

The leadership and management at provider level was absent which meant that the registered manager was performing his role beyond the scope of his remit. This had led to a decline in the standards of the service and the registered manager did not have sufficient time to make improvements. There was little quality assurance in place to identify issues and take remedial action. Some complaints were dealt with but others were not recorded or resolved and some relatives and staff felt that their concerns were not listened to. There were inconsistencies in the maintenance, design and decoration of the service which had an impact on the safely and effectiveness of the environment for people. Elements of the environment were poorly maintained and presented an infection control risk.

This inspection identified that there had been breaches of a number of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014 and the overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service provides accommodation and care for up to nine people with the learning disabilities and autistic spectrum disorder. Some people also have a physical disability. The service also takes people for respite breaks.

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.

Staff had received training in administering medicines but medicines were not always well managed as poor stocktaking procedures made it difficult to be sure that people had received their medicines as prescribed.

Staff were trained in safeguarding people from abuse and systems were in place to protect people from abuse. There was a lack of clarity over some financial procedures which could have left people open to financial abuse.

Risks were assessed but action was not always taken to minimise these risks. Systems were not in place to ensure the safety of the service vehicles.

Staffing levels meant that people’s needs were met, although some feedback indicated that sometimes people were not able to take part in certain activities due to staffing constraints.. Recruitment procedures were not always robust and references had not been sought for one person.

Training was provided for staff to help them carry out their roles but a structured induction was not in place. Staff were not well supported by the manager as regular supervision and appraisal were not in place.

People, and their relatives or legal representatives, gave their consent before care and treatment was provided. Staff had not been provided with training in the Mental Capacity Act (MCA) 2015 and Deprivation of Liberty Safeguards (DoLS). The MCA and DoLS ensure that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. Where people’s liberty needs to be restricted for their own safety, this must done in accordance with legal requirements. Appropriate DoLS applications had been made.

People were supported with their eating and drinking needs and staff helped people to maintain good health by supporting them with their day to day physical and mental healthcare needs.

Staff were caring and treated people respectfully making sure their dignity was maintained. Staff were positive about the relationships they had built with the people they were supporting and caring for.

People, and their relatives or legal representatives , were involved in planning and reviewing their care and were encouraged to provide feedback on the service. Care plans identified people’s particular preferences and choices but plans and risk assessments had not always been appropriately reviewed. People were supported to play an active part in their local community and follow their own interests and hobbies.

Formal complaints were not logged but informal issues were dealt with appropriately and to people’s satisfaction.

Staff were not always well supported by the management of the service. Staff were not clear about management roles and lines of accountability were not evident.

Quality assurance systems were in place and audits were carried out regularly to monitor the delivery of the service but these were not robust.

We identified several breaches of regulation during this inspection, and you can see what action we told the provider to take at the back of the full version of the report.

Relatives who completed surveys as part of the home's quality monitoring process made positive comments about the care. They said: 'Our young adult is very happy at the home and always comes home immaculately dressed and obviously well cared for.' and 'We are happy with the way things are going.'

Staff knew people well and they understood specific needs. We saw that there were respectful and caring interactions between members of staff and people living in the home. Staff listened to people and provided care and support in ways that met their needs and took into account their individual preferences.

The service co-operated with other agencies, such as health services, to ensure people received the care and support that best met their needs.

There were systems in place to support staff and provide them with the training they needed to ensure they had the skills and knowledge to provide safe and effective care.

Futures Care Home Care Home was well run by a competent manager and there were effective processes to monitor the quality of the service. They consulted with people and took their views into account to make improvements.

Relatives who completed surveys as part of the home's quality monitoring process made positive comments about the home. One relative said 'On the whole we are very pleased with [our relative's] placement.' Positive comments were also made about the staff and management of the home. One relative said '[The management team] have been very supportive' and another said they were pleased 'With the staff and management who work very hard to give the residents a comfortable home and a good life.'

We saw that people smiled and were relaxed and comfortable with staff and others living in the home. We also saw friendly and patient exchanges between staff and people living in the home.

During our inspection we saw that people received good care and that staff treated them with respect.

The management team and staff were able to demonstrate a good understanding of people's needs, likes, dislikes and preferences. People had a variety of ways of communicating their needs and we saw that staff understood people's individual ways to communicate.