Archived: Little Acorns

Updated 22 January 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 8, 9, 23 July and 25 August 2015 and was unannounced. The inspection team consisted of three inspectors and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service for people with autism.

During this inspection we looked at four care plans and daily records, medicine administration records, records relating to people’s finances, three recruitment files, training records and records relating to quality assurance processes. This included staff meeting minutes, and minutes relating to a meeting held with relatives.

We spent time talking with seven people who used the service and with 13 staff. Following the inspection we spoke with two relatives and with seven health and social care professionals to gain their views on any improvements following the last inspection.

Updated 22 January 2016

We carried out an unannounced comprehensive inspection of this service in March 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider is required to send us an action plan to show how they intend to improve the service and meet the identified breaches. We had not received this action plan until after the completion of this focussed inspection completed in July 2015.

This report only covers our findings in relation to those requirements we were reviewing from the previous inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

This inspection took place on the 8, 9 23 July and 25 August 2015 and was unannounced.

We wanted to check on any improvements made following our last inspection carried out in March 2015 where we found a number of breaches. These breaches were under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Since April 2015 we have been operating under new regulations, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 so for the purposes of clarity we have mapped the old 2010 regulations with the new 2014 regulations within the main body of the report.

Little Acorns is registered to provide accommodation with personal care for up to 11 people who have autism. Little Acorns is also registered to provide a personal care service to people who live in their own homes in the community. At the time of this inspection there were nine people living permanently in Little Acorns and there were also three people who regularly stayed there for shorter periods of respite care. Three people who shared a house received a personal care service, plus one person who had respite care at this service. One older person who lived in their own home received personal care visits from care staff five times a day.

The Nominated individual is also the registered manager of the service. Since our inspection of the service on 20 August 2014 the registered manager had ceased to provide day to day management of the service. When we inspected the home in February and March 2015, there was an acting manager who had been appointed. Currently the nominated individual remains legally responsible as the registered manager for the day to day management of the service. 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.

In March 2015 we found that people were at risk of receiving inappropriate and unsafe care. The delivery of care did not meet people’s individual needs or ensure their safety and well-being. People’s needs and risks had not been fully assessed or translated into care plans to address their needs and risks. There were not always enough staff to ensure people’s safety and well-being.

Concerns found during this inspection were so great that the service was, and continues to be, subject to a multi-agency safeguarding process. As part of that process, a multi-agency safeguarding protection plan was agreed with the provider, CQC, police and health and social care professionals to protect people’s safety and well-being. This process included health professionals visiting the home regularly as part of the support plan and in a protection role. There has also been further information of concern which is currently being followed up via the safeguarding processes.

We also found the quality of the service was poor because of a lack of governance systems. Insufficient actions had been taken to identify areas of poor service or to take actions to address them. Effective systems were not in place to monitor and assess the quality of provision. The systems to record, investigate and respond to incidents, accidents and complaints were poor. Medicines and access to medicines when needed was poorly managed.

There was a lack of respect shown by some staff when talking to people about personal matters. There was a lack of respect shown in the daily notes made by staff. People were restricted by rules and regulations which had not been agreed with them and there was no evidence these had been set up in people’s best interests.

Where people were subject to a number of restrictions and rules which they had not agreed to, there were no risk assessments, no best interest assessments and no Deprivation of Liberty Safeguards (DoLS) authorisations.

People’s views were not actively sought about the service and there were no systems in place to encourage people to raise concerns or complaints. People were not actively supported to raise complaints.

People’s records were not kept securely to maintain confidentiality. Records were not always accurate and some were poorly maintained.

During this most recent inspection completed in July and August 2015, there was still evidence that people were at risk of receiving inappropriate and unsafe care at Little Acorns. There were insufficient numbers of staff to meet people’s needs. Staff were expected to carry out duties away from Little Acorns, which meant they could not provide care to people. These duties included providing personal care to people at another location and a morning and afternoon chauffeur service for people attending day services at the home.

We found some improvements in the way people who received personal care in their own home were being supported. One person confirmed they had been involved in the development of their own care plan and others were able to describe how they were being supported to follow up on their aspirations for work and social activities as part of the care and support they had received. We had received some information of concern which suggested that one person receiving personal care was not getting what they needed. We found there were times this person had not received all of the visits which had been agreed. We also found staff who were allocated to work with people at Little Acorns were covering some of the visits to this person. This meant that managers were having to make a decision whether to reduce the number of staff who supported people at Little Acorns at times or the person missed a visit.

Some action had been taken to address the concerns which related to fire safety within the building but some other concerns regarding handrails on the swimming pool and the kitchen used by service users for activities had still not been addressed.

During this inspection, we observed some staff practices which showed there was still a lack of respect and dignity shown to people on occasions, although we also observed some staff showing a caring and positive approach towards people. There was evidence provided from health and social care professionals that Little Acorns staff were still failing to follow guidance they provided. This meant some people were not receiving the care they should have had.

We found there were some improvements as medicines were no longer stored in the upstairs cupboard. However we found that the systems to record medicines administration were not always completed fully. Systems to monitor and audit medicines and prescribed creams were not robust.

Some work had begun on looking at people’s care files and care plans and risk assessments. However, this was still work in progress and there were still gaps and lack of reviewing plans which meant staff did not always have accurate information on which to base their practice and how to support people. This placed people at risk of receiving inappropriate care and support as there were newer staff and agency staff who did not have the historical knowledge of how to work with people with complex needs.

Some improvements had been suggested to look at activities for people outside of the service, although these had yet to be put into effect. These included possible visits to a sensory park in Exeter and the use of an activities centre where they planned to look at boating, archery etc. No risk assessments had been undertaken to show the service had considered the risks associated with these types of activities. However there were still some people who had very rigid routines which had not been agreed as part of a best interest assessment. Staff were not following the support plans devised by healthcare professionals to enable them to have stimulating and enriched experiences. For example one person should have been doing sensory cookery sessions each day but this had only occurred once in a four week period. Another person was not supported to have regular opportunities to pursue their love of trains by undertaking a weekly individual train journey, although this had been recommended and had been agreed with the person concerned and staff at Little Acorns.

Where people had complex needs which had increased, there had been no analysis of these behaviours, what the triggers may be or risk assessments in place to protect the person and staff. For example one person had increased anxiety in the early morning period. There was one waking night person available during this time and there was no clear guidance as to how best to support this person through their anxiety.

Another person had increased challenging behaviour when out. There was no analysis of what may be causing this. There had been a recent incident where the person sustained bruising due to having to be supported to move to a safe place by two staff. Following this there had been no change to their support/care plan. On the first day of the inspection staff said this person was out on a trip with people, not employed by the service, who had known and worked with the person some years previously. There had been no risk assessment around this trip or any evidence that the people who took the person out had been made aware of changes in the way the person acted or behaved in recent times. Staff from Little Acorns had not accompanied the person on the trip which meant the person and the accompanying people were at risk of an incident which would not be managed according to the latest information available.

Although staffing levels had increased, newer staff did not always have a full induction or enough time to be fully supported before they were expected to be part of the staff team supporting people. We found two waking night staff who were inexperienced, had only received a very brief induction and had only shadowed one other shift before they were left to work independently. This placed staff and people at risk because new staff did not have the skills and training to understand the needs of people they were working with. One member of staff had been threatened and on some shifts, hit by a person who had woken early and been distressed. The member of staff said they had lost confidence in working at night.

There were not always enough staff available in sufficient numbers and with the right skills to meet people’s needs and ensure people’s safety and well-being. Staff were being used from the staffing levels from Little Acorns to cover transporting day care and respite people and to cover domiciliary hours for people living in their own homes in the community.

Recruitment was not robust, newer staff had started before all the checks to ensure they were suitable were in place. One newer staff member had given a very brief employment history and this was not followed up. References were received after the date of new staff commencing work, without any other checks to ensure their suitability to work with vulnerable people being in place..

Records relating to people’s finances had improved with receipts being kept and numbered. However there were still areas where people’s monies were unaccounted for. The registered manager agreed to obtain an independent audit of people’s finances and make a safeguarding alert.

There were recorded incidents of people needing to be restrained to prevent injury to themselves of others, but not all staff had received training in how to do this safely.

One person was at risk of choking as staff had not read their risk assessment relating to this risk had had been seen assisting them to eat food which presented a risk by a healthcare professional.

We found there had been some improvement that complaints were now dealt with effectively. For example we saw a senior member of staff had acknowledged a concern made by a family and had responded to this appropriately. However another relative said they had not received a response to a request to make a complaint.

Some staff showed a caring and positive attitude to people when working with them. However we also observed some less caring approaches by some staff.

There was a lack of management leadership and lack of systems to check on the quality of care, which meant people were at risk of receiving care which was not appropriate to their assessed needs and did not follow best practice. There was no evidence of audits being completed to ensure the right staff with the right skills were being employed, supported and trained to do their job.

During the inspection, we identified a number of serious concerns about the care, safety and welfare of people who received care from the provider. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, now replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.