Archived: Langley House

Due to people's verbal communication difficulties most of the evidence in this inspection was gathered through talking to staff and observing practices.

As well as people's verbal communication difficulties, people also have very complex and challenging needs. Many people require a lot of support and one to one staffing. Many other people in the home are vulnerable and require protection. Throughout the inspection we observed that staff were busy supporting people and managing their challenging and complex needs. Staff told us they felt they needed more staff 'on the shop floor' to ensure people attended their activities and received the level of support they required to reduce the risk of aggressive incidents.

We observed staff managing people's complex needs in a patient manner using effective diffusion techniques to reduce anxiety and prevent aggression. There appeared to be a good rapport between the staff and people living in the home. Staff appeared to understand people's communication needs and people responded well to staff. The atmosphere was generally calm albeit a bit noisy at times.

We observed the lunchtime period in the main house. The atmosphere was calm and relaxed. There were two areas for people to eat which created a better atmosphere than seen at the previous inspection. Staff were observed being patient and offering some choices.

We observed people moving freely throughout the home and appeared comfortable with furnishings. Areas that are restricted to people because of safety reasons can be accessed with the support of staff and in accordance with individual risk assessments. We found the home to be clean and tidy. Some people's bedrooms were homely and decorated to suit their tastes and needs. Two bedrooms were uninviting and stark due to the design and decoration. However, there is action being taken to improve this. The infection control team had visited the home and provided advice and guidance on the home's practices. The two bedrooms mentioned above are planned for redecoration using more welcoming, warming materials and appropriate paints. Another unused bedroom was being decorated to enable this process to begin by enabling a person to move into that room while their bedroom was being decorated.

We found the manager had worked with the local learning disability teams, safeguarding and speech and language therapists to review the service and communication systems for some of the people living in the home. The manager had action plans in place to continue working with the speech and language therapy team to improve the communication systems for everyone in the home. Reviews of people's care were being completed involving other professionals to ensure practices and communications systems were appropriate.

During the last inspection in February 2011 we found that people were not always receiving the level of support they required to meet all of their needs and activities, both in and out of the home. It was not clear what the correct and required staffing levels should have been. There was not a robust system for covering staff shortfalls.

We found during this inspection that the manager had established the correct staffing levels in the home should be nine members of staff. We saw on the duty rotas that for much of the time this was achieved. On other occasions the levels were reduced to eight and occasionally to seven. This was usually due to last minute sickness or holidays.

The provider had arranged a big recruitment drive which had helped the home appoint some new staff. Interviews were also being carried out on the day of the inspection. The home had also appointed a second deputy manager and more senior staff. The home is improving the arrangement for covering staff shortages through increasing their bank staffing levels. This was not fully achieved yet.

People's activities are dependent on appropriate levels of staff. The home has a policy that the majority of people require two to one staffing when out in the community. The manger told us rotas are arranged to fit in with people's activities as much as possible but this is not always achieved due to the home not having full levels of staff. On the whole, we found that people were going out on activities although not always in accordance with their care plans. We were told that often people refuse to go to their activities and staff often forgot to record this. This was discussed with the manager who told showed us a new recording tool that is being introduced. This will record activities offered, if they were refused, or the reasons why the activity did not take place and what the person did instead. This will enable the manager to monitor people's activities in and out of the home.

We observed staff delivering care and support in a respectful and patient manner. We observed staff members being very busy supporting people and managing challenging behaviours. We saw that many of the staff members were competent and skilled in the way they supported people. They were caring and kind and appeared to understand people's needs. Due to the complex needs and communication difficulties of people living in the home staff have to have a good understanding of how people express themselves. Some staff members were observed speaking on behalf of people and advocating for them. We were told that some people have a 'worry card' that they can use if they are not happy. The manager has said he is reviewing this as it is not felt to work for individuals.

People living in the home have very complex needs and often display behaviours that can be challenging to manage. The manager told us that they require high levels of staff to support people's needs. On the day of our visit we were told that the optimum level of staff does not always match with the staff available. We were told that they aim to have a minimum of eight staff on duty each day. This provides five staff in the main house, two in the three bedroom annexe and one in the one bedroom annexe. We were told that many people living in the home require two to one or one to one support for certain tasks and activities. The home has its own transport, however we were told by staff that they are unable to get out as often as they would like due to staff shortages. The home has started a gardening and wild life project in the grounds where people living in the home can become involved. People living in the home have limited regular activities that are community based.

The manager has highlighted the need for the people living in the home to have a better involvement in menu choices. This is particularly challenging for the home due to people's complex needs. We were told that communication systems will be explored to find the most appropriate way to achieve this. Some staff told us that they know what people's preferences are and they ensure they respect this. We were told that if people indicate they do not want a particular meal an alternative is always provided.

We observed the lunch time period in the main house. One staff member was very patient and caring in their approach and manner. They took time explaining what the lunch was and encouraging the person to sit down and eat it. The whole process took nearly half an hour but the staff member remained patient and cheerful. Another staff member was observed feeding a person in a respectful and caring manner. Lunchtime in the main house was generally noisy and not very relaxed. This was partly due to the complex behaviours that some people displayed but also because some staff members were in and out of the room rather than sitting with people. The manager has highlighted the need to review how mealtimes are organised to make it a better experience for people living in the home. One person had various adaptations to support them, these did not appear very effective. It was not clear if these had been implemented through advice from professionals, such as occupational therapists or speech and language therapists

We also observed lunch being fed to someone in the three bedded annexe. Due to the complex needs of the people living in this part of the home two staff members are needed to feed one person. Although this person was eating their food it did not appear to be a relaxing or enjoyable experience for either staff or the person receiving the food. Gentle restraint was used throughout to protect staff from being hurt. The use of this gentle restraint in this way had not been agreed in best interest meetings with other professionals. The Deprivation of Liberty safeguards had not been considered. We spoke with a speech and language therapist who told us they are working with the staff to help improve communication and the eating experience for this person.

Due to some people's complex needs the home has imposed some restrictions and practices to protect people. For example, some bedroom doors are fitted with alarms that sound when a person goes in and out of the room. This alerts staff to the person's movements. Risk assessments have been completed in these cases. However, there was no evidence to show that restrictive practices have gone through a best interest meeting. This means that these restrictions have not been discussed and agreed with other professionals, have not been confirmed as being in the person's best interest and are not reviewed regularly. The home had not considered whether this was a Deprivation of Liberty and therefore used the appropriate safeguards.

Another example was that some people display behaviours that cause challenges when they are in their bedroom. Because of this the bedroom walls have ceramic tiles from the floor to the ceiling. The same tiles are used throughout the floor of the bedrooms. There are no curtains at the windows and the beds are stripped of bedding during the day. These bedrooms are stark and uninviting. The manager had recognised that these bedrooms may not be appropriate so had sought professional advice. We were told that the advice from a professional suggested the tiles did not help the person's behaviours. There was no evidence in care records to show that advice had been sought from professionals in infection control to ensure that the tiling was the only option. There was no evidence to show that other professionals were involved in the decision making process to use the tiles in the first place. The care plans and risk assessments of these people did not provide enough information to show if the reasons for the particular behaviours had been explored. The risk assessments did not show enough detail on how to prevent these particular behaviours.

During a visit to the home we read a sample of people's records. Many were in the process of being reviewed. Those that had been reviewed were organised well and provided detailed information about people's needs and risks. We were told that part of this review process is involving other professionals to ensure people's care is delivered appropriately. For example, we spoke with a speech and language therapist who has been helping the staff plan and deliver care in a way that suits the person's needs. However, some care plans and assessments of risk had been completed by staff without considering consulting other professionals. This would ensure that some actions described to deliver care and reduce risks were appropriate. People's records showed that people receive support to attend appointments, such as doctor's, hospital, dentist and chiropody.

On the whole, we found the main house and the one bedroom flat to be pleasantly decorated and furnished throughout. Some bedrooms throughout the home were looking tired and in need of decoration. We were told that redecoration is being arranged. The three bedroom annexe has a lounge that is situated in a conservatory. There were no curtains in the conservatory. We were told that these had been pulled down by a person living in the home. Staff members are in the process of arranging replacements.

We found the lounge in the main house has a sofa that had not been purchased by the home. The reasons behind this were explained. However there is no evidence to show that the home had sought advice from specialists, or other professionals to explore alternative options.