Dillon Care Pathway

Dillan Care Pathway provides personal care to people across two supported living locations; one in Barnet and one in Harrow. At the time of the inspection, 14 young adults over the age of 18 with a learning disability, were using the service, all of whom receive personal care. Some people who used the service also had a physical and/or sensory disability.

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

Improvements had been made to the service since our last inspection. People told us they liked living at Dillan Care Pathway and led active and social lives. People received their medicines as prescribed. Staff were safely recruited, and staffing levels were sufficient.

Where risks to people had been identified, staff responded to these by following guidance in people's care plans. Staff knew people well and as such they were able to tell us about how they kept people safe.

The management team monitored the quality of the service provided to help ensure people received safe and effective care. This included seeking and responding to feedback from people in relation to the standard of care. The management made regular checks on all aspects of care provision and actions were taken to continuously improve people's experience of care.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of key questions Safe, Responsive and Well-led, the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• Model of care and setting maximises people’s choice, control and independence. People were supported to have maximum choice and control over their lives to enable them to live their life to the full.

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human rights. People were supported in a positive way to enable them to live as independently as possible.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives. The management team and staff had a positive impact on people's wellbeing, confidence and quality of life.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (report published 20 August 2019)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made.

Why we inspected

We carried out an announced comprehensive inspection of this service on 3 July 2019. No breaches of legal requirements were found however we identified the provider needed to make improvements with regards to staff recruitment and overall governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check improvements had been made. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

The provider was working to ensure the service was working in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

The provider had worked to make improvements throughout the service which had a positive outcome for people. People were supported to engage in more meaningful activities and outings which enhanced well-being and reduced social isolation.

Safeguarding processes were in place to help safeguard people from abuse. Risks associated with people’s care had been assessed and guidance was in place for staff to follow.

There were sufficient staff available to meet people’s care needs, however we identified gaps in the recruitment process.

Care plans were detailed, and person centred and evidenced that people and their relatives were consulted around their care preferences.

People received their medicines as prescribed. Improved systems were in place to ensure that medicines were managed safely.

There were quality monitoring systems and processes in place to identify how the service was performing and where improvements were required. We will assess whether the improvements made have been sustained and embedded at a future inspection.

People and their relatives spoke positively about staff and the care they received. We observed caring interactions between staff and people in their care. Staff knew people well.

Staff received regular training and supervisions. However, we found that a process was not established to ensure that newly recruited staff were supported following the completion of their induction and that their competencies in the role had been assessed.

Staff supported people to meet their health and nutritional needs. Staff worked with health care professionals to maintain people's wellbeing.

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

At the last inspection in January 2019, we found that the service was not consistently applying the principles and values of registering the right support. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. At this inspection, we found that improvements had been made in this area.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 4 April 2019) and there were three breaches of regulation. We issued a warning notice to the provider on 12 March 2019 in respect of a breach of Regulation 9 (Person Centred Care).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

People were positive about living at Dillan Care Pathway. Overall, relatives were satisfied with the service, however, we received consistent feedback that the service could offer more with regards to activities and community access.

Not all people were receiving care which was personalised to their needs and preferences. Meaningful activities in one location were lacking and people were not supported to access the community on a regular basis. Care records indicated that people spent large amounts of time watching television and videos, colouring books and walking within the house and garden.

Risks associated with people’s care needs had not always been assessed in a person-centred way. Detailed guidance was not always available for staff to keep people safe.

Systems were in place to ensure people had received their medicines, as prescribed. However, guidance for the use of ‘as needed’ PRN medicines was not in place and detailed records were not kept when PRN medicines were administered.

The registered manager had completed audits on the home to support quality checks. However, for some areas, these had not identified where improvements needed to be made. Policies were out of date and not based on current best practice.

We observed some positive interactions between people and care staff. However, we also observed some negative interactions, which did not promote a respectful environment.

People had good health care support from professionals. Staff worked in partnership with health and care professionals.

People and relatives were positive about the food choices on offer. People’s cultural dietary needs were met.

There was sufficient staff to support people. Staff were safely recruited. However, gaps in staff member’s employment was not always explored and documented.

More information is in the detailed findings below.

We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around safe care and treatment, person centred care and the governance of the service. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: Good (report published July 2017).

Why we inspected: This inspection was brought forward in response to incidents that had occurred in the service and concerns that had been raised about the safety and management of the service.

Enforcement: We served a warning notice on the registered provider for a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated

Activities) Regulations 2014.

Follow up: We will re-inspect to check compliance with the warning notice. We will also ask the provider to submit an action plan detailing the steps they intend to take to ensure the required improvements are implemented. We will also continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

At the last inspection, the service was rated Good.

At this inspection we found the service remained Good.

The service operated effective systems to prevent abuse of people using the service by ensuring staff had a good understanding of their role in identifying and reporting abuse or any concerns of poor care. The service kept accurate records of accidents and incidents and demonstrated learning had taken place to prevent future reoccurrences. Sufficient staff were deployed to meet people’s individual needs. The service maintained safe medicines administration processes and met infection prevention control requirements.

The service followed safe recruitment procedures to ensure staff had been properly vetted before starting work with vulnerable people. People’s health and care needs were met by well trained staff. Staff received regular support and supervision. People’s nutrition and hydration needs were met and they were offered plenty of options in line with their cultural dietary needs.

The service operated within the legal framework of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

People and their relatives told us staff were friendly, caring and helpful. People received person-centred care from staff that treated them dignity and respect.

Staff supported people to attend a wide range of individual and group activities on the premises and in the wider community, including college. The service was responsive to people’s changing needs and documented changes in people’s care plans. Care plans were personalised and detailed life histories, individual needs and likes and dislikes were recorded.

The service carried out regular monitoring checks and audits to identify any gaps and areas of improvement in quality and safety of the service delivery.

Further information is in the detailed findings below.

Dillan Care Pathway is registered to provide domiciliary care and a supported living service. At the time of the inspection, they did not have any people receiving domiciliary care services. Dillan Care Pathway provided supported living services including personal care and support to people with a learning disability, autistic spectrum disorder or a mental health condition. A supported living service is one where people receive care and support to enable people to live independently.

At the time of our inspection, the service was providing 24 hour supported living services to eight people, majority of people using the service were under the age of 30 and this service was provided from one address. The provider also operated a residential care service from the same address. The same staff team and policies covered both services. As the residential care service was inspected within the same month, we have utilised information from both inspections for each report.

The service was located in two adjoining terraced houses and there was access to a back garden. The exit from the connected house was via a main door at 24 Talbot Crescent. Bedrooms were located on the ground floor and the first floor. Bedrooms had toilet and shower facilities. There was no lift at the premises and hence, people using wheelchair resided on the ground floor.

The service had a registered manager who has been registered with the Care Quality Commission. 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.

People and their relatives told us they found staff caring, friendly and helpful. People and relatives told us staff listened to them and their individual health and care needs were met. Staff were able to demonstrate their understanding of the needs and preferences of the people they cared, for example we could see staff provided care that maintained people’s privacy and dignity.

The service supported people to attend a wide range of activities in the community, including college.

We checked medicines administration charts and found that clear and accurate records were being kept of medicines administered by staff. Care plans and risk assessments supported the safe handling of people's medicines. Care plans were personalised and detailed life histories, individual needs and likes and dislikes were recorded. Risk assessments were detailed and individualised, and care records were maintained efficiently.

There were safeguarding policies and procedures in place. Staff were able to demonstrate their role in make safeguarding alerts and raising concerns. Staff had a good understanding of the threshold of safeguarding and the role of external agencies.

Staff told us they were supported well; we evidenced records of staff supervision. Staff told us they attended induction training and additional training and training records evidenced this.

Staff files had records of application form, interview assessment notes, criminal record checks and reference checks. Up until September 2015, references were not always from previous employers nor validated by company stamp or headed paper. Since September 2015 the provider had been adopting a more rigorous check of references.

The service operated within the legal framework of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

The service had good systems and process in place to assess, monitor and improve the quality and safety of service provided. There was evidence of regular monitoring checks of the quality and safety of the service.

a table in one of the lounges was not safe and some lighting was poor and badly maintained. We issued the home a compliance action, and in response the provider sent us a plan to rectify our findings.

At this inspection, we returned to review the changes made by the home. We found that broken furniture and loose fittings had been replaced. Where there was ongoing maintenance work in the home, these areas were fenced off. We saw staff ensured people's safety within their environment.

At this inspection, we found capacity assesments had been obtained and care plans had been updated to match requirements. Care plans were up to date and accurately described people's communication methods, daily preferences and health needs. A key working system had been implemented. The number of staff on shift each day was increased from six to seven. Established care staff were clear about the difference between people who had supported living needs and the two service users requiring residential care living at the location. The provider had continued to recruit care workers.

Overall, we found the service had taken steps to address people's individual needs.

The provider had made some improvements since our inspection of 7 March 2013 in relation to staff recruitment and training and records relating to these. They had introduced systems to monitor the quality of service provided although these needed further development.

However, issues related to obtaining valid consent, delivery of care and employment of sufficient numbers of staff had not been resolved. People had complex needs but requirements specified in their support plans were not provided as there were insufficient staff. Records about people's care were not up to date, following review of changing needs, or complete. The registered manager had arranged for more staff to be recruited, however there was little change in staffing complement and was not linked to people's needs in relation to their supported living care contracts.

We also identified some new concerns, in relation to the environment for example. A table in one of the lounges was not safe and some lighting was poor and badly maintained.

However we found that the provider did not act fully in accordance with their own policy where people lacked capacity to make informed decisions about their care. Of the four care plans we reviewed, we found some aspects of planned care were not recorded as being delivered. The registered manager was unable to demonstrate how people were being provided with the care as required in their contracts with local authorities. Staff received some training but supervision and appraisals were not being held routinely. We found that appropriate checks prior to employment had not always taken place. Monitoring of the quality of the service did not address areas needed to protect people from avoidable risks. The provider had also failed to notify us of incidents of injury and abuse.