Archived: Dunsland

Dunsland is a residential care home providing personal care and support for up to 14 people aged 18 years and over living with learning disabilities, autism, physical and mental healthcare needs. At the time of the inspection, 10 people were living at the service.

The service has not been developed and designed fully in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The service was a large home, bigger than most domestic style properties, and larger than current best practice guidance for people with learning disabilities and autism.

The size of the service was having a negative impact on some of the people due to building design and layout, and the number of people sharing communal areas of the service. Not all the principles had been applied to the service provided, to ensure 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 includes having control, choice, and independence. People using the service should also 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

People were not being supported by consistently caring and suitably trained staff. This was confirmed by our observations and feedback received from people living at the service.

We identified ongoing significant environmental risks and concerns impacting on the standards of safe care being provided. People living at the service were not always able to assess risks independently and relied on staff for support. Leadership and governance arrangements within the service had further deteriorated since the last two inspections.

We identified new and repeated breaches of regulation and the provider, in the absence of a registered manager, was not meeting their legal regulatory responsibilities to ensure people received good standards of care or that sufficient action was being taken to address shortfalls from the last two inspections.

People were not always supported to have maximum choice and control of their lives. We observed examples of restrictive practice. Staff did not always support them in the least restrictive way possible; policies and systems in the service were not followed to support good practice or reflecting the principles and values of Registering the Right Support.

We continued to identify concerns regarding the levels of activities and social stimulation for each person. This had less impact on those people able to access the community independently. The service had not implemented recommendations made in the last comprehensive inspection report regarding people’s end of life care planning, and care records did not consistently contain protected characteristics in relation to personal choice and preferences.

The care environment remained unclean, with ongoing concerns regarding infection, prevention and control risks to people. We continued to identify concerns regarding people’s medicines management at the service.

Rating at last inspection

Dunsland was previously inspected 09 May 2019 and rated as Inadequate overall, with breaches of regulation and the service was placed into special measures. The report was published 27 August 2019.

A focussed inspection visit looking at safe and well-led, in response to concerns received was completed 17 October 2019, the service remained rated as Inadequate, with breaches of regulation and remained placed in special measures. The report was published 22 November 2019.

This will be the third, consecutive inspection where the service has been rated inadequate and remained in special measures.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified repeated breaches of regulation in relation to the provision of safe care and treatment, keeping people safe from risk of harm or abuse, maintenance of the care environment and good governance processes. We have also identified breaches of regulation relating to adherence with the Mental Capacity Act (2005), staffing levels; training and competence, provision of dignified and person-centred care and support, at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special Measures

The overall rating for this service remains 'Inadequate' and the service remains 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.

Dunsland is a residential care home providing personal care and support for up to 14 people aged 18 years and over living with learning disabilities, autism, physical and mental healthcare needs. At the time of the inspection, 11 people were living at the service and one person was in hospital.

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The service was a large home, bigger than most domestic style properties, and larger than current best practice guidance for people with learning disabilities and autism. The size of the service was having a negative impact on some of the people due to building design and layout, and the number of people sharing communal areas of the service.

Not all of the principles had been applied to the service provided, to ensure 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 includes having control, choice, and independence. People using the service should also 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

People were not always supported by enough suitably trained staff. This was confirmed by our observations of care, reviews of incidents and feedback we received.

We identified environmental risks and concerns impacting on the standards of safe care being provided. The care environment continued not to be clean throughout, and concerns identified during the inspection had not been found by the management team as part of their audits and quality checking processes. Leadership and governance arrangements within the service remained a concern since the last inspection. The remained concerns in relation to the safe management of people’s medicines.

We identified breaches of regulation and the provider, in the absence of a registered manager, was not meeting their legal, regulatory responsibilities to ensure people received good standards of care.

People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible; policies and systems in the service were not followed to support good practice or reflecting the principles and values of Registering the Right Support.

People’s care records were not person-centred, and did not reflect changes in ability, risk or behavioural presentation. The manager had not completed reviews and made the necessary changes to each person’s care records or aspects of their medicine management plans since the last inspection.

Rating at last inspection:

Dunsland was previously inspected 09 May 2019 and rated as Inadequate overall and the service was placed into special measures. The report was published 27 August 2019.

Why we inspected:

We received concerns in relation to the management of medicines, the condition of the care environment, the standards of care being provided and the overall safe running of the service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

The overall rating for the service remains the same, and the service continues to remain in special measures. 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 Dunsland on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation keeping people safe from harm and risks of abuse, and repeated breaches of safe care and treatment and good governance procedures at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good and as part of this process we will ask for the service to provide a detailed improvement plan. We will work with the 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.

Special Measures:

The overall rating for this service remains ‘Inadequate’ and the service remains 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.

Dunsland is a residential care home that was providing personal care for up to 14 adults who have a learning disability or mental health need at the time of the inspection. At the time of our inspection 12 people were receiving a service. Accommodation was provided in an adapted building where each person had their own room and shared communal spaces.

The service was operating before the principles and values that underpin Registering the Right Support had been developed. However, the service would be expected to develop in line with these principles and other best practice guidance. Registering the Right Support 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 should receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 14 people. 12 people were using the service at the time of our inspection. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building continuing to resemble two semi-detached houses from the outside. Also there were no identifying signs, intercom or cameras, for example, outside to indicate it was a care home. Staff did not wear uniforms or name badges and mostly people were supported to access the local community in small groups, one to one with staff or independently.

People’s experience of using this service:

The service was not well maintained, and systems designed to identify safety issues relating to the environment were not effective and placed people at risk.

Audits and quality assurance visits either did not identify serious issues with the building or recorded them and then did not take effective action to mitigate these risks. The environment was not suitable for some of the people living at the service and work was needed to ensure it was always clean and well maintained.

Complaints were poorly managed and not dealt with in line with the provider’s own procedure.

Staff received the training they needed to carry out their roles but some further training was needed. This had already been acknowledged by the provider, who had started a new training programme.. There was no structured induction for new staff, although this was planned to be introduced. Staff were trained to administer medicines but some aspects of medicines management were not well managed. Health needs were mostly managed well but records were not always completed so we could not be assured of this.

Staffing levels fluctuated and the service had just taken on the responsibility for providing daytime occupation for people which was a challenge. This occasionally meant that people’s opportunities to access the local community were affected or people were going out in groups which was not always appropriate. Those people who were more independent had good access to meaningful occupation and spent time within their local community and on following their own hobbies and interests at the service.

People told us they were happy at the service and were positive about the staff. Relationships were good and people were consulted about their care. Records did not demonstrate that people’s capacity to consent to their care was always appropriately assessed and decisions taken in their best interests. People were supported to have choice and control of their lives but the service could not demonstrate that systems ensured support was always provided in people’s best interests.

The new manager had begun to address some of the issues they inherited when they took over the service. Staff were in support of what the manager was trying to do. The provider did not have sufficient oversight of the serious issues at the service, despite regular quality audits and checks by senior management. Some key systems to identify and address issues were not fit for purpose. However, the provider promptly acknowledged this failing and took remedial action, which began on the day of the inspection visit. They continued to keep us updated with this.

We have made recommendations about the management of people's finances, the management of consent, procedures relating to end of life advanced care planning and about the need to seek out and act on feedback from relevant people.

The service aimed to apply the principles and values of Registering the Right Support. This aims to 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.

The outcomes for people using the service did not fully reflect the principles and values of Registering the Right Support for the following reasons: people were not fully included in decisions about their care and treatment and did not always receive care and support tailored to their individual needs.

Rating at last inspection: At the last inspection the service was rated Good (published 5 November 2016.)

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

Enforcement: We have identified breaches of regulation in relation to safety, premises, complaints and good governance at this inspection. 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

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

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 of their 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.

Dunsland provides accommodation, care and support for up to 14 people living with a learning disability. At the time of our inspection there were 11 people living in the home.

The manager has been in post since January 2016. 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 were cared for in a safe way. Steps had been taken to identify and mitigate any risks to people’s wellbeing and safety and in the environment of the home. Risk assessments were detailed and gave clear guidance for staff on how to manage risk. People were supported by staff who knew how to protect people from harm. Staff were knowledgeable in their work and had received training appropriate for their role. There were enough staff to support people effectively.

There were safe recruitment practices in place which ensured that appropriate checks had been carried out on staff before they started working in the home.

Medicines were managed and stored safely in the home. Staff had the necessary training in order to administer people’s medicines in a safe way.

People had not received a mental capacity assessment so it was not clear what decisions people could make for themselves, and what decisions they needed support with. Therefore, there was not clear why people needed support in certain areas.

People’s support plans were person centred and reflected people’s wishes around how they wanted their care to be delivered. Staff knew how to promote people to be as independent as possible and people were supported to pursue their interests and hobbies as well as play an active part in the running of the home.

Prompt referrals were made to relevant healthcare professionals where concerns were raised regarding a person’s health or wellbeing. People were also supported to eat and drink sufficient amounts. People were consulted on what food they preferred and the menus were devised according to people’s preferences.

Staff who worked in the home were caring. People were consistently treated with dignity and respect and their right to privacy was upheld. Staff knew how to support people with their individual care needs and asked people about their preferences. People were able to have their relatives and friends visit the home.

People’s care needs were constantly reviewed and people’s support plans were updated to reflect any changes required in their care.

There was an appropriate complaints procedure in place and staff knew how to support people in the event that they wanted to make a complaint. An easy read version of the complaints procedure was placed in a communal area so people could easily access it. Where concerns had been raised, appropriate action was taken.

The service was being well run and people’s needs were being met appropriately. Staff felt supported by the manager and there was frequent and effective communication between the manager, staff and people living in the home. The manager was approachable and encouraged staff to put forward new ideas about how the service could improve.

There were a number of systems in place to monitor and asses the quality of the service. Regular audits were carried out by the manager. These identified any areas for improvement and any remedial action that was needed.

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our discussions with four people who used the services and three staff members. In addition we looked at two people's care and support plans.

Is the service safe?

Risk assessments were in place to ensure that as far as possible people were safe in the home and that staff were safe in their working environment. Where risks to people had been identified measures had been taken to minimise or remove them. Appropriate vetting of staff combined with on-going support and appraisal meant that the provider took reasonable steps to ensure that vulnerable adults were protected from the risk of abuse. We looked at staff rotas and found that there were enough qualified, skilled and experienced staff to meet people's needs throughout the day and night.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. At the time of the inspection no applications had needed to be submitted. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service caring?

People we spoke with said that staff treated them with respect and consideration. They felt that staff listened to them and took time to explain things. People also told us that they were consulted about the care and support they received.

People's needs were assessed and care and support was planned and delivered in line with their individual care plans. The care plans we looked at were personalised and detailed and provided a good level of information for the staff providing the care.

During the inspection we observed that staff were kind and caring in their interactions with people.

Is the service responsive?

The provider had a system of dealing with complaints. We found that people's complaints had been dealt with in a timely manner. People knew how to make a complaint if they were unhappy. The complaints process was displayed in the entrance hall,making it easily accessible to people and visitors. Where shortfalls or concerns were raised these were addressed by the provider.

People told us that the provider responded to their changing needs in a timely manner. People's needs were assessed and reviewed on a monthly basis or as and when needed. Where changes occurred, the service referred to health professionals for advice and guidance if required. All changes were well documented and recorded.

People who used the services and their family members or representatives, were asked for their views about the care provided and these were acted on by the provider.

Is the service effective?

People using the services that we spoke with said, or indicated to us, that the care and support provided was of good quality. From our observations we saw that care and support was effective and consistent.

People were supported to be as independent as possible. One person told us, "I like to help in the kitchen if I can. But only when someone is there to help me."

We saw that staff knew the people they were supporting and caring for and that the people receiving the care and support were happy. We noted that if something was not right that staff responded quickly to resolve matters.

People told us, or indicated to us, that they liked living at Dunsland and that staff were kind and caring.

Staff explained how they were able to communicate with people who were not able to express themselves verbally.

Is the service well led?

Views of people using the services and, where possible, of their families were obtained and opportunities were in place for social gatherings where further views and opinions of the services, and staff, could be gained.

Staff told us that they felt supported and had received sufficient training to carry out their role effectively. They added that if they felt they needed further or additional training or support that they were confident this would be arranged by the provider.

There were quality monitoring systems in place and regular audits and spot checks took place to ensure that people received a good service.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they did.

One person told us that they particularly enjoyed helping around the house and we observed other people also undertaking various household tasks as they wished. We observed people choosing and preparing what they wanted for lunch and saw that staff empowered people by assisting when needed or when asked, rather than 'doing for' people.

Staff spoke respectfully with people living in the home and consistently included them in conversations and friendly banter.

Care records contained sufficient information, that was easy to follow, to ensure people received individually tailored care and support.

Assessments took into account the risks to which people were exposed but they also reflected people's wishes and independence in a balanced way.

There were policies in place to safeguard people living in Dunsland and the manager had kept the Care Quality Commission informed of any safeguarding issues. We saw examples that assured us that the manager and provider had responded appropriately to any suspicion or allegation of abuse.

Staffing levels were sufficient to meet people's needs appropriately.

The manager provided us with all the records we asked to see during this inspection and we saw that these were kept securely, were accurate and fit for purpose.

We saw that a number of improvements had already been made since the manager started working in the home and we acknowledged further areas for improvement that were 'work in progress'.

We saw that where one person required one-to-one support 24 hours a day, this was provided appropriately by staff who showed good knowledge and understanding of the person's support needs.

We noted from minutes of the most recent 'residents' meeting that people had been involved in making choices with regard to the menu options and were supported to understand the positive aspects of 'healthy eating'.

We did not speak directly with people living in the home about safeguarding. However, our observations showed people to be relaxed and comfortable with the staff and we noted positive and friendly interactions between the staff and people being supported.

We found the home to be clean and hygienic, with a homely atmosphere and noted that people had individual rooms, which either had been or were being decorated and furnished in accordance with their preferences and choices.