Archived: The Laurels

The service was registered for the support of up to 41 people. At the time of the inspection nine people were using the service.

The service consisted of four separate Lodges within one building. At the time of the inspection, all nine people were living in one lodge. Two people from these eight were staying with relatives, so there were seven people staying in the lodge when we visited.

The Laurels is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

There was unsafe assessment, monitoring and management of risk for people with support needs regarding constipation, behaviours that may challenge, choking, breathing, skin integrity, mobility and posture.

Risks around people’s deteriorating health and well-being were inconsistently managed and monitored by staff.

Medicines were not always managed safely. People had not always received their medicines as intended when they needed them.

People were not always safeguarded from abuse.

Lessons were not always learnt, and actions not taken to investigate safety incidents, and prevent them re-occurring.

Staff practice, and reporting systems to safeguard people from abuse, were not always effective to ensure people were safe from harm.

Staff did not always have the required competencies or knowledge to safely meet people’s individual needs.

Service management, and the provider’s wider quality assurance and governance systems, had not always ensured actions were taken to address any issues and risks in a timely manner. People’s care records were not always up to date or accurate.

The provider had failed to act upon known areas of concern, non-compliance, and risk to improve the quality of care for people at The Laurels. This had exposed people to on-going poor care and risk of avoidable harm.

Staff told us they had not always worn the correct personal preventative equipment (PPE) when supporting people. The provider acted immediately to address this with staff and offer additional training and guidance. The provider had ensured there were adequate stocks and supplies of PPE available.

The provider had acted to manage other infection risks during the Covid-19 pandemic. Additional infection prevention and control measures in line with Department of Health and Social care guidelines had been put in place to ensure people’s safety.

Staff had alerted appropriate external agencies when they had displayed signs and symptoms of Covid-19. This had helped prevent infection and maintain people’s health and well-being.

Relatives told us the service was always clean and well maintained whenever they had visited, or from what they had seen on video calls.

We observed there was a high ratio of staff supporting people during the inspection. Staff and people said there were currently enough staff. Relatives told us they thought staffing levels had improved and more staff had been recruited recently.

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 guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

The model of care and setting did not maximise people’s choice, control and

independence.

The service was in private grounds in the countryside. Opportunities for people to access the local community were limited. Staff wore uniforms and name badges to say they were care staff when coming and going with people.

The service is bigger than most domestic style properties. There were identifying signs on the road before the service’s private drive, the service grounds and on the exterior of the service to indicate it was a care home.

Right care:

Care was not always person-centred or promoted people’s dignity, privacy and human rights.

People were not supported safely.

People were not always listened to.

Staff did not always respond in a compassionate or appropriate way when people experienced pain or distress.

Right culture:

The management team had begun to plan how to work to ensure they could provide good quality personalised, respectful support for people living at the service.

People had recently been allocated keyworkers, to help them get the support they needed and wanted.

Staff said they were being encouraged to understand how to support people in a person-centred way.

We observed staff supporting some people in a positive manner during our inspection visits

However, significant work was still needed to change the existing culture, ethos, attitude and practice of staff at The Laurels in order to achieve this vision.

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 Inadequate (published 9 July 2020). The service has been rated requires improvement or inadequate for the last eight consecutive inspections.

At the last inspection we found multiple breaches of regulations. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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 coronavirus and other infection outbreaks effectively.

We carried out a comprehensive inspection on 20 and 21 August 2019 and an announced targeted inspection on 19 May 2020. Breaches of legal requirements were found at both inspections.

We undertook this focused inspection to confirm the provider now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 not changed. 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 The Laurels 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 four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulations 12, 13, 17, 18 in relation to: safe care and treatment, safeguarding people from abuse, good governance and staffing.

We have also identified a breach of Care Quality Commission (Registration) Regulations 2009 regulations 14 and 18 in relation to failing to notify CQC of incidents regarding staffing, abuse or allegations of abuse in relation to service users and of the absence of a registered manager.

We took enforcement action to issue a Notice of Decision to vary a condition of the provider's registration

and remove this location. The Laurels is now de-registered and the provider is no longer able to provide regulated activities at or from this location.

Follow up

We will continue to monitor information we receive about the service until we return to visit. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘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 act 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.

The Laurels is a residential care service that provides nursing and personal care for 9 people and younger adults with learning disabilities or autism spectrum disorder and physical disabilities at the time of the inspection. The service can support up to 41 people.

The service is larger than current best practice guidance and consisted of four separate Lodges within one building. At the time of then inspection, all nine people were living in one lodge. The service was in private grounds in the countryside. The service is bigger than most domestic style properties. There were identifying signs on the road before the service’s private drive, the service grounds and on the exterior of the service to indicate it was a care home. Staff wore uniforms and name badges to say they were care staff when coming and going with people.

The Laurels is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation in relation to incidents that occurred between 2016 and 2018. The investigation is on-going, and no conclusions have yet been reached.

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

There was unsafe assessment, monitoring and management of risk for people with support needs regarding epilepsy, constipation, behaviours that may challenge, nutrition and hydration, choking and aspiration. Risks associated with people’s deteriorating health were not always assessed or monitored safely. This exposed people to risk of harm.

Medicines were not always managed safely. People had not always received their medicines as intended when required. Staff did not always have the required competencies or knowledge to meet people’s individual needs safely.

Staff practice and reporting systems to safeguard people from abuse were not always effective. Lessons were not always learnt, and actions were not consistently taken to investigate safety incidents and prevent them re-occurring.

People’s care records were not always up to date or accurate. Service management and the provider’s wider quality assurance and governance systems had not always ensured actions were taken to address any issues and risks in a timely manner. The provider had failed to act upon known areas of concern, non-compliance and risk, to improve the quality of care for people at The Laurels.

Rating at last inspection

The last rating for this service was Inadequate and there were multiple breaches of regulations. We published a report of our findings on 8 November 2019.

At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about management of risks for people with epilepsy, constipation, behaviours that may challenge, complex eating and drinking risks, choking and aspiration, and skin integrity support needs. We also had concerns about unsafe management and use of medicines, the provider’s governance framework, quality assurance systems and how they were working in partnership with other agencies. The overall rating for the service has not changed following this targeted inspection and remains Inadequate.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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

Enforcement

We have identified two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulations 12 and 17 in relation to: safe care and treatment and good governance. We also identified a new breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulation 13 in relation to safeguarding people from abuse.

On 26 May 2020 we imposed conditions on the provider’s registration telling them how they must act to address serious concerns regarding unsafe care for people with known risks associated with their support needs regarding epilepsy, constipation, behaviours that may challenge, nutrition and hydration, choking and aspiration and monitoring and acting in response to people’s deteriorating health. The condition requires the provider to submit a monthly report to the Commission on their actions to improve in these areas.

Follow up

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

The Laurels is a nursing home providing personal care and accommodation for up to 41 people with learning disabilities, physical disabilities and complex needs. The Laurels originally had four lodges but two are closed and people currently lived in two lodges called Juniper and Cherry. At the time of the inspection there were 12 people living at The Laurels.

The Laurels is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

The service was registered before the 'Registering the Right Support' guidelines were in place. However, the service was not operating in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. These values were not always seen consistently in practice at the service. For example, some people were not being supported to be as independent as they could be with activities or communication, and some were not receiving the assistance with communication they needed to be as independent as possible.

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

People’s relatives gave universally positive feedback about the service. Comments such as, “We are extremely happy with all aspects of [name’s] care and couldn’t wish for more. We chose The Laurels for the facilities, the care given, the spacious accommodation, and the stimulation a larger home provides.”

However, our inspection found that sufficient improvements had not been made in a number of key areas. This was the sixth consecutive inspection where a breach of regulation concerning safe care and treatment was found. People were not consistently kept safe from risks around epilepsy, constipation and medicines. Not all lessons had consistently been learned and we found some issues with medicines errors and behaviour management.

There was a gap in training for agency staff and the competency of agency nurses was not checked. There was a risk that people would not have their healthcare needs met and we found issues with turning charts, and constipation risk management. There remained conflicting information between different care documents which demonstrated a lack of clarity about the care that was delivered to people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Some decisions made on behalf of people didn’t involve them and some DoLS conditions may not have been met.

Some people were not supported with their communication needs in the way they were assessed. This left them at risk of not being able to be involved in their care.

Care plans did not have goals or aspirations and were not person centred. People were going out more often, but more improvement was required around in-house activities to evidence people’s involvement and link to their goals and aspirations.

The governance and auditing of The Laurels was not well led as audits had not been effective in putting right issues we found at the last inspection. This is the eighth consecutive inspection where governance and audits had not identified shortfalls. There was a new manager at the service who was registering with CQC and was working to change the culture in the service.

Staffing levels appeared to be safe from our observations and staffing levels on the rota matched the dependency tool. The service was clean and there was an infection control audit and champion, and staff used personal protective equipment to keep people safe from the risk of infection.

People had enough food and drink to maintain their health. Fluid charts had been completed accurately and peoples recommended daily amounts were met. People would receive joined up support if they moved from or to the service.

Staff and people were being more involved in the running of the service. The management had a vision for the service based around people having control of their lives. There was a culture change underway and the service felt happier and less hectic. Changes made to the service, such as people answering their own doors, was progress towards more person-centred support.

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 Inadequate (published 17 May 2019) and there were multiple breaches of regulation.

This service has been in Special Measures since April 2018

Why we inspected

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

Enforcement

We have identified breaches in relation to person centred care, dignity, mental capacity, safe care and treatment, staffing, and governance. One breach around dignity had been met but there were continued breaches of five areas since the previous inspection and one new breach around consent.

On 26 May 2020 we imposed conditions on the provider’s registration telling them how they must act to address serious concerns regarding unsafe care for people with known risks associated with their support needs regarding epilepsy, constipation, behaviours that may challenge, nutrition and hydration, choking and aspiration and monitoring and acting in response to people’s deteriorating health. The condition requires the provider to submit a monthly report to the Commission on their actions to improve in these areas.

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We also imposed conditions on this location regarding the restriction of new admissions and ensuring an external pharmacy audit is completed every month. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

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.

Special Measures:

The overall rating for this service is ‘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.

The Laurels is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The Laurels is registered to provide accommodation, nursing care and personal care, treatment of disease, disorder or injury and diagnostic and screening procedures. The Laurels is registered to provide this support for up to 41 people and younger adults with a learning disability or autistic spectrum disorder, physical disabilities and sensory impairments.

The Laurels is situated in a self-contained plot of private, access-controlled land in a geographically isolated rural setting. The service is separated into four different areas called ‘Lodges’; Juniper, Cherry, Birch and Aspen. At the time of the inspection there were 27 people living at The Laurels; nine people in Cherry, five people in Birch, five people in Juniper and eight people in Aspen. People have their own bedrooms and each Lodge has a self-contained lounge and dining area. All people living at The Laurels also have access to a communal lounge, gym, computer room, spa-pool, swimming pool and sensory room.

The Laurels had been built and registered before Registering the Right Support (RRS) had been published. However, the provider had not developed the service in response to the values that underpin RRS or changes in best practice guidance for providers of learning disability and autism services.

These values and guidance includes advocating choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen. We found The Laurels did not always conform to this guidance and values when supporting people or in the model, scale and geographic setting of the service. Due to this, it is unlikely that a request to register The Laurels today would be granted.

The Laurels has been without a formal registered manager since 10 April 2018. A registered manager is a person who has registered with the CQC 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. An area manager from the organisation had been assuming the registered manager responsibilities for the service on an interim basis since then.

The service had recruited a manager to permanently fulfil the registered manager’s role at the beginning of June 2018. The manager was now in post and in the process of formally registering with the Care Quality Commission (CQC).

Services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. Between May 2017 and April 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

The Laurels was inspected in May 2017 and rated as ‘Requires Improvement’ overall, including a rating of ‘Inadequate’ in the Well-led section of the report. We identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations, including a breach relating to ineffective quality assurance systems and failure to keep people protected from abuse and improper treatment.

At an inspection in November 2017 the rating for ‘Well-led’ had improved from ‘Inadequate’ to ‘Requires Improvement’. The service remained rated as overall ‘Requires Improvement’ and we identified a breach of regulations; The registered person had not ensured that all staff received appropriate training to enable them to carry out the duties. The provider wrote to us to tell us the action they were taking to address this.

We last inspected the service on 21 and 22 February 2018. That inspection was a focused inspection where we only looked at the service performance relating to the key lines of enquiry ‘Safe’ and ‘Well-Led’. The inspection was prompted in response to concerns shared with the CQC by the local authority safeguarding team. The concerns were regarding people who might present physically challenging behaviour receiving unsafe support from staff.

At this last inspection in February 2018, we rated the service as inadequate in ‘Safe’ and ‘Well-Led’. We identified breaches of the regulations regarding failures to keep people safe from abuse and improper treatment, provide safe care and treatment and operate effective quality assurance systems. Therefore, following this inspection the overall rating changed to ‘Inadequate’ and the service was placed in special measures.

Services in special measures are kept under review and inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. At this inspection we found the provider had not taken effective action to improve the service. The overall rating for this service is ‘Inadequate’ and the service therefore remains in special measures.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. This service will be kept under review and, if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling or varying the terms of their registration.

Risks and quality issues at the service had not always been identified. Where risks and quality issues had been identified, actions were not always assessed and prioritised effectively to make sure urgent issues could be, and were, achieved in a timely manner. Actions that were implemented were not adequately monitored by management to ensure the quality and safety of the service was continually improving.

The provider had failed to ensure sufficiently skilled and trained staff were deployed to meet people’s needs. Staff were not always aware of what they were expected to do or have support to understand their specific responsibilities and accountabilities.

The service was not managing or monitoring risks to people’s safety adequately. Staff were not always aware of risks to people. People who displayed behaviours that can challenge were not having their needs met and had been subject to unsafe support, including unnecessary and unsafe forms of control and restraint. Medicines were not being safely or properly managed.

Legal requirements of the service had not always been met. This included submission of CQC statutory notifications and sharing of required information with other agencies related to the service.

Systems and processes to safeguarded people from abuse were not operating effectively. Safeguarding incidents had not been adequately reviewed internally or reported to the local authority to gain input from external health and social care professionals.

Records relating to people’s health care and support, including complex nutrition and hydration support, were not being completed consistently and this was not being monitored or managed effectively. We have made a recommendation about seeking advice, implementing and using healthcare monitoring systems effectively.

The service was not always obtaining appropriate consent from people regarding their care and treatment. People’s support was not always provided in line with the principles of the Mental Capacity Act 2005 (MCA). Assessments of people’s needs were not effective and people’s support was not always appropriate, met their needs or fully reflected their preferences.

People’s care plans were health focused and included limited information about people’s social and emotional needs. People’s support was not always person-centred or responsive to allow people to follow their individual interests or achieve their aspirations. People did not have support to access the wider community and take part in meaningful activities.

People’s dignity and privacy was not always respected. Staff had not always had the time to get to know people or access information about them. Some staff lacked knowledge about how people preferred to communicate or how to encourage them to express their views.

Historical physical environment issues relating to fire safety and decoration had been addressed. Plans were in place to make further adaptions to areas of the service to better meet people’s needs and promote their independence.

People told us there was a lot of support to socialise with other people at the service. Visitors were welcome to the service. People also had support to arrange visits to see and stay in touch with their relatives. This helped people to avoid becoming isolated and maintain relationships with important people in their lives.

People told us staff were kind. We observed staff engaging with people in a compassionate manner.

There had been a very recent change in management and the new manager hoped to implement changes to address the issues to achieve the expected quality of support for people at the service.

Staff told us that the recent change in management had been positive and they were being involved in the attempts to develop the service. People and their relatives also told us that there had recently been a renewed emphasis on encouraging them to share their views on issues and how to make sugges

This inspection was carried out in part in response to concerns shared with us by the local authority, West Sussex County Council (WSCC) Adult Safeguarding team. These concerns related to unsafe care and risk management of specific individuals’, bowel care, nutrition, hydration, behavioural, wound management, postural support and on-going healthcare need

The inspection was also undertaken in part in response to review and analysis of information we had received about the service via our on-going monitoring and inspection processes. This information indicated that all people at the service may be at risk due to on-going unsafe management of medicines.

Following the last inspection on 20, 21 and 24 June 2018 the provider was not meeting multiple legal requirements. At this inspection we checked that improvements had been made to meet some of these requirements which related to the information of concern we had received. The requirements that we checked to see if they had improved were regarding; managing risks to people, management of medicines, deployment of suitably trained staff, preventing and learning from safety incidents, safeguarding people and operating effective governance frameworks and quality assurance systems.

We inspected the service against two of the five questions we ask about services: is the service well led and is the service safe. No urgent risks were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them.

The Laurels is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided.

The Laurels is registered to provide accommodation, nursing care and personal care, treatment of disease, disorder or injury and diagnostic and screening procedures. The Laurels is registered to provide this support for up to 41 people and younger adults with a learning disability or autistic spectrum disorder, physical disabilities and sensory impairments.

The Laurels is situated in a rural part of West Sussex on a self-contained complex. The service is separated into four different areas called ‘Lodges’; Juniper, Cherry, Birch and Aspen. At the time of the inspection there were 19 people living at The Laurels; 10 people in Cherry, four people in Birch and five people in Juniper. Aspen Lodge was closed and there were no people living there.

People have their own bedrooms and each Lodge had its own lounge and dining area. All people living at The Laurels also have access to a communal lounge, gym, computer room, spa-pool, swimming pool and sensory room.

The Laurels had been built and registered before Registering the Right Support (RRS) had been published. The provider had not developed the service in response to the values that underpin RRS or changes in best practice guidance for providers of learning disability and autism services. These values and guidance includes advocating choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen.

We found The Laurels did not always conform to this guidance and values when supporting people or in the model, scale and geographic setting of the service. Due to this, it is unlikely that a request to register The Laurels today would be granted.

The Laurels has been without a registered manager since 10 April 2018. A registered manager is a person who has registered with the CQC 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. The service had recruited a manager to permanently fulfil the registered manager’s role at the beginning of June 2018. The manager was in post and in the process of formally registering with the Care Quality Commission (CQC).

Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have been made.

Between May 2017 and July 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

We last inspected the Laurels on 20, 21 and 24 June 2018. We carried out a full comprehensive inspection of the service. The service was rated 'Inadequate' and we identified multiple breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 regulations.

These breaches regarded; failures to keep people safe from abuse and improper treatment, provide safe care and treatment, operate effective governance frameworks and quality assurance systems, provide person centred care to people, treat people with dignity and respect, provide care and treatment with the consent of relevant people and deploy sufficient numbers of suitably skilled and experienced staff.

The service was also in breach of the Care Quality Commission (CQC) (Registration) Regulations 2009 regarding failure to notify the CQC as required regarding allegations of abuse in relation to service users.

We found urgent and serious evidence of abuse, unsafe and improper treatment and on-going high risks for some people who could display behaviours that could be physically challenging living in a part of The Laurels called Aspen Lodge. We also found urgent and serious risks of harm presented to all people living at The Laurels presented by unsafe management of medicines.

Due to the serious and urgent nature of concerns, after the inspection we issued a Notice of Decision (NoD) to the registered provider on 26 June 2018. The NoD told the provider to act to review the management of their medicines and make sure people living in Aspen Lodge were supported by sufficient, suitably trained staff. We also told the provider that they should not admit any new people to live at The Laurels without permission from the CQC. Shortly after the NoD was issued, the provider temporarily closed Aspen Lodge.

Following the issue of the NoD, after the report was published for the inspection on 20, 21 and 24 June 2018, the service was rated as Inadequate overall, requiring improvement in the key questions ‘Caring’ and ‘Responsive’ and Inadequate in ‘Safe’, ‘Effective’ and ‘Well-Led’. This was the second time the service was assessed as ‘inadequate and therefore the Laurels remained in special measures. Services in special measures are kept under review and inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

During this focused inspection we found concerns consistent with the information shared with us by the local authority safeguarding team regarding poor record keeping, information sharing and risk management relating to specific individuals’ bowel care, hydration, postural, wound management and on-going healthcare support needs. These concerns meant people were at a high risk of potential harm.

Where people at risk of constipation had identified actions to manage risks if they did not have a bowel movement, this was not always monitored effectively. When action was needed after periods they had not had a recorded bowel movement, such as giving them medicines or seeking medical advice, this was not always done.

Systems in place to monitor people’s vital health signs to help warn staff that they may be unwell and require medical assistance were not operating effectively. Staff were not always recording or analysing information about vital health signs correctly, so did not always know if a person was unwell or needed assistance. Where signs showed a person was unwell and needed further medical help, staff were not always acting to do this.

People requiring support to take fluids and were at risk of dehydration had not always been assessed to know how much fluid they needed to have each day to manage this risk safely. Where people had been assessed as needing certain amounts of fluids every day, it was not always recorded that they had received enough to drink to keep them safe.

People requiring support to move and position their bodies due to physical disabilities had several conflicting guidelines for staff to follow to know how to safely manage risks associated with this, such as pressure wounds. Staff were not all following the same advice and the person was being supported in different ways. This meant it was not known if the person was being supported to manage their risks associated with their body positioning needs safely.

It was not always recorded when people had been supported to have their medicines. Staff had missed giving some people their required medicines. Stocks of medicines were not always recorded accurately. This represented an on-going risk that people could not receive their medicines safely or as intended.

We also found the provider had not taken effective action to improve the service in relation to managing risks to people, providing safe care and treatment, safeguarding people from abuse, safe management of medicines and operating effective governance frameworks and quality assurance systems.

The quality and safety risks and governance issues found during this inspection corresponded wi

We inspected the service against two of the five questions we ask about services: is the service well led and is the service safe. No urgent risks were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them.

The inspection was prompted in part by notification of an incident following which a person using the service became critically unwell. This incident is subject to a separate investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of choking, aspiration and on-going healthcare support needs for people using the service. This inspection examined those risks. We also looked to see how the service was providing enough skilled staff, preventing and learning from safety incidents, safeguarding people and operating effective quality assurance and governance systems.

The Laurels is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided.

The Laurels is registered to provide accommodation, nursing care and personal care, treatment of disease, disorder or injury and diagnostic and screening procedures. The Laurels is registered to provide this support for up to 41 people and younger adults with a learning disability or autistic spectrum disorder, physical disabilities and sensory impairments.

The Laurels is situated in a rural part of West Sussex on a self-contained complex. The service is separated into four different areas called ‘Lodges’; Juniper, Cherry, Birch and Aspen. At the time of the inspection there were 19 people living at The Laurels; 10 people in Cherry, four people in Birch and five people in Juniper. Aspen Lodge was closed and there were no people living there.

People have their own bedrooms and each Lodge had its own lounge and dining area. All people living at The Laurels also have access to a communal lounge, gym, computer room, spa-pool, swimming pool and sensory room.

The Laurels had been built and registered before Registering the Right Support (RRS) had been published. The provider had not developed the service in response to the values that underpin RRS or changes in best practice guidance for providers of learning disability and autism services. These values and guidance includes advocating choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen. We found The Laurels did not always conform to this guidance and values when supporting people or in the model, scale and geographic setting of the service. Due to this, it is unlikely that a request to register The Laurels today would be granted.

The Laurels has been without a registered manager since 10 April 2018. A registered manager is a person who has registered with the CQC 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. The service had recruited a manager to permanently fulfil the registered manager’s role at the beginning of June 2018. The manager was in post and in the process of formally registering with the Care Quality Commission (CQC).

Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have been made.

Between May 2017 and July 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

We last inspected the Laurels on 15 and 21 August 2018. This was a focused inspection looking at the key questions ‘Safe’ and ‘Well-Led’. The inspection was prompted by concerns that people using the service may be at risk of harm. Following the August 2018 inspection, the key questions were both rated ‘Inadequate’ and the overall rating for the service was ‘Inadequate’.

This was the third time the service was assessed as ‘Inadequate’ following receipt of this rating after inspections in February and June 2018. Therefore, the Laurels remained in ‘Special Measures’. Services in special measures are kept under review and inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

At this inspection, we focused on specific concerns and looked at the management of risk of choking, aspiration, wound management and on-going healthcare support needs for people using the service. We also looked to see if the provider had made improvements to prevent and learn from safety incidents, safeguard people and operate effective quality assurance and governance systems.

Not all staff had read or had access to people’s eating and drinking choking and aspiration risk management assessments and guidelines. Not all of these documents had been recently reviewed. Some people had several different sets of aspirations and choking risk management documents available for staff. In some cases, these documents contained conflicting or incorrect directions.

Where there were directions to take actions if there was a choking incident, people’s plans did not always contain enough detail about how to do this safely. Staff had not always had the correct training to be able to take these necessary actions and did not feel confident to do so. Monitoring records of people’s eating and drinking to help manage the risks of choking and aspiration were not completed accurately.

There had been incidents at the service where people had been placed at risk of harm when people had not been supported to manage choking and aspiration risks safely by staff. There remained an increased the risk of people coming to harm or that they could be supported inappropriately in ways that did not respect their freedom, choice and control.

Not all staff understood their responsibilities to report accident, incidents or safeguarding concerns internally as soon as possible. Where incidents and safeguarding concerns had been reported internally without an undue delay, information about safeguarding concerns and incidents and accidents was not always shared with partnership agencies by management. Where this had been shared, this had not always been done in a timely manner. This meant further review and investigation to agree all necessary actions keep people as safe as possible did not always happen quickly, or at all.

Systems in use at the service to monitor people’s health needs had recently been revised to help identify any potential or actual concerns to people’s well-being. Changes had been introduced very recently and were not yet fully embedded. Not all staff working at the service had received support to understand and use the systems. Some staff were not confident about how to use them. This presented a risk that people’s health needs might not be monitored effectively and action taken quickly to keep people safe.

Quality assurance and governance frameworks were not always operating effectively. Quality and safety risks found during this inspection had not always been identified by the provider’s quality assurance systems. Where they had been identified, they had not always been acted on in a timely manner or monitored and managed effectively. The quality and safety risks and governance issues found during this inspection corresponded with themes of concerns and breaches of regulatory requirements in our inspection processes dating back to May 2017. This meant the provider’s governance framework had not been able to ensure that staff at all levels understood and had carried out their responsibilities successfully.

The provider had not always ensured the service worked effectively with partnership agencies. Feedback from local authority and healthcare professionals raised reservations that management and staff at the service had not always worked in an open and transparent way when being approached to review people’s care. The provider was not always ensuring the service was meeting its legal requirements, including submitting statutory notifications of incidents.

The provider had systems in place to ensure that any vacancies were covered by agency staff. On on-going service review was taking place to re-assess people’s support levels to make sure they were getting the correct amount of support they were funded for. This had resulted in an initial reduction of overall staffing levels at the service. Staff raised concerns with us about the reduction in staffing levels leaving some people at risk of not meeting their needs. We did not find any people at direct risk of harm from the changes and the provider had restored staffing levels in response to the concerns while the review was on-going.

People said they liked living at the Laurels. There had been several recent changes to the service and higher organisation’s management. The current manager was committed to overcoming issues to be able to deliver a good quality service. Staff said management was visible and supportive. People’s relatives said although there had been past issues with the management of the service,

¿The Laurels is a residential care service that is registered to provide accommodation, nursing and personal care for up to 41 people with the following support needs; learning disabilities or autistic spectrum disorder, physical disabilities, sensory impairments, younger adults.

¿At the time of this inspection The Laurels was providing support for 14 people.

¿ The Laurels is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going and no conclusions have yet been reached.

¿ The Laurels had been built and registered before the CQC policy for providers of learning disability or autism services ‘Registering the Right Support’ (RRS) had been published. The guidance and values included in the RRS policy advocate choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen.

¿ The Laurels requires further development to be able to deliver support for people that is consistent with the values that underpin RRS. For example, care planning processes did not always consider people’s personal information and how these informed their individual support needs and wishes, people did not always agree, review or develop their support goals and people could not always take part in meaningful activities or have regular access to the community.

People’s experience of using this service:

¿ Medicines were not always being managed safely.

¿ Risks to people were not always assessed, monitored and managed safely.

¿ Lessons were not always learnt and improvements made when things had gone wrong at the service.

¿ There were not always suitably trained staff deployed and the service did not always make sure that staff had the skills, knowledge and experience to deliver effective support.

¿People’s needs and choices were not always assessed so staff knew and understood how to deliver support for them to achieve effective outcomes.

¿Staff, teams and services did not always work together well to deliver effective support for people.

¿People did not always receive personalised care that was responsive to their individual needs.

¿Information about people’s care and treatment was not always made available in the most accessible way for people.

¿Quality assurance and governance systems were not operating effectively and were not supporting staff and management to understand their responsibilities and ensure that quality performance and risks were understood and managed.

¿ We received mixed feedback directly from people using this service.

¿ Two people we spoke with said they did not feel safe and one person raised specific concerns about unsafe staff practice. Six other people we spoke with said they liked staff, felt safe and liked living at the Laurels.

¿ Most people we spoke with said they liked staff and they were kind, however some people said staff were not always caring. Not all people we spoke with said they felt staff knew them, listened to them and respected their choices.

¿ People were aware of how to make complaints, but not all people said they received appropriate responses when they had done so.

¿ People said they were not always being offered support to take part in activities they wanted and go out of the service but that this was improving recently.

¿We have made a recommendation that the provider introduces appropriate support and accessible information for people using the service about understanding abuse and discrimination.

¿ This inspection identified continued breaches of Regulations 9, 10, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Rating at last inspection:

¿ There had last been an inspection of The Laurels in 10 October 2018, the report for which was published on 5 February 2019. This was a focused inspection that looked only at the key lines of enquiry (KLOE), Safe and Well-Led. Both KLOE were rated Inadequate and the overall rating for the service was therefore also Inadequate.

¿ The Laurels had been rated overall Inadequate in the four previous inspections that had taken place at the service between February 2018 and October 2018.

¿ At each of these four consecutive inspections there have been multiple and repeated breaches of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified.

¿ The Laurels has been placed in Special Measures since April 2018. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. Services in Special Measures will be kept under review and, if needed could be escalated to urgent enforcement action.

Why we inspected:

¿ This inspection was scheduled and planned based on the previous rating to explore if the provider had acted to significantly improve the service to ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Enforcement:

¿On 26 May 2020 we imposed conditions on the provider’s registration telling them how they must act to address serious concerns regarding unsafe care for people with known risks associated with their support needs regarding epilepsy, constipation, behaviours that may challenge, nutrition and hydration, choking and aspiration and monitoring and acting in response to people’s deteriorating health. The condition requires the provider to submit a monthly report to the Commission on their actions to improve in these areas.

¿We imposed conditions on the provider’s registration, due to repeated and significant concerns about the quality and safety of care at several services they operate. The conditions are therefore imposed at each service operated by the provider, including The Laurels. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Follow up:

¿The overall rating for this service is ‘Inadequate’ and the service remains in Special Measures. Services in special measures will be closely monitored and are expected to make significant improvements to ensure their rating is at least good. Where necessary, another inspection will be conducted within or before a further six months. If there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will act to prevent the provider from operating this service. This will lead to cancelling or varying the terms of their registration.

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

The service has been subject to a period of increased monitoring and support by commissioners. The service has been the subject of multiple safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation.

The Laurels was inspected in May 2017 and rated as ‘Inadequate’ in the Well-led section of the report due to breaches of Regulations. This included a breach of Regulations relating to ineffective quality assurance systems. At the last inspection in November 2017 the rating improved to Requires Improvement’ however the provider remained in breach of Regulations as further work was needed to ensure people received a consistent quality service. The provider wrote to us to tell us the action they were taking.

At this inspection we found the quality of care provided to people had deteriorated as risks to people’s health and well-being had not been managed safely. Shortly after the inspection we wrote to the provider. We informed them the Care Quality Commission was significantly concerned about some areas of care and highlighted some new potential risks for people living at the home. The provider had failed to highlight the new concerns prior to this inspection. The provider responded to us and informed us of the action they were taking to improve the quality of care they provided to people living at The Laurels.

At the last inspection we identified incidents of aggression between people had not been reported to external agencies such as the West Sussex Safeguarding Adults team. At this inspection we found people had not been consistently protected from abuse as incidents of physical aggression had not been sufficiently reviewed by the provider and had not been shared with the appropriate partner agencies. We also found staff used inappropriate forms of control and restraint when supporting people who displayed behaviours which may physically challenge others.

At the last inspection we recommended the provider review care documents written on behalf of people. At this inspection care records did not consistently demonstrate people had received the safe care and treatment as referred to in their care plans. This included for people with specific communication and behavioural needs and people who had a percutaneous endoscopic gastrostomy (PEG) feeding tubes.

At the last inspection we found systems to assess and monitor the service were not effective. Shortly after the inspection the provider wrote to us to inform us of the action they were taking. At this inspection we continued to find they were not sufficiently robust as they had not ensured a delivery of consistent, high quality care across the service or pro-actively identified all the issues we found during the inspection. This included checks made on how medicines were managed and gaps within specific staff training.

At this inspection, there was a registered manager in post who had registered with the Commission in December 2017. 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.

The Laurels is a residential care home that also provides nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Laurels accommodates 41 people across four separate units called Birch Lodge, Juniper Lodge, Cherry Lodge and Aspen Lodge. People who live at The Laurels may have a learning disability, autism, physical disabilities and or sensory impairments. Some people had lived at The

Laurels for many years and as such had developed needs associated with advancing age. Each unit had a separate lounge/dining room and there is also access to a communal lounge, a spa pool, a multi-sensory room, gym, computer room and swimming pool. All bedrooms were single and had their own en-suite bathing facilities. At the time of our inspection there were 31 people living at The Laurels.

The Laurels has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. The Laurels was designed, built and registered before this guidance was published. However the provider has not developed or adapted The Laurels in response to changes in best practice guidance. Had the provider applied to register The Laurels today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen, but this was not always the case for people. The Laurels is a large clinical setting rather than a small-scale homely environment. The Laurels is geographically isolated on a campus in rural Horsham with many people having moved to The Laurels from other local authority areas and therefore not as able to retain ties with their local communities. For some people, there were limited opportunities to have meaningful engagement with the local community amenities. Some people had limited contact with specialist health and social care support in the community due to specialist staff (physiotherapy, dietician) that were employed by the provider. Most people's social engagement and activities took place either at The Laurels or at another service operated by the provider, such as the provider's day centre.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms 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.

At this focused inspection we found the service was in breach of four of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, three of which were continued breaches from the previous inspection.

On 26 May 2020 we imposed conditions on the provider’s registration telling them how they must act to address serious concerns regarding unsafe care for people with known risks associated with their support needs regarding epilepsy, constipation, behaviours that may challenge, nutrition and hydration, choking and aspiration and monitoring and acting in response to people’s deteriorating health. The condition requires the provider to submit a monthly report to the Commission on their actions to improve in these areas.

The Laurels is a care home that provides both nursing and residential care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Since our previous inspection in May 2017, we had been made aware that following the identification of risks relating to people's care, the service had been subject to a period of increased monitoring and support by commissioners. Between December 2016 and August 2017, The Laurels has been the subject of 23 safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. Our inspection did not examine specific safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and November 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

The Laurels accommodates 41 people across four separate units called Birch Lodge, Juniper Lodge, Cherry Lodge and Aspen Lodge, each of which have separate adapted facilities. People who live at The Laurels may have a learning disability, physical disabilities and or sensory impairments. Some people had lived at The Laurels for many years and as such had developed needs associated with advancing age. Each unit has a separate lounge/dining room and there is also access to a communal lounge, a spa pool, a multi-sensory room, gym, computer room and swimming pool. All bedrooms are single and have their own en-suite bathing facilities. At the time of our inspection there were 29 people living at The Laurels.

The Laurels cares for people with a learning disability and therefore should be delivering care in line with the values underpinning 'Building the Right Support' and 'Registering the Right Support' guidance.

The registered manager was present during our inspection. They had not been in day to day management of the service since a new manager had been recruited and in post from 8 August 2017. The registered manager still retained oversight of the service as they were employed by the provider as an area manager with responsibility for a number of services operated by the provider including The Laurels. The new manager was also present during our inspection. They had submitted an application to register with CQC and were due to be interviewed as part of this process the same week as the inspection took place. 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.

We carried out an unannounced comprehensive inspection of this service on 10 May 2017 where it was awarded an overall rating of ‘Requires Improvement.’ The domains of ‘Safe’ and ‘Effective’ were rated ‘Requires Improvement,’ the domains of ‘Caring’ and ‘Responsive’ were rated ‘Good’ and the domain of ‘Well Led’ was rated ‘Inadequate.’ Four breaches of regulations were identified. These related to the management of incidents that placed people at risk of harm or abuse, quality monitoring systems and accurate records and failure to display the last CQC inspection report rating. The provider had also failed to submit statutory notifications to CQC in line with their legal responsibilities. The provider submitted an action plan that detailed the steps that would be taken to achieve compliance. At this inspection we found that improvements had been made in all areas but that these needed to be embedded and sustained to help ensure people receive a constantly safe and well led service. This is the second consecutive time that the service has been rated ‘Requires Improvement.’

Everyone said that improvements in the management of the service had taken place. Everyone that we spoke with said that the new manager was a good role model and had made improvements that benefited people and staff. Audits had been completed that identified areas for improvement without the need for external agencies interventions. The provider had communicated learning for safeguarding situations at other services they operated. Despite the improvements further work was needed to ensure quality and governance systems identified all areas for improvement and to ensure sustained improvements over time. Further improvements were also still needed in relation to record keeping.

Prior to our inspection we had received notifications from the new manager when incidents of aggression between people who lived at the service occurred. These demonstrated that the new manager understood their responsibilities to report potential assault to us and to the local authority safeguarding team. However, during the inspection we identified an incident of aggression between two people that had not been reported to external agencies. As a result, the new manager undertook a review that identified a further three events that had not been reported. These were submitted retrospectively.

There was evidence to show that risks to people’s risks wellbeing and safety were identified and assessed and support provided that maintained people safety but did not put unnecessary restrictions on their freedom. People had risk assessments and care plans in place for identified needs that contained adequate information to provide safe care. However, further guidance in areas including behavioural support and specific health needs including suctioning of airways, epilepsy and diabetes would help staff to provide consistent and safe care.

Although staff received basic learning disability awareness training as part of their induction this had not equipped them with sufficient knowledge and understanding to meet people’s diverse needs. Despite this people said that staff were kind and caring and this reflected most of our observations during the inspection. The atmosphere in the service was calm and relaxed and people appeared at ease in the presence of staff.

Processes had improved for ensuring people’s rights to consent were upheld. Mental capacity assessments had been completed when people lacked capacity to agree to equipment viewed as restrictive being used and applications submitted to the relevant authorising authority. The new manager had identified further work was still needed in this area and plans were in place to address this.

People could join in activities in the service and at other services operated by the provider on the same site. People were also supported to attend college and go to church. People had not always accessed physiotherapy or hydrotherapy sessions as planned and also said they wanted more opportunities to access activities and events in the wider community. The new manager had taken action in these areas which needed to continue and to be embedded.

Staffing numbers had been increased and their deployment reviewed. As a result people received support from regular staff who understood their needs better. Staff said that the support they received to undertake their roles had improved. Staff had been provided with further safeguarding training and those we spoke with demonstrated understanding of their roles and responsibilities to report concerns and to protect people from harm and abuse.

Infection control promoted a safe and clean environment. Aspen unit was not decorated or furnished to the same standard as the other three units but arrangements were in place for this to be addressed. There was wheelchair access throughout the service so that people could move freely. Pictorial signage was in use that helped people who could not read to orientate.

The chef was knowledgeable about people’s dietary requirements and preferences and people were supported to eat and drink in line with their assessed needs. People had access to a range of healthcare professionals and the service worked in collaboration with others to ensure that people's needs were met. Since being in post the new manager had introduced Multi-Disciplinary Team (MDT) meetings for each unit that formed the service in order to improve communication between all staff involved in people’s care and support. A new clinical lead had been employed who had arranged quarterly meetings with the GP to take place to discuss people’s needs, arranged a meeting with the Elderly Liaison Nurse and had been in contact with the Continence team in order to promote greater collaboration and effective care for people.

Systems were in place that supported people to make decisions and to express their views. Efforts had been made to provide information in accessible formats and each person was allocated a key worker. A complaints procedure was in place as well as a comments book that people could use to share their views.

At this inspection we found the service was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In December 2018 we imposed conditions on the provider’s registration, due to repeated and significant concerns about the quality and safety of care at several services they operate. The conditions are therefore imposed at each service operated by the provider, including The Laurels. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use th

The Laurels provides accommodation in four units called Birch Lodge, Juniper Lodge, Cherry Lodge and Aspen Lodge, which are all on one site. The Laurels provides nursing and personal care for up to 41 people who may have learning disabilities, physical disabilities and sensory impairments. At the time of our inspection there were 36 people living at The Laurels.

People living at the service had their own bedroom and en-suite bathroom. In each unit, there was a communal lounge and separate dining room on the ground floor, where people could socialise and eat their meals if they wish. The units shared transport for access to the community and offered the use of specialist baths, spa pool, physiotherapy, weekly GP visits, 24-hour nurse support, multi-sensory room, social and recreational activities programme and a swimming pool. The service had a gym, which offered exercise equipment and had been developed by the physiotherapists employed by the provider. There was a room allocated for using computers. This was a space for people to contact their relatives through Skype, Facebook and email. The service could accommodate relatives who wished to visit their family.

The service had a registered manager but at the time of the inspection, this person was no longer managing the service on day to day basis. A home manager was appointed in January 2017 and had submitted an application to register. The service is required by a condition of its registration to have a registered manager. A registered manager is a person who 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. The home manager was not available on the day of inspection. The registered manager, although regularly based at the service, was working as an area manager for the provider. Following the inspection we met with the provider who informed us the home manager had left SHC Rapkyns Group Limited. The nominated individual confirmed that the registered manager who had been promoted to area manager had returned to the Laurels as the registered manager, in day to day charge.

The inspection was bought forward as we had been made aware that following the identification of significant risks relating to people’s care, the service had been subject to a period of increased monitoring and support by commissioners. The service had been the subject of eight safeguarding investigations by social services. Following the inspection, we received assurances from the Clinical Commissioning Group (CCG) that they had also visited the service and risks relating to safeguarding concerns they were investigating had improved. They offered assurances that care plans relating to some of those people had improved and their needs were being met. However, despite these improvements and measures being in place, we identified a number of further risks, which were not appropriately managed and found four breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009. At the last inspection in April 2016, the service was found to be compliant with our regulations and was given a rating of 'Good.'

Individual risks relating to people's health and welfare were not always identified and assessed to reduce those risks. Risk assessments were not always in place to provide detailed guidance to staff in how to protect people from harm. Incidents and accidents were not analysed effectively to learn lessons and reduce the likelihood of them happening again.

Staff had received safeguarding training, demonstrated an understanding of key types of abuse and explained the action they would take if they identified any concerns. However, whilst some incidents had been reported, other incidents, such as verbal abuse, intimidation and physical abuse between people, had not been identified as safeguarding concerns and had not been reported to the local authority safeguarding agency or to the Care Quality Commission as required by law.

The Deprivation of Liberty Safeguards (DoLS) protects the rights of people ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect the person from harm. Staff had received training with regard to the Mental Capacity Act 2005 and DoLS. Staff had a good understanding of the Mental Capacity Act 2005 (MCA); however, this was not always demonstrated when best interest decisions had been made for people who were deemed to lack capacity.

Previous robust systems of audit and control had not been continued and had led to a lack of managerial oversight and the failings identified during this inspection. On the day of the inspection the area manager failed to provide us with the essential records to complete the inspection. The area manager told us he lacked the knowledge of where records were kept within the service, and therefore was not forthcoming with providing the information we requested for the inspection. Consequently, we requested a number of records to be emailed to us following the inspection. This included records of complaints and how complaints had been managed. However, we never received that information. Systems to assess and monitor the service were in place but these were not sufficiently robust as they had not ensured a consistent high quality service across the service or pro-actively identified all the issues we found during the inspection.

The provider had failed to display their ratings on the website which we discussed with the area manager on the day of inspection. Following the inspection the rating is now displayed.

The provider had not notified the Care Quality Commission of incidents which they needed to tell us about.

Staff we spoke with gave us mixed opinions about the current management arrangements, vision, values and culture of the service.

There were sufficient staff in place to meet people's needs. However, we have made a recommendation regarding how staff are deployed to safely and effectively meet people’s individual needs. The provider used a dependency tool to assess that staffing levels were based on people's needs. These were up to date and reviewed monthly. Robust recruitment practices ensured that new staff were vetted appropriately and checks were undertaken to confirm they were safe to work in a caring profession.

Policies and procedures were in place and medicines were managed, stored, given to people as prescribed and disposed of safely. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing.

Staff received an induction into the service and the home manager checked competencies in a range of areas. Staff had received a range of training and many had achieved or were working towards a National Vocational Qualification (NVQ) or more recently Health and Social Care Diplomas (HSCD). Staff were able to pursue additional training which helped them to improve the care they provided to people. We saw that some staff had not received support and supervision in line with the company policy. However, the staff told us they felt they supported each other well and found the provider approachable and supportive.

At this inspection, people described staff as kind and caring. People told us they felt they were treated with respect and dignity. Our observations reflected this. The home had been decorated and arranged in a way that supported people living with complex needs.

People enjoyed the meals at the service and were offered choice and flexibility in the menu. The chef had a good understanding of people's likes and dislikes and took great care to provide specific dishes or supplies to meet people's requests. People had access to a range of healthcare professionals and services. People's rooms were decorated in line with their personal preferences. The premises were purpose built and provided space for people to move around freely, to relax and to enjoy outdoor spaces.

People were involved in planning and reviewing their care as much as they could, for example in deciding smaller choices such as what drink they would like or what clothes to choose. Where people required more time to make choices, staff were patient in repeating choices each time and explaining what was going on and listening to people's responses. Staff had a good knowledge of people, including their needs and preferences. Care plans were personalised to reflect people’s needs, choices and preferences.

People's privacy was respected. Staff ensured people kept in touch with family and friends. People were able to see their visitors in communal areas or in private. The service provided support for people's emotional well-being through the provision of meaningful social activities and opportunities. People were offered a wide range of both group and individual activities that were meaningful to them and which met their needs and preferences.

People and their relatives were involved in developing the service through meetings. People and their relatives were asked for their feedback in annual surveys.

At this inspection, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations. We also found one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

The Laurels provides accommodation in four lodges called Birch Lodge, Juniper Lodge, Cherry Lodge and Aspen Lodge, which are all on one site. The Laurels provides nursing and personal care for up to 41 people who may have learning disabilities, physical disabilities and sensory impairments. There were a high number of vacancies, this was due to The Laurels being registered by CQC on 20 July 2015, at the time of our inspection there were 28 people living at The Laurels. Additional people moving in to The Laurels were going through a period of assessment and transition.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 living at the service had their own bedroom and en-suite bathroom. In each lodge there is a communal lounge and separate dining room on the ground floor where people can socialise and eat their meals if they wish. The lodges share transport for access to the community and offers the use of specialist baths, spa pool, physiotherapy, weekly GP visits, 24-hour nurse support, multi-sensory room, social and recreational activities programme and a swimming pool. The service had a gym, which offered exercise equipment and had been developed by the physiotherapists employed by the provider. There was a room allocated for using computers. This was a space for people to contact their relatives through Skype, Facebook and email. The service could accommodate relatives who wished to visit their family.

People received excellent care in a way that was personalised and responsive to their changing needs. Risks to people were managed in a proactive way, which enabled them to live independent and fulfilling lives. Staff worked closely with community health professionals and therapists to maximise people's well-being. People felt safe at The Laurels and had positive and caring relationships with the staff who supported them.

The service placed a strong emphasis on meeting people's emotional well-being through the provision of meaningful social activities and opportunities. People were offered a wide range of both group and individual activities that were meaningful to them and which had a positive impact on their lives. Visiting was unrestricted and people's relatives felt included in the care of their loved ones.

People were provided with a variety of meals and the extensive menu catered for any specialist dietary needs or preferences. Mealtimes were often viewed as a social occasion, but equally any choice to dine alone was fully respected.

People had confidence in the staff who supported them and felt safe in their care. People benefitted from sufficient staff deployed which meant that they never had to wait long for assistance. Staff treated them with kindness and took steps to promote their privacy and dignity at all times.

Staff enjoyed working at the service and felt well supported in their roles. They had access to a wide range of training, which equipped them to deliver their roles effectively. Staff completed an induction course based on nationally recognised standards and spent time working with experienced staff before they were allowed to support people unsupervised. This ensured they had the appropriate knowledge and skills to support people effectively. Records showed that the provider's required staff training was up to date. Staff told us that they felt supported and received training to enable them to understand about the needs of the people they care for. People and their relatives felt the staff had the skills and knowledge to support people well.

We saw that staff recruited had the right values, and skills to work with people who used the service. Where any issues regarding safety were identified in the recruitment process, appropriate safeguards had been put in place. Staff rotas showed that the staffing levels remained at the levels required to ensure all peoples needs were met and helped to keep people safe.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely. Nurses had completed safe management of medicines training and had their competency assessed annually. The nurses were able to tell us about people's different medicines and why they were prescribed, together with any potential side effects.

Staff told us they worked as part of a team that was a good place to work and staff were very committed to providing care that was centred on people's individual needs.

People received care and support which was responsive to their needs. Care plans provided detailed information about people so staff knew exactly how they wished to be cared for in a personalised way. People were at the forefront of the service, were cared for as individuals, and encouraged to maintain their independence. A wide and varied range of activities was on offer for people to participate in if they wished. Regular outings were also organised outside of the service and people were encouraged to pursue their own interests and hobbies.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The members of the management team and nurses we spoke with had a full and up to date understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals. We found that appropriate DoLS applications had been made, and staff were acting in accordance with DoLS authorisations.

The registered manager was a strong leader and role model and there were systems in place to develop staff skills and promote reflective practice. Staff were proud to work at The Laurels and felt valued and empowered to deliver high quality care. People benefitted from living in a well organised, forward thinking service where their needs were always put first. The culture of the service was open and people felt confident to express their views and opinions. The registered persons provided clear leadership and direction to staff and were committed and passionate about the quality of care provided. Quality assurance processes were robust and action plans to improve the service were prioritised and completed quickly. National best practice legislation and local policies were referenced to set and measure standards of care.