Archived: Boundary House

Boundary House is a residential care home providing accommodation, personal care and support for up to 16 people with a learning disability or autistic people. At the time of the inspection there were 10 people living in the home. There were 10 single bedrooms and shared facilities in one area known as Horizon House and six self-contained flats in the area of the home known as Boundary House. The home is in a rural location with a day centre and offices on the same site.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and 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 supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People were not supported to manage risks to themselves and from the environment. This placed people at risk of harm. We were not assured that people received the correct level of 1-1 staff support. People were not always supported by the correct staff and this caused them distress.

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.

The systems in place limited the ability of staff to provide support that enhanced people’s choices and control. Information about people’s changing care needs and the support they required was not always shared with staff.

People’s health needs were not always met, and staff did not always support people to access health care services. We have made a recommendation that the provider review how they support people with healthy eating and improve their mealtime experience.

Right Care:

People were not supported to stay safe and their human rights were not always protected. Safeguarding incidents were not always identified and reported.

Incidents were not used to support staff learning and ensure people were receiving the right care. Staff were not well supported because they had not received the training they needed to carry out their roles. This meant people did not always get the support they needed.

People did not always receive person centred care because their needs were not always met.

Right Culture:

Best practice guidance in a range of areas such as communication, distressed behaviours, and bowel management were not followed. The provider had not effectively engaged in external support. This meant people did not receive a high-quality service that supported them to achieve good outcomes.

Staff morale was low. There had been multiple changes of managers and staff lacked direction and support. This impacted on their ability to provide a person-centred culture. Governance systems were inadequate and did not contribute to the delivery of a safe high quality service.

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 21 December 2021). The service remains inadequate. This service has been rated inadequate for the last two consecutive inspections. This means the service has remained in special measures.

We imposed positive conditions on the providers registration after the last inspection. They must not admit any new people to Boundary House without the permission of the CQC. The provider must submit governance documents and assurances on the first Monday of each month to the CQC.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 8 and 14 September 2021. Breaches of legal requirements were found. We undertook this focused inspection to check the provider had made improvements and to confirm they now met legal requirements. This report only covers our findings in relation to the Safe, Effective and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained inadequate. 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 Boundary House on our website at www.cqc.org.uk.

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 COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staffing, safeguarding, person-centred care, consent, and governance. We have made a recommendation regarding healthy eating and mealtimes.

Following this inspection we took action to cancel the provider's registration.

Follow up

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.

Boundary House provides accommodation, personal care and support for up to 16 people with a learning disability or autistic spectrum disorder. At the time of the inspection there were 15 people living in the home. There were 10 single bedrooms and shared facilities in one area which is known as Horizon House and six self-contained flats in the area of the home known as Boundary House. The home is in a rural location with a day centre and offices on the same site.

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

People were not always receiving safe care and treatment. Allegations of abuse or harm had not always been reported to the local safeguarding team or the Commission. We could not be sure that these allegations had been dealt with appropriately or that action had been taken to prevent a reoccurrence. During the inspection we made safeguarding referrals to the local authority safeguarding team. People had not always received medical attention in a timely manner.

There was no effective oversight or management of incidents which had occurred. As a result, staff were placing themselves and others at risk. Incidents happened regularly and people were harmed. People's care needs, risks and behaviours were not always properly assessed or planned for. Care plans and risk assessments were not being followed by staff consistently. This placed people at risk of not receiving they support they required.

There were not always enough staff on shift to meet people’s assessed needs. People told us that staffing shortages meant they couldn’t always choose what they wanted to do or if they got to go out. Not all staff had training or competency assessments that had been renewed as required by the providers training policy. Staff had not received regular supervisions or annual appraisals and often relied on their colleagues for support and guidance rather than the management team.

Infection, prevention and control measures were not being followed to prevent the spread of infections. Hazardous chemicals were not always securely stored. Testing of the fire equipment such as alarms, emergency lighting and fire doors had not been carried out regularly. This put people’s health and safety at risk.

Some areas of the home had furnishings that were worn and dirty and not fit for purpose. The shared areas of the home were not homely.

People were not supported to have maximum choice and control of their lives and staff did not always 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. We saw records that one person had been physically restrained by up to five members of staff. Deprivation of Liberty Safeguards had expired and had not been renewed when needed for some people.

There was a lack of oversight and governance over a prolonged period. The provider had recognised that there were areas that needed improving and were keen to take action.

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

This service was not able to demonstrate how they were meeting some of the underpinning principles of Right Support, Right Care, Right Culture.

Right care:

• The care and support provided did not always meet the needs of people with learning disabilities. Staff did not receive the training needed on how to meet the needs of people with learning disabilities and autism, so they did not have the skills they needed to provide appropriate support.

Right Support

• People's care wasn't person centred or planned with people having choice and control over how their health and care needs were met. Care plans were not consistently followed. People were not always cared for in a safe and consistent way.

Right culture:

• The ethos, values, attitudes and behaviours of leaders and care staff did not always ensure people with learning disabilities led confident, inclusive and empowered lives. This was because there was a lack of leadership and oversight. The service was not person centred, open and inclusive nor did it always achieve good outcomes for people. People's human rights were not always respected; people had been harmed and others put at risk of harm.

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 good (report published 17 July 2019).

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, the environment, storage of chemicals, training and support of staff. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

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 COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions 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.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Boundary House 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 breaches in relation to people’s health, safety and welfare, staffing levels, training and support, infection prevention and control and the environment.

We have placed conditions on the provider's registration for Boundary House. We have stopped them from allowing any new people to move into Boundary House. The provider must also improve their quality assurance systems and send a summary to the Commission every month to be reviewed.

Follow up

We will request an action plan for 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.

The care service has been developed and designed 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. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy. Details regarding conformity are detailed in the body of the report.

People’s experience of using this service:

Risks to people, including the environment and people’s health conditions, were assessed and mitigated.

Staff were knowledgeable about safeguarding people from abuse.

Staff administered people’s medicines safely and they were stored appropriately. Staff supported people to attend medicines reviews and access healthcare when they needed.

People received care according to their individual needs and preferences, and there was detailed guidance for staff in care plans. This included their health and social care needs and preferences.

There was enough suitably qualified and competent staff to meet people’s needs.

Staff supported people to maintain a balanced diet with a choice of food, and enough to drink. Staff supported people with any special diets as needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff asked people for consent and supported them to make decisions, but further records were needed around people’s mental capacity to make specific decisions.

Staff adapted communication to ensure people understood information and could communicate effectively, and people were involved in their care.

People and staff had built positive trusting relationships, and staff respected people’s dignity and privacy.

People were supported to maintain and increase their independence as much as possible.

Staff supported people to engage in varied activities, and staff supported them to engage with the local community.

There was good leadership in place. Staff worked well as a team and were well-supported.

There were effective systems in place to monitor and improve the service.

Rating at last inspection: Good (Published December 2016)

Why we inspected: We inspected this service in line with our inspection schedule for services currently rated Good.

Follow up: We will continue to monitor the service according to our schedule for returning to locations rated Good.

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

At the time of our inspection a registered manager was in 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 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that people’s rights were being protected as DoLS applications were in progress where required and had been submitted to the relevant local authorities.

People who lived in the home were assisted by staff in a way that supported their safety. People were treated with respect and dignity and had health care and support plans in place to ensure that their needs were being met.

Risks to people who lived in the home were identified and plans were put into place to enable people to live as safely and independently as possible. Medication was audited, safely stored and administered to people.

There were sufficient numbers of staff available to meet people’s care and support needs. Staff had an understanding of how to report suspicions of harm and poor care. Safe recruitment procedures were in place.

Staff assisted people with their care needs, their eating and drinking support needs and encouraged people to pursue their interests and engage in activities of their choice.

Staff received training, supervision and appraisals so that they could provide effective care and assistance to meet people’s individual needs and wishes.

Arrangements were in place to regularly monitor the health and safety and the quality of the care and support provided for people living at the home.

People’s complaints and suggestions were listened to and resolved where possible.