Archived: Grove Villa Care

Grove Villa Care is a care home registered to provide accommodation and personal care for up to 16 people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. People using the service had a range of physical and learning disabilities. Some people were living with autism and some required support with behaviours that challenged.

The service had a registered manager in post. A registered manager is a person who is 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.

We last inspected Grove Villa Care on 20 April 2017, we found significant shortfalls and the service was rated inadequate and placed into special measures. The provider and registered manager had failed to notify CQC of notifiable events in a timely manner. Risks relating to people's care and support were not always adequately assessed or mitigated. Medicines were not managed safely. The provider had not ensured that staff had all the training they required to meet people's needs, support them consistently and keep them safe. The provider and registered manager had failed to enable and support people to communicate their preferences. People did not always receive care and support in the way they preferred and were not enabled to understand their care and support options. People did not always receive person-centred care. Staff and the registered manager were not fully aware of their individual responsibilities to identify and report abuse when providing care and treatment. People were not fully protected from abuse and the registered manager had not followed the correct procedures to make sure people were as safe as possible. The provider and registered manager had failed to establish and operate systems to assess, monitor and improve the quality of the services provided and reduce risks to people. The provider and registered manager had failed to make suitable arrangements to respect and involve service users and had failed to maintain accurate and complete records.

We took enforcement action and issued a warning notice relating to ‘Safe Care and Treatment.’ We placed a positive condition on the provider’s registration, asking them to send us monthly updates regarding the service. We required the provider to make improvements and the service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. At this inspection we found that improvements had been made in some areas, however there were still serious concerns regarding the provider’s oversight and overall management of the service and some continued breaches of the regulations.

The service was not fully working towards 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. 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; the policies and systems in the service did not always support this practice. Some people were not allowed to access their kitchen, even though they wanted to, as staff described it as ‘unsafe.’ No risk assessment had been completed regarding the risk of people using the kitchen and no plans were in place to increase people’s independence and skills.

At our last inspection, risks relating to people’s care and support had not always been assessed and mitigated. At this inspection the registered manager and deputy manager had begun to re-write people’s care plans. Nine of 16 had been completed. The new care plans contained more detail regarding how to give people appropriate support, such as how to recognise and respond if they experienced a seizure or displayed behaviour that challenged. However, there was still a lack of essential guidance for staff if people choked. The care plans that had not been updated still did not contain information regarding people’s seizures and when staff should seek medical assistance. When incidents occurred the deputy manager now completed an overview of incidents to look for patterns and trends and ways of reducing the chance of them happening again.

Staff did not always treat people in a respectful manner. They had written that people were ‘hoarders’ and ‘messy eaters’ and had given no consideration to how people may have felt to be described as such. A staff member had headphones in throughout the inspection and ignored people when they spoke to them.

A communication board had been introduced which enabled people to make choices between different things such as different foods and activities by using pictures. The registered manager and deputy manager had chosen not to implement a recommendation from a speech and language therapist regarding a visual timetable for a person and told us they were using the communication board instead. The communication board did not provide the same support as a visual timetable.

Staff had not received training in best practice for supporting people with learning disabilities. The registered manager lacked the knowledge and understanding regarding supporting people with learning disabilities. Although some care plans had been re-written since our last inspection, people’s needs had not been assessed in line with best practice as a result.

People were going out more regularly since our last inspection and the deputy manager regularly monitored when people were going out and how often. The registered manager completed checks on the service, but had not identified the issues we highlighted at this inspection. The provider lacked oversight of the service. They did not complete any formal checks and the registered manager had not received regular supervision. We requested information to be sent after the inspection, and this was not received in a timely manner. Although some action had been taken since our last inspection both the provider and registered manager had failed to acknowledge the severity of the issues identified and the breaches had not been met fully. We had not been notified of safeguarding incidents that occurred within the service, as required by law and staff had not been recruited safely.

People and their relatives were asked their views on the service annually, but had not been asked formally, since our last inspection. The service had received some support from the local authority safeguarding and commissioning teams since our last inspection. They were working with the registered manager and staff to encourage improvements. There were enough staff to keep people safe. Medicines were now managed safely and people received them as and when required. People received support to manage their health care needs, and saw a doctor when they became unwell. People were supported to eat and drink safely. The service was not currently supporting anyone at the end of their life

Some areas of the service had been re-decorated since our last inspection and people had been involved in choosing the colours of the walls. The service was clean and people were protected from the spread of infection.

The registered manager told us there had been no complaints since our last inspection. The registered manager had applied for Deprivation of Liberty Safeguards when people’s liberty was restricted.

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

Grove Villa Care is a ‘care home’. 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. Grove Villa Care accommodates 16 people in one adapted building. There were 15 people using the service at the time of our inspection. People using the service had a range of physical and learning disabilities. Some people were living with autism and some required support with behaviours that challenged.

The care service had not been developed and designed in line with the values that underpin Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People were not supported to live an ordinary life, like any citizen.

A registered manager was employed to manage Grove Villa Care and two other services the provider owned on the same site. The registered manager was not present at the time of our inspection and was not leading the service. 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 inspected Grove Villa Care on 20 April 2017 and 18 January 2018 and found significant shortfalls. The service was rated inadequate on both occasions and placed into special measures.

Following our April 2017 inspection, we placed a condition on the provider’s registration, requiring them to send us monthly reports about the actions that had been taken to meet the breaches of regulations found at the inspection. We have not received some these reports as required.

At our last inspection we found that the registered persons had failed to ensure that staff had the necessary guidance to keep people safe. Staff had not been recruitment safely and staff were not appropriately trained and competent to carry out their roles. People were not treated with respect and dignity and did not received person-centred support to communicate their needs. People were not involved in planning their care and had not been supported to take part in pastimes they enjoyed. The registered persons had failed to establish and operate systems to assess, monitor and improve the quality of the services provided and reduce risks to people. People views were not used to improve the service and suitable arrangements were not in place to maintain accurate and complete records. CQC had not been notified about significant events that happened at the service in a timely manner.

We took regulatory action against the provider after our inspection in January 2018 and this is ongoing. Full information about CQC’s regulatory response to the serious concerns found during our inspections is added to reports after any representations and appeals have been concluded.

The service is in special measures. We kept the service under review and inspected the service again within six months to check that the significant improvements required had been made. At this inspection we found that minor improvements had been made in some areas, however there were still serious concerns regarding the registered person’s oversight and overall management of the service. Some breaches of the regulations continued and there were new breaches of other regulations.

The registered persons did not have oversight of the service. Checks and audits of the service had been completed in some areas of the service but these had not identified the shortfalls we found during our inspection. Lessons from previous inspections had not been used to improve the service and there continued to be breaches of five regulations. The views of people, their relatives, staff and community professionals were not obtained or acted on to continually improve the service.

Staff had not been deployed to provide people with the care and support people needed when they wanted it and people were not supported to be independent and achieve their goals and aspirations. People did not always receive the support they needed when they requested it. Staff had not been fully supported to consistently promote people’s dignity by treating them with respect. Plans had not been put in place with people since our last inspection to make sure people received care and support in the way they preferred at the end of their life. Records in respect of each person and governance processes were not accurate, complete and kept securely.

Assessments of people’s needs and some risks had not been completed and care had not been planned with people, to meet their needs and preferences and keep them safe and well. Accidents and incidents had not been analysed to look for any patterns and trends. At our last inspection we found that there was still a lack of essential guidance for staff if people were at risk of choking. At this inspection we found that this guidance was available in people’s care plans.

People were not fully protected from the risk of fire and staff did not know how to support people to remain safe in an emergency.

Changes in people’s health were identified and people were supported to see health care professionals, including GPs when they needed. However, professionals’ advice had not always been followed on to keep everyone well and support them to share their views and choices.

Incidents had not been recognised as potential safeguarding incidents and had not been shared with the local authority safeguarding team so they could be investigated. Some people were isolated. People did not have enough to do during the day. Activities were not planned around each person’s preferences and people were not supported to continue to develop their independent living skills and achieve their goals.

The provider’s complaints process had not been followed and complaints had not been robustly managed to ensure that they were thoroughly investigated and quickly resolved.

Mealtimes were not a positive experience, some people had to wait for the support they needed and other people’s meals were interrupted when staff left them to support others. People were offered a balanced diet of food they liked and that met their preferences.

People were not supported to have maximum choice and control of their lives and staff did not supported them in the least restrictive way possible. The provider’s policies and systems in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) were not followed. Assessments of people’s capacity to make decisions had not always been completed when they were needed. Information was not available to people in a way their understood to help them make decisions and choices, including communication tools recommended by healthcare professionals. The registered persons did not fully understand their responsibilities under DoLS and authorisations had not been applied for when there was a risk that people may be deprived of their liberty.

Staff had not been recruited safely and checks had not been completed to make sure they had the skills knowledge and experience they needed to fulfil their role. Disclosure and Barring Service (DBS) criminal records checks had been completed. Staff were not supported meet people’s needs and had not completed the training they needed to fulfil their role when they began working at the service.

Some parts of the service were not clean and staff did not always follow infection control processes to protect people from the risk of infection. The building was not well maintained in all areas and shortfalls were not addressed quickly. People were able to use all areas of the building and grounds and were encouraged to make their bedroom feel homely.

The registered persons had not informed CQC about all the significant events that had happened at the service, so we could check that appropriate action had been taken.

No significant improvements were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At the last inspection we found serious concerns regarding the provider’s oversight and overall management of the service continued. Breaches of six regulations continued and there were new breaches of four regulations of the Health and Social Care Act 2008. There was also a continued breach of the Care Quality Commission (Registration) Regulations 2009. The service was rated Inadequate and remained in special measures.

Following our last inspection, the provider sent us improvement action plan to show what they would do and by when to address the breaches. The improvement action plan was not adequate. Despite a request for a more robust plan, the information we received from the provider did not assure us that they understood our concerns and had a plan in operation to address them promptly.

At this inspection we checked to see if concerns in relation to protecting people from abuse, unsatisfactory medicines management, unsafe care, poor staff recruitment and deployment and infection control risks had been addressed. We also checked to see if the management and leadership of the service had improved and the views people and others involved in their care had been used to improve the service. We found the provider had made no significant improvements and people continued to be at risk at the service.

Grove Villa Care is a ‘care home’. 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. Grove Villa Care accommodates 16 people in one adapted building. There were 15 people using the service at the time of our inspection. People using the service had a range of physical and learning disabilities. Some people were living with autism and some required support with behaviours that challenged.

The care service had not been developed and designed in line with the values that underpin Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People were not supported to live an ordinary life, like any citizen.

There was no registered manager at the service. 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 provider did not have oversight of the service. Checks and audits completed had not identified the shortfalls we found during our inspection. Many areas of the service had not been checked. The views of people, their relatives, staff and community professionals were not obtained to improve the service.

Staff had not been deployed to provide people with the care they needed. Some people remained isolated. Staff had not been recruited safely and checks had not been completed to make sure they had the skills knowledge and experience they needed to fulfil their role.

Risks had not been assessed and action had not been taken to keep people safe and well when their needs changed, including the risk of falling. Staff did not always follow guidance when people had seizures. People were not protected by safe and effective medicines management processes. Medicines were not always stored safely. One medicine was out of stock and others had not been administered as prescribed.

People were not fully protected from the risk of fire and staff did not know how to support people to remain safe in an emergency.

Incidents of potential abuse by people to other people had not been recognised as potential safeguarding incidents and reported to the local authority safeguarding team so they could be investigated.

Records in respect of each person were not accurate and complete. Accidents and incidents analysis was incorrect as it was based on flawed information. Areas of the service and equipment were not clean.

The provider had not informed CQC about all the significant events that had happened at the service, so we could check that appropriate action had been taken.

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

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service did not always receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 18 people. Thirteen people were using the service. This is larger than current best practice guidance. There was a risk that the size of the service had a negative impact on people, there were identifying signs outside of the property and industrial bins which indicated it was a care home. Staff were encouraged to wear a uniform that suggested they were care staff when coming and going with people.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; people lacked control over their lives, had limited independence, were not included in everything that happened at the service and had limited inclusion in the local community. Some action had been taken since our last inspection to support people to begin to live a fuller life and achieve the better outcomes. However, people had lived at the service for many years and had little or no experience of a service which reflected the principles and values of Registering the Right Support and had not been supported to expect these from any service they received.

People’s experience of using this service:

• At our previous four inspections we found that people received an inadequate service which did not protect them from harm and no significant action had been taken to improve the service people received.

• At this inspection people continued to receive a service which was not well led and managed. They and their loved ones had not been asked for their views of the service to ensure it met their needs and expectations. People were not involved in planning what happened at the service and had not been taken part in the selection of their keyworker or new staff.

• Quality assurance checks had not been completed on the service to identify any shortfalls. The provider and manager did not know about the shortfalls we found at the service.

• Records about people’s care, the staff and governance of the service were not accurate and complete. They were muddled and could not easily accessible. Agency staff who worked alone at night have limited information about people and their needs.

• People continued to be at risk at the service. Despite improvements in the management of safeguarding risks, people were not always protected from other risks, such as the risk of falling or not receiving their medicines safely. One person had lost a significant amount of weight and had not been supported to regain this.

• Effective processes were not in operation to learn lessons and improve the service people received when things went wrong.

• One person’s behaviour which challenged continued to have a negative impact on other people and we observed the atmosphere in the service change when the person returned home and other people were quieter and appeared anxious.

• Robust assessments of people’s needs had not been completed to inform staff about people’s skills and abilities and plan their care and support.

• Care had not been consistently planned to ensure people’s healthcare needs were met consistently and care and treatment was effective.

• Information about people’s equality and diversity needs and wishes had not been obtained so their care would be delivered as people wished.

• People had not been fully involved in planning their care, including their end of life care preferences, with staff and did not have copies of their care plans to refer to. Care plans had not been reviewed to ensure they reflected people’s needs and were accurate.

• Two people had moved out of the service and staff had more time to support other people. However, staffing levels were not consistent or based on people’s needs, so people were not always supported to go out or be as involved as possible in their care.

• New staff had not always been recruited safely and had not received a suitable induction to develop this skills and knowledge they needed to meet people’s needs. Staff had not developed all the skills and knowledge they required to fulfil their role and their competence to provide people’s care had not been assessed.

• People were now being supported to take part in some day to day tasks, such as making snacks and drinks. However, these goals had not been agreed with them to make sure they were what the person wanted to achieve. People’s skills had not been assessed so their progress towards goals could be reviewed and celebrated.

• Staff had worked with the local authority safeguarding staff to protect people from the risk of abuse.

Rating at last inspection: Inadequate (The last inspection report was published on 25 December 2018).

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

Enforcement: The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. We will keep the service under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, we will inspect it again within six months. We expect that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

Follow up: We will continue to monitor the service and work with partner agencies.

Grove Villa Care is a residential care home and was providing personal care to 12 people with a learning disability at the time of the inspection. The service can accommodate up to 16 people in one adapted building. We have applied a condition to their registration to stop them admitting anyone new into the service without our prior permission.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The provider and registered manager had not ensured people had control over their lives. People had limited independence, were not included in everything that happened at the service. They were not part of the local community. People were not involved in planning and co-ordinating their care and the service was not centred around them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 16 people. This is larger than current best practice guidance. There was a risk that the size of the service had a negative impact on people, there continued to be identifying signs outside of the property and industrial bins which indicated it was a care home. Staff were encouraged to wear a uniform that suggested they were care staff when coming and going with people.

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

People continued not to live fulfilled lives at Grove Villa Care. The service rarely applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not reflect the principles and values of Registering the Right Support for the following reasons. People were not involved in planning their care and had not been supported and encouraged to be as independent as possible. People’s care was not centred around them but was planned around what staff wanted or thought was best for people. People were not treated with respect or supported to be an active part of their community.

People were not protected from the risks of harm and abuse. The police were investigating allegations of financial abuse and we found further concerns during our inspection. Some concerns had been raised by staff but there had been a delay in these disclosures being made which put people risk. Action had not been taken to understand people’s diverse needs and make sure they were not discriminated against.

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 supported this poor practice.

The provider and registered manager continued to lack oversight of the service. They had not checked the service met the standards required. The provider’s consultant had recognised that the service continued to be in breach of regulations, but action taken to make improvements had not been effective.

Assessments of people’s needs, and any risks had not been completed. People had not been supported to plan taking risks and how risks would be managed. People continued to be at risk of falling and choking because staff did not adequately monitor them.

People were not always supported to remain as healthy as possible. Staff had not planned people’s care following hospital stays to make sure they did not become unwell again. People’s medicines were not always managed safely. Medicines records were inaccurate and staff’s ability to administer medicines safely had not been assessed.

People were not always involved in planning and preparing meals. Some people had not been supported to tell staff about the food they liked, and staff had not looked at their cultural needs and preferences.

Staff did not feel supported by the provider and consultant and the relationship between them had broken down. Staff were demotivated, and some felt bullied. The registered manager had not consistently challenged poor practice or held staff accountable. There was no clear philosophy of care based on good practice and staff did what they wanted. Staff had not received the support and guidance they needed to provide good care. Records in respect of people’s care were inaccurate in places and were not always held securely.

There continued not to be enough staff to support people, with staffing based on contracted hours and not people’s needs. Additional staff had been deployed at times, but this was not consistent to ensure people always had the support they needed to remain safe. Staff had not completed the training they needed to fulfil their role. The registered manager continued not to follow safe recruitment practices.

The service was clean and well maintained. However, action had not been planned to ensure people were safe in an emergency, such as a fire. A process not in place to receive and respond to day to day concerns people had. A process was in place to investigate and resolve any complaints.

The registered manager and provider had not informed CQC of significant events that had happened at the service, so we could check that appropriate action had been taken. The CQC performance rating was prominently displayed.

Rating at last inspection and update

The last rating for this service was Inadequate (published 26 April 2019) and there continued to be multiple breaches of regulation. At this inspection improvements had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about financial abuse and low staffing levels. A decision was made for us to inspect and examine those risks. We also followed up on action we told the provider to take at the last inspection.

Enforcement

We have identified continued breaches in relation to the management of the service, staffing, the protection of people from risks, supporting people to live health lives, involving people in their planning their care and developing independence at this inspection.

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

Follow up

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

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.

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

Grove Villa is a large detached house in a quiet residential area, it shares a site with two other services owned by the same provider. It provides care and support for up to 16 people, with a learning disability. There were 16 people living at the service when we visited.

There is a registered manager working at the service. 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 providers changed to a limited company in April 2016.

The culture of the service, was one that staff 'did for' people rather than ‘with them’, which is in contrary to best practice when supporting people with learning disabilities and meant people did not learn and develop.

People were not involved in developing and updating their care plans. People’s care plans were not always person centred and some contained inaccurate information. Staff knew people well, some interactions between people and staff positive but people with more complex support needs had limited interaction from the staff. People were not always treated with dignity and respect, the language used to describe people was not always respectful and indicated that staff were in control of the environment instead of people. For example staff described people as being rude and told one person to return to bed as it was too early to get up.

There was a board in the dining room letting people know what activities were happening each day; however this was not being used so people did not know what was on offer. Staff had been advised to use communication tools with some people but this was not happening.

Some people attended local day services and took part in other activities they enjoyed. Other people who had more complex support needs or who could show behaviours which could challenge had limited opportunities to take part in activities or go out and about. Some people had not left the service, except to attend medical appointments for several months. There were no goals recorded for people or plans to help people reach their goals or develop new skills.

People told us they felt safe at the service. Staff told us about different types of abuse and said they would report any concerns to the registered manager or the Care Quality Commission. However, we found six incidents had been recorded, which were potentially abusive. The registered manager said they were unaware of the incidents and had not reported them to the local safeguarding team. We asked the registered manager to speak with the local duty team at social services to discuss these issues, and they contacted them whilst we were there.

Some risks to people were identified, however one person did not have a risk assessment around choking despite this being highlighted by the local community team as a risk. Some risk assessments gave staff the guidance needed to manage and minimise the risks, but others did not. People did not have personal emergency evacuation plans to detail what support they needed to leave the premises in an emergency such as a fire. Risks to the environment were assessed and managed safely.

People’s medicines were not always managed safely. Staff signed medicines records before giving medicines to people and did not always have the guidance needed around the use of ‘as and when required’ medicines. People were not always given emergency medicines in line with guidance from a health care professional.

Most staff were recruited safely, however one staff member did not have any references on file. Staff had induction training and were introduced to people by established staff before supporting them. Staff completed basic training; however further training was required to meet people’s needs. Staff had regular one to one meetings, but appraisals had not been completed. There were enough staff to keep people safe, but staff told us there were not always enough staff to support people’s activities. Staff told us they felt supported by the registered manager and deputy manager.

Some people were not fully involved in choosing what they wanted to eat each day. When people were at risk of losing weight they were referred to a nutritionist and any guidance put in place was followed by staff.

People had access to healthcare professionals when required and any concerns about people’s health were responded to quickly. However, staff did not always have the guidance needed to support people to manage their long term health conditions.

Staff had some understanding of the Mental Capacity Act 2005 (MCA.) However, some people did not have capacity assessments in place to assess if they could make individual decisions. Some people had had procedures such as flu vaccinations, without their capacity being assessed or a best interest decision being made. Some people’s care plans stated they lacked capacity in some areas, but daily records showed, they were making decisions on a regular basis. There was a risk decisions could be made for people when they were, in fact, able to decide for themselves.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. The registered manager had applied for DoLS for people when their liberty was restricted and some of these had been authorised. However, on the day of the inspection they could not tell us who had a DoLS in place and who did not. They sent us this information after the inspection.

The registered manager was accessible to people, professionals and staff. However, the registered manager did not have a plan to develop or maintain their skills. Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. The registered manager had not submitted notifications, in a timely manner. Audits were completed but had not identified the issues found at this inspection. There was a complaints procedure in place, which was in an accessible format. No complaints had been received since the change in provider in April 2016.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

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.