Archived: New Redvers

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 supporting people with a learning disability or autistic people

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

The provider could not show how they met some of the principles of Right support, right care, right culture. This meant we could not be assured that people who used the service were able to live as full a life as possible and achieve the best possible outcomes.

People told us they were happy, and they liked living at New Redvers. One person said, “I like living here.” Another said, “We have had a lot of staff changes here, I miss some of the old staff, but I like the new staff too. They are very nice.” Another person said “Since (name of CEO) and (name of consultant) have been here it become 1000% better. They have been spending money decorating. We have some chickens; food is much better and hopefully we are getting some pigmy goats.”

Although people told us they felt safe and were happy living at New Redvers, the service did not focus on people's quality of life, and care delivery was not person centred. Staff knew people well, but they did not recognise how to promote people's rights, choice or independence.

The culture of the service did not reflect best practice guidance for supporting people with a learning disability or autistic people. Senior managers and staff did not understand the underpinning principles of Right support, right care, right culture guidance, or how these could be used to develop the service in a way which supported and enabled people to live an ordinary life, enhanced their expectations, increased their opportunities and valued their contributions.

People’s human rights were not upheld, staff used punitive practices as a way of controlling people’s behaviour and language used by staff was disrespectful and demeaning. People were not involved in a meaningful way in the development of their care and support and information was not provided in a way which met people’s individual communication needs. All of which created a closed culture, which increased people’s dependence on staff who had limited understanding of how to support people in a way which upheld their human rights.

People’s basic right to privacy and dignity and to be free from all forms of discrimination under the Equality Act 2010, was not always understood by staff or respected. This meant that people experienced a poor quality of life which was not person centred as staff did not put the needs of people first.

People were not always protected from the risk of abuse or avoidable harm. We found where some risks had been identified, sufficient action had not always been taken to mitigate those risks and keep people safe. Key pieces of information relating to people's care and support needs were not always being recorded or followed up. Other risks were well managed.

People were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible and in their best interests.

People who had behaviours that could challenge themselves or others, had proactive plans in place to reduce the need for restrictive practices, however, these were not always followed. Support did not always focus on people’s quality of life and staff did not regularly evaluate the quality of support given, involving the person, their families and other professionals as appropriate.

People were not always protected from the risk and spread of infection.

People were not supported by staff who understood best practice in relation to learning disability and/or autism. Governance systems did not ensure people were kept safe and received a high quality of care and support in line with their personal needs.

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 12 February 2021). Following that inspection, the provider was asked to complete an action plan to show what they would do and by when the improvements would be made. This was not received by the Commission.

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 and to provide assurance that the service is applying the principles of Right support, right care, right culture.

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 have found evidence that the provider needs to make significant improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

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 New Redvers 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 regulation in relation to safe care and treatment, safeguarding people from abuse, the need for consent, staffing, recruitment, notifications, duty of candour and governance. Please see the action we have told the provider to take at the end of this report.

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

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

We will meet with the provider following this report being published and work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

New Redvers is a residential care home that provides personal care and support for up to 19 people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were 13 people living at the service.

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

People told us they were happy and felt safe living at New Redvers and relatives did not raise any concerns about people’s safety. We found the service was not operating in accordance with the regulations and best practice guidance. This meant people were at risk of not receiving care and support that promoted their wellbeing and protected them from harm.

The provider demonstrated a commitment to people living at the service and spoke passionately about providing good quality care. However, they did not have sufficient oversight of the service to ensure people received the care and support they needed.

Systems and processes to monitor the service were not being regularly undertaken or robustly completed. This meant they were ineffective, did not drive improvement and opportunities to learn from incidents, address poor performance and improve practice had been missed.

People were not always protected from the risk of avoidable harm. Where some risks had been identified, sufficient action had not been taken to mitigate those risks and keep people safe Key pieces of information relating to people's care and support needs were not always being recorded or followed up.

Some risks, such as those associated with people’s environment, had not always been assessed or managed safely. For example, routine environmental checks in relation to water temperatures, window restriction and fire safety were not always being carried out.

People's medicines were not always managed safely.

Staffing levels were not always sufficient to meet people's needs and to keep them safe. Staff recruitment was not always safe as information received about potential new staff had not always been reviewed or followed up.

The service did not have an effective system in place for recording what training staff had received. This meant the provider could not be assured that staff had the necessary skills to carry out their roles. Staff told us they felt supported. However, formal supervisions were not taking place.

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. The lack of effective leadership did not promote and ensure a positive and person-centred culture in the home were people were supported. This meant we could not be assured that people who use the service were able to live as full a life as possible and achieve the best possible outcomes that include control, choice and independence or that they were being supported to be the best version of themselves.

Whilst we did not find people were being disadvantaged, people were not supported to have maximum choice and control of their lives and staff were not supporting people in the least restrictive way possible.

People were not always protected from the risk and spread of infection. Staff had not undertaken sufficient training and did not have the information they needed to ensure people were fully protected from the risks of infection.

People were encouraged to share their views through regular house meetings and relatives felt comfortable raising concerns and were confident these would be acted on.

The provider had been working with representatives from the local authority safeguarding and quality teams following concerns identified to make improvements needed.

Throughout the inspection we found the provider and nominated individual to be open and responsive to our feedback. Whilst they had not been fully aware of all the concerns we identified, they were aware of the need to improve and keen to make those improvements.

Following the inspection, the provider informed the Commission they had appointed a management consultancy service to manage the home on a day to day basis and support the necessary improvements.

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 (published on 15 September 2018).

Why we inspected

We received concerns in relation to the management of people’s medicines, health care needs, staffing levels, fire safety and the overall management of the service. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 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.

We have found evidence that the provider needs to make improvement. Please see the safe, effective and well-led sections of this full report.

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 New Redvers 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 safe care and treatment, safeguarding people from abuse, the need for consent, recruitment, staffing, notifications, and governance at this inspection.

Please see the action we have told the provider to take at the end of this report. 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

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.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress and continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme.

At our last inspection in May 2017, we found two breaches of regulation and the home was rated overall as ‘Requires Improvement’. Following that inspection, the provider contacted us outlining the steps they would take to meet the relevant legal requirements. At this inspection, we found improvements had been made.

New Redvers had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published; we found it followed some of these values and principles. These values relate to people with learning disabilities being able to live an ordinary life.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

New Redvers is set over two floors. The home was clean, tidy and people's bedrooms were decorated with their own furniture and items of importance. However, some areas of the home needed redecoration. For example, some carpets were worn and stained, paintwork and walls were marked and some radiator covers were damaged. The outside garden area was quite extensive, but poorly equipped with seating etc, which limited the opportunities for people to spend time outside. The registered manager and the provider’s representative were aware of our observations about the environment and assured us there was an on-going refurbishment programme in place. We asked the registered manager for a copy of the home’s refurbishment plan but this was not provided.

We have made a recommendation in relation to the environment and outside space.

People told us they felt safe and were happy living at the home. One person said; “I like living here, I do feel safe.” Another person said, “I feel quite safe here.” A relative said, “I do not have any concerns about [person’s name] safety.”

People receive care and support from sufficient numbers of staff to meet their needs and checks were carried out on staff before they started work to assess their suitability. Staffing levels were organised around each person’s specific support needs. For example, were people required 1:1 or 2:1 staff support, this was being provided. At the time of the inspection there were four members of staff on duty in addition to the registered manager. At night people were supported by one waking night staff member and one sleep-in staff member who could be woken if needed.

People received their medicines when they needed them and in a safe way. People were cared for and supported by staff who knew them well. Staff were kind, caring, treated people with respect and maintained their dignity. The manager and staff understood their roles and responsibilities to keep people safe from harm; protect people from discrimination and ensure people's rights were protected.

People's care records reflected their needs, were regularly reviewed and updated. We looked at the care and support records for four people living at the home. These were developed using a range of formats including symbols, pictures and words. They described what was important to people, what people could do for themselves and how staff should offer support. People told us they were actively involved in developing their care and support. Each person had a copy of their support plan, which some choose to keep in their bedrooms.

People were encouraged to make choices and were involved in the care and support they received. Staff displayed a good understanding of the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguarding (DoLS) in ensuring people’s rights to make choices where they had the capacity to do so were respected.

People were supported to maintain a healthy and balanced diet. We received mixed comments about the meals provided by the home. Some people told they enjoyed the food provided by the home. Comments included, “The food is very good” and “very nice,” and “I like the food.” However, some people told us there was not enough variety. We discussed what we found with senior staff who told us the meals were planned on a weekly basis by the people living at the home. Staff assured us they would address people concerns at the next meeting and remind people they could choose an alternative if they did not like what had been chosen. People who needed assistance from staff to ensure they ate and drank enough to maintain their health had their food and fluid intake monitored. Where people had specific dietary needs, these were fully understood by staff and catered for.

People, relatives and staff told us they were encouraged to share their views and spoke positively about the leadership of the home and told us the home was well managed. The registered manager was aware of their responsibilities in ensuring the Care Quality Commission (CQC) and other agencies were made aware of incidents, which affected the safety and welfare of people who used the service.

There were effective quality assurance systems in place and the management team carried out a regular programme of audits to assess the safety and quality of the service and identify issues. These included audits on medicines records, incidents and accidents, care records and environment.

People were protected from the risk of cross contamination and the spread of infection. Staff had access to personal protective equipment (PPE) and received training in infection control. Equipment used within the home was regularly serviced to help ensure it remained safe to use.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not always safe because there were not enough staff on duty, and on the premises, at night. We raised our concerns with the provider and the nominated Individual, who took immediate action and increased the staffing levels at night. A nominated individual is the providers representative and responsible for supervising the management of the regulated activity. Following the inspection, we shared our concerns about people’s safety with the local authority’s quality assurance and improvement and safeguarding teams.

We looked at home’s quality assurance and governance systems and found these were not all effective. There were a variety of systems to monitor the home. These included a range of audits and spot checks, for instance, checks of the environment, medicines, care records, accidents and incidents, finances and people’s wellbeing. Although some systems were working well, others were not effective, as they had not identified a number of concerns we found at this inspection. For example, the home’s policies and procedures for fire safety at night, medical emergencies and missing persons were not accurate, up to date or being regularly reviewed.

We discussed these findings with the nominated individual who assured us this had been an oversight and gave us assurances this had not placed people at unnecessary risk. Staff we spoke with were clear about the action they should take in the event of an emergency.

People told us they felt safe and were happy living at New Redvers, comments included “I feel very safe here,” “If I have worries I would talk to my keyworker” and “I’m happy living here with my friends.” Relatives told us they did not have any concerns about people's safety. People were protected from abuse and harm. Staff received training in safeguarding vulnerable adults and demonstrated a good understanding of how to keep people safe. There was a comprehensive staff-training programme in place. This included safeguarding, first aid, infection control, moving and handling, and food hygiene.

People were encouraged to make choices and were involved in the care and support they received. Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and how to support people within their best interests. People told us staff treated them with respect and maintained their dignity. Throughout the inspection, there was a relaxed and friendly atmosphere within the home and staff spoke about people with kindness and compassion.

People and relatives told us they were involved in identifying their needs and developing the care provided. People's care plans were informative, detailed, and designed to help ensure people received personalised care.

People received their prescribed medicines when they needed them and in a safe way. There was a safe system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely when they were no longer required. Staff had received training in the safe administration of medicines.

People were encouraged to lead active lives and were supported to participate in community life where possible. People were empowered to access support from a range of services, such as dentists, opticians, chiropodists, and GPs and staff worked alongside these organisations to support people when required. People spoke positively about activities at the home and told us they had the opportunity to join in if they wanted. Activities were designed to encourage social interaction, provide mental stimulation, and promote people’s well-being.

People, relatives, and staff spoke highly of the management team and told us the home was well managed. Staff described a culture of openness and transparency where people, relatives and staff, were able to provide feedback, raise concerns, and were confident they would be taken seriously.

Throughout the inspection, we observed that the home maintained a high standard of cleanliness and steps had been taken to minimise the spread of infection. We saw the premises and equipment were clean and staff had been provided with aprons and gloves Records showed that equipment used within the home was regularly serviced to help ensure it remained safe to use.

We found 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 registered manager was not present or running the service at the time of this inspection. A manager had been appointed to run the service and had been in post since September 2013. They were not a registered manager. We were told they were supported by the provider's wider management team.

We found that people were not always consulted about daily decisions or supported to express their views or consent. Some steps had been taken to contact advocates for people. However, the principles of the Mental Capacity Act 2005 were not put into practice or understood.

Records at the service were lacking in some information and instructions on record keeping were not followed by all staff. There were no verifiable records for some important monitoring checks on some people's health. There was a risk of inconsistent, unsafe or inappropriate care.

There was an on-going failure to operate effective quality assurance systems. It was not always clear who had responsibility for completing specific tasks. There was insufficient monitoring of completion of tasks. The service was not well led and the provider's management team did not work effectively to improve the service.

This inspection was carried out by an adult social care inspector. During the inspection we looked at the evidence to answer the key questions:

Is the service safe?

Is the service well led?

New Redvers is a care home without nursing providing care and support for up to 19 people with a learning disability. Some of the people who lived there also had physical disabilities.

We, the Care Quality Commission (CQC) inspected New Redvers on 11 June 2013, and again on 25 November 2013. At these inspections we had continuing concerns in relation to consent to care and treatment, assessing the quality of the service and records. We issued the provider with warning notices in relation to assessing and monitoring the quality of the service and records.

On 3 February 2014 we again inspected the home as we still had concerns over how they assessed the quality of the service and records management. We carried out a provider level review and looked at whether the issues were shared across other homes operated by the provider.

We inspected the home again on 24 and 28 April 2014 and found that although improvements had been made the provider was still not fully compliant. As a result we served compliance actions in relation to assessing and monitoring the quality of service and records management. On the inspection of 24 and 28 April 2014 we also identified new concerns in relation to safeguarding practices at the home. The provider sent us an action plan telling us what they were doing to put this right. We met with the provider on 14 May 2014 to discuss our concerns with them and the actions we would consider taking if the home did not improve. We saw that the provider had employed a specialist management consultancy service and had clarified the management structure.

On this inspection we looked at what had changed.

We spoke with and spent time with six of the eleven people who lived at the home. We also spoke with four members of staff and two members of the management team. We reviewed records relating to the management of the home which included three care plans in detail and observed the care and support people received.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People we spoke with told us they were happy at the home and felt safe there. We saw that systems for protecting people from abuse had improved. For example we saw that there were more robust and transparent systems for supporting people with their personal finances. Concerns about safeguarding issues were being reported appropriately by the provider to external organisations for investigation.

We found that people's medication was being managed safely.

However we found that some recording systems were still not robust enough and some internal audits were still not being completed, for example for infection control. This could leave people at risk of unsafe or inappropriate care.

Is the service well led?

We found that there had been improvements within the home. The manager who had been in post for nearly a year told us they had developed more confidence in their role. Staff we spoke with told us that things were getting better at the home.

However we still had concerns that people who lived at the home did not benefit from safe quality care, treatment and support due to a lack of effective decision making and unclear leadership within the provider organisation.

The employment status of the Registered Manager for the purposes of CQC was unclear. The Registered Manager had not been working at the home for around a year. The current manager in post was not yet registered. They are referred to throughout this report as the manager. The nominated individual, who is the person nominated by the provider company to oversee the operation of the organisation had sought a meeting with the Director of the company. This was to discuss a lack of clarity in roles and accountability within the organisation. This told us that there was still poor communication and understanding of people's roles at times within the organisation.

We found that some areas of the provider's action plan were incomplete or inaccurate. This did not give us confidence that the plan was being implemented effectively. We found that sufficient changes had not taken place for the service to become compliant.

We inspected the home again on 3 February 2014. We found that we still had some concerns over consent to care and treatment, assessing and monitoring the quality of service and records.

We held a provider level review looking to see if the issues we had found were identified at other homes operated by the same provider. We found that there was not a co-ordinated quality assurance policy and that the management team did not work effectively together to improve the service across all the locations we inspected. However we found the impact of this had varied between locations. The provider sent us an action plan in relation to the February inspection on 17 April 2014.

On this inspection of the 24 and 28 April 2014 we inspected the home to monitor the progress that had been made in relation to the warning notices we had issued. We identified that improvements had taken place in relation to the specific actions in the warning notices for the management of records and quality assurance systems. We also identified some new concerns in relation to safeguarding. We have decided as a result to downgrade the warning notices to compliance actions to reflect the fact that improvements have taken place. However these are not yet sufficient to become compliant with the whole of the regulation. We found progress had been made on the compliance action regarding consent to care and treatment.

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found '

Is the service safe?

Although some improvements had been made to the systems for care planning and assessing of people's needs we found there were still inconsistencies. For example we had concerns that staff were not using guidance in the care plans consistently to help keep people safe and reduce risks. The home's management were not using management tools to learn and prevent re-occurrence of incidents that presented risks. Incidents had not always been reported to external agencies. This meant that people were at increased risk of unsafe or inappropriate care.

We identified concerns in relation to the way in which people's personal finances were used or accounted for. We found that the lack of robust and detailed systems for the management of people's money and supported decision making left people at risk of financial abuse.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We saw that although no-one at the home was the subject of an authorisation to deprive them of their liberty this was being reviewed by the local authority as a part of a review of all the people they funded at the home.

We found that records relating to the maintenance and upkeep of the environment and risk assessments had improved. This helped to ensure people lived in an attractive and safe environment.

Is the service effective?

We found that the home manager and staff had an increased understanding of decision making in relation to people's capacity, best interest decisions and acting upon people's wishes with regard to their care and treatment. We saw people being supported to take part in activities of their choice.

Improvements had been made with regard to protecting people's rights to make decisions where they were able to do so. Where people had lost this capacity the provider had taken steps to ensure that best interest decisions had been or were being made when required. We saw records of recent best interest decisions in relation to people's health and welfare which described the rationale behind decisions and who had been involved. This demonstrated the home protected the rights of individuals in these instances.

Is the service caring?

People told us they were positive about living at New Redvers. One person said, 'Yes, I like it here. I get on with people I do' another said 'I am alright. I like to go out into town and I do.'

We saw people interacted well with staff and sought them out for re-assurance or guidance. We saw staff spoke respectfully to people. We asked one person about their key worker. They told us 'She's very nice. She helps us a lot. She goes out with us.'

We spoke with staff to see how they ensured people exercised choice in their lives. We spoke with one member of staff who told us how they were careful not to present a whole range of options at once, as this caused one person to become anxious. They explained how the person was better equipped to make a decision if they were presented with options one at a time and could consider and discount each option. We spoke with the person who confirmed that they like to hear, 'not lots, just one thing to choose' and that this helped them decide what they wanted to do. This told us that staff were aware of presenting information and choices in a way that suited individual needs.

Is the service responsive?

People who used the service were asked for their views about their care and treatment. However we did not see evidence that these had been acted upon. For example we saw that there had been two residents' meetings in the last two months. The minutes of those meetings showed that these were largely focussed on food and outings. There were no actions points from the meetings. For example, where people expressed a wish to do a particular activity there was no indication of how that wish would be considered or progressed and whether people's key care workers had been informed. This meant that there was a risk that when people raised issues they would not be fully addressed.

We also found that staff concerns had not always been directed appropriately, or responded to in a timely way.

Is the service well-led?

The Registered Manager was no longer working at the home, and had not been since 2013. A new manager was in post, but was still in their probationary period. They are referred to throughout the report as the manager. We have not yet received an application from the previous manager to de-register.

The management of the home was working through action plans set for the CQC or by the CQC, the commissioning authority and by a care management company. None of the plans had yet been completed, however progress could be identified.

We found there was a lack of clarity over people's roles and responsibilities at the home and in the higher management structure of the provider organisation. For example we were told that decisions had been made by an area manager about a person's care without reference to the manager of the home.

Clear and effective systems were not in place to make sure the manager and staff learned from events such as incidents, complaints or concerns. This meant that people were not benefitting from learning to prevent incidents re-occurring.

We found that audits had not always identified issues, or if completed had not led to clear action where identified. This had the potential to put people at risk.

A specialist learning disability advisor accompanied us on this inspection. We spoke with seven people who lived at the home. Most people were positive about life at New Redvers. Comments included, 'I like my room and I like going out to the caf'. Where people were unable to communicate with us we used observations to help us understand their experiences of living at New Redvers. Most of the interactions we observed were friendly and respectful.

We found that staff and management at the service did not demonstrate full understanding of their responsibilities in relation to the Mental Capacity Act (2005) and issues of consent. We also found that some records at the service were not fit for purpose and some personal records were not stored securely.

People and their relatives told us that the service was improving. Comments included, "They are doing more with all the residents, the management is better". However, we found that quality assurance systems were not effective.

We had received specific concerns about fire safety prior to our visit. Those concerns were not substantiated.

We observed people being supported to make choices about daily living, such as whether to go an outing or what to eat. However, we found that records showed that some people had not been supported to go out into the community regularly. We observed staff asking people for consent. We found that Mental Capacity Act (2005) assessments had not been undertaken for people who might not have been able to make some decisions about their care. This meant that there was a risk that their rights might not be protected and decisions taken on their behalf might not be in their best interests.

We found that there had been efforts to improve the organisation of care plans. However, care plans had insufficient or out of date information. This meant there was risk of unsafe or inappropriate care being delivered. Some records were not fit for purpose.

The provider had identified staff training needs and we saw records which showed that further training and refresher training was underway for care workers. However, we found that the interim management team had not provided effective management or quality assurance.