Rose Farm House

Rose Farm House is a residential care home providing personal care to five people with learning disabilities and autism at the time of the inspection. It is a specialist service for people that have anxious or emotional behaviour that has limited their quality of life and experiences. The service can support five people. The accommodation is spread over one main building which contains two bedrooms and one flat and two annex's each of which contained a one person flat.

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

People had been exceptionally well supported to reach goals that had been previously deemed unattainable. People could display high levels of behaviour of distress, which had previously impacted on every part of their life, however no longer did. People had been supported to reduce the frequency and severity of their behaviour of distress through staff adapting their approach and learning lessons on how to support people more effectively. As a result, the volume and frequency of physical intervention that needed to be used had decreased for everyone living at the service. Staff told us this was important to keep people as safe and distress free as possible.

People had been supported to review and reduce medicines they were taking. Some people had taken medicines for long periods of time, to support them to reduce behaviours of distress. Staff had worked with healthcare professionals to reduce and remove these medicines with no adverse effect on the person, and no increase in distress. People were supported by a core staff team who knew them well and had developed their approach to support people in the most positive way. People were at the centre of everything within Rose Farm House, including the recruitment of new staff.

Staff and the registered manager demonstrated a positive culture within the service which supported people to achieve their goals. For example, one person was supported to be baptised. Staff worked with external agencies to provide the best outcomes for people. Health escalation plans were put in place to anticipate people’s needs and make getting support fast and effective. People were listened to, and their aspirations championed by staff. Relatives told us they were kept informed about every part of their relatives’ care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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. The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• Model of care and setting maximises people’s choice, control and independence. People had been supported to gain new skills and take more control of their life for example with finances.

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human rights. Staff demonstrated a person-centred approach and supported people to uphold their human rights, for example contesting their DoLS.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives. There was a clear culture of striving for excellence and supporting people to lead the best life.

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 3 September 2018).

Why we inspected

The inspection was prompted in part due to concerns received about restrictions on people and concerns of a closed culture. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe 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.

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.

At the last inspection the service was rated overall as requires improvement. Following this we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well-led to at least good. At this inspection we found that the service had improved and the service is now rated Good.

At the previous inspection of the service on 15 June 2017, there was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In that the provider had failed to assess and mitigate the risks to the health and safety of people of receiving support. At this inspection the provider had taken the appropriate action. The registered manager had assessed risks and there was a plan to minimise these risks in place. There was clear, detailed and appropriate guidance for staff.

At the previous inspection of the service on 15 June 2017, there was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In that the provider had failed to protect people from improper treatment. The provider had provided care that intended to control and restrain people that was not assessed, agreed, reviewed and was not always the least restrictive option. At this inspection the service had made the improvements required. There were systems in place to keep people safe and to protect people from potential abuse. Staff had undertaken training in safeguarding and understood how to identify and report concerns. The use of restraint had been reviewed and some people were no longer subject to restrictive practices or restraint. Where restraint continued to be used, this had been properly assessed and appropriately agreed in advance. Plans had been updated to ensure that staff always used the least restrictive option and restraint was regularly re-assessed and reviewed. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible.

At the previous inspection of the service on 15 June 2017, there were two breaches of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In that the provider had failed to maintain an accurate and complete record about people's support needs and. had failed to carry out effective audits to identify the shortfalls found at that inspection. At this inspection people’s support records were complete and up to date and the registered manager regularly audited the service to identify where improvements were needed. These checks were effective and actions identified had been undertaken.

When we completed our previous inspection on 15 June 2017 there were concerns relating to the services pre-admission assessment procedure and made a recommendation about this. At that time, this topic was included under the key question of responsive. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this topic is included under the key question of effective. Therefore, for this inspection, we have inspected this key question and also the previous key question of responsive to make sure all areas are inspected to validate the ratings. At this inspection the provider had reviewed the pre-admission procedure and no new people had been admitted to the service.

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.

The service had a registered manager 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 2008 and associated Regulations about how the service is run.

The registered manager continued to monitor the quality of service provided by seeking feedback from relatives and health and social care professionals. Safeguarding referrals were made on time and as appropriate and the service could demonstrate that lessons were learnt when things went wrong. However, the service had recently made improvements to the communication processes as they had received feedback from relatives and health and social care professionals that some areas of communication about these topics had not always been prompt and robust. At the time of the inspection these improvements had not yet been measured to see if they were effective. We made a recommendation about this.

Medicines continued to be managed safely and people received their medicines on time and when they needed them.

There were sufficient numbers of staff to meet people’s needs and support people effectively. Staff had the training, skills and knowledge they needed to support people with learning disabilities. Spot checks were carried out to monitor staff performance and staff had regular supervision meetings and annual appraisals. New staff had been recruited safely and pre-employment checks were carried out.

Peoples support was personalised to them and met their needs. People’s support plans were updated when their needs changed. People and their relatives were involved in decisions about their support.

People continued to be supported to maintain their health and wellbeing by improving their diet to achieve their weight goals. People were supported to maintain their health and had regular access to healthcare services. When people accessed other services such as going in to hospital they were supported by the service staff and there was continuity of care.

People were treated with respect, kindness and compassion. Staff took the time to listen to people and engage with them in a meaningful way. People were supported to communicate their wishes and express their feelings. Staff recognised when people were upset or anxious and responded to this appropriately. Staff were aware of people’s decisions and respected their choices. People’s privacy was respected and levels of dignity were maintained.

People were supported to increase their independence and undertake activities of daily living. People were supported to maintain relationships. There was a complaints system in place if people or their relatives wished to complain.

The environment had been adapted to meet people’s individual needs and was personalised to reflect the people that lived there. The service was clean. Staff were aware of infection control and the appropriate actions had been taken to protect people.

Staff, relatives, community health and social care professionals told us the service was well-led. The registered manager had a clear vision and values for the service, which staff understood and acted in accordance with. Staff and the registered manager understood their roles and responsibilities. The service worked in partnership with other agencies to develop and share best practice.

Rose Farm House is a detached property located in a rural setting close to Ramsgate and Margate. Staff provide 24/7 care and support for up to five people with learning disabilities and / or Autistic Spectrum conditions. There are three bedrooms in the main house and two one bedroom self-contained flats attached to the main house. On the day of our inspection there were five people living at the service.

High Quality Lifestyles Limited is part of the Priory Group. There was 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.

Staff had worked hard to increase people’s independence and opportunities. People who were previously restricted or who had reduced opportunities due to their behaviours were now leading more fulfilled lives and were part of the community. However, the need for very clear and recorded assessment and agreement, by people, their loved ones and others, for the physical restraint being used for some people had been overlooked. People were being restrained by two or three staff with no assessment or thought given to the risks to people and with no recorded agreement and review of each incident.

Staff were committed to providing individual care to people and the aim of the service was to do things with people rather than for them. The registered manager was qualified and experienced. However, the governance and oversight had failed to recognise that restrictions had been imposed, including the use of restrictive physical intervention, without agreement, assessment and regular review. The governance, or oversight, of incidents of when restraint was used was lacking. The provider took action to address this after our inspection.

People’s needs should be assessed before they moved in but this had not happened for everyone. Each person had a support plan, a behaviour support plan and health action plan detailing their needs. People and their loved ones had been involved in writing their support plans. Not all support plans were up to date so staff may not have up to date guidance about people’s support needs. Support plans were not readily available for staff to refer to as they were stored in a separate building away from the main house.

People were given choices in a way they could understand and staff knew about the Mental Capacity Act (MCA). Staff had not always worked in line with the principles of the MCA. People and their loved ones had opportunities to air their views and make complaints and these were mostly acted on although some issues remained unresolved.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. 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. DoLS applications had been made to the relevant supervisory body in line with guidance.

Staff knew about different types of abuse and who to report any concerns to. Most risks to people were managed although some risks had not been assessed. There were enough trained staff to meet people’ needs and staff were checked before they worked with people. People had a say in recruiting the staff who might support them. Medicines were managed safely and people were supported to eat a healthy diet, to take part in cooking meals and to remain healthy. Staff had sought advice and guidance from a variety of healthcare professionals to ensure people received the care they needed.

Staff were respectful and kind and listened attentively to people and celebrated their achievements. Staff respected people’s privacy. People were supported to learn new independent skills and to achieve their goals. Information was produced in a way people could understand and people and their loved ones were supported to air their views. Staff carried out checks of the environment and some records and some people took part in these checks, although the issues found at this inspection had not been picked up.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We set out to answer our five key questions:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not safe. Before the inspection concerns were raised about infection control and the environment.

The flooring in the bathroom upstairs was not sealed and water was leaking through the ceiling. The carpets were not suitable for everyone's needs and could not be cleaned thoroughly.

The annex was poorly maintained. Doors were damaged; plaster was missing from parts of the walls. Paintwork was patchy and uneven. One wall was damp and parts of the ceiling were stained. Flooring was damaged in areas. Some of the furniture was broken including storage units and fittings.

Risk assessments were reviewed regularly and care plans updated. People were referred to healthcare professionals appropriately. Managers and staff learned from accidents and incidents by looking for patterns and trends to prevent further incidents.

Staff had knowledge of safeguarding people from abuse and how and where to report any concerns. Staff knew where the policies and procedures were and said they could refer to them should it be needed.

Is the service effective?

The service was effective. People told us that they were happy with the care they received and that their care needs were met. One person said, "I am happy here. Staff treat me well. I have no worries". Another said, "Staff talk to me when I am worried. I like it here".

Is the service caring?

The service was caring. People were supported by kind and attentive staff. Staff showed patience and gave encouragement when supporting people. People we spoke with said they felt staff respected their privacy and dignity and staff were polite and caring.

Is the service responsive?

The service was responsive. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We reviewed and discussed with staff the care plans of two people who used the service. Care plans had guidelines about the support needed to meet the people's needs. Staff had an awareness of the detail in the care plans and of people's needs.

People were supported to attend health appointments, such as, doctors or dentists.

Is the service well-led?

The service was well led. Staff told us that they felt well supported and were given the information they needed to support the people who used the service.

Staff meetings were held where changes or issues with people's care were discussed. Surveys were sent to people who used the service and their relatives to gain their views about the service.

The manager carried out audits but actions from the audits were not always addressed.

Through direct observation, discussions with staff and records we viewed, we saw that the service actively encouraged people to be members of the wider community. The service provided imaginative and varied opportunities for people to develop and maintain social, emotional, communication and independent living skills.

During the inspection we were able to observe people who used the service being supported with their hobbies and interests. People also took part in many every day activities. These included going for a walk and shopping. People were also supported to carry out household chores such as vacuuming and laundry.

People told us they received care from a small team of staff and were happy with the care received and had no concerns relating to the home.

One person spoke of his part time job and how staff supported him. Another said he enjoyed his computer and liked going out with staff and cooking. All spoken with expressed a great deal of satisfaction from living within the service and did not raise any concerns about the quality of care. All said if they were not happy they would speak to staff or the manager.