Archived: Heathers

Heathers is a residential care home providing personal care to eight people with learning disabilities, autism and mental health conditions at the time of the inspection. The service can support up to nine people. The care home accommodates people in individual self-contained apartments with ensuite bathrooms, kitchen and living area. Two apartments are in the main ‘farmhouse’ and the remaining accommodation is around an adjacent courtyard. There is communal outdoor space and a communal activity room.

The service had not been developed and designed in line with the principles and values that underpin Registering the Right Support. The service was in an isolated location at the end of a mile long un-made road. There was no nearby local community for people to engage with. People were supported on a one to one basis in their own self-contained apartments and little attempt was made to help them socialise with each other.

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

At our last inspection we found evidence of a closed culture where staff failed to report concerns and escalate them to managers. There was evidence of incidents of abuse by staff. At this inspection while we found that some staff had left the service which improved the atmosphere in the short term, the provider had failed to address the concerns about the poor culture. They had not ensured staff understood how to report and escalate safeguarding concerns. There was no clear leadership in the service, with repeated changes of management. The provider had poor oversight of the service and had not identified that their own targets and timescales for change had not been met. Communication with people and their relatives was poor. The service did not actively engage the support of professionals to improve the quality of care for people unless it was at crisis point.

Action was not taken in response to safeguarding recommendations. The service failed to properly assess and manage risks, particularly risks in relation to people’s distressed behaviours. People’s risk assessments and care plans were out of date and did not contain accurate guidance on how to support people. Records were not reviewed following incidents. The provider had not reviewed the guidance and assessed risks in relation to Covid 19. Staffing levels had improved since the last inspection, however there were still significant gaps in the evenings where there were insufficient staff to support people safely. There were occasions at night when there were not enough staff on duty and on one of these occasions a serious incident had occurred which could have resulted in harm to people living at the service and staff.

The service did not apply 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 fully reflect the principles and values of Registering the Right Support for the following reasons. There was a closed culture that did not support people to have choice and control. People were not supported to engage in meaningful activities either within the service itself or in the local community. People were not supported to develop skills to support their independence.

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 16 April 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

This service has been in Special Measures since 15 April 2020.

Why we inspected

The inspection was prompted in part by concerns relating to notification of an incident which could have resulted in serious harm to staff and people using the service. These concerns related to the management of risk in relation to people’s behaviours. When we followed up our concerns it became apparent the provider had not made the improvements they said they would make following our last inspection. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The overall rating for the service has stayed the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Heathers 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, staffing, governance, notification of other incidents and duty of candour 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 request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The 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.

Heathers is a residential care home providing personal care to eight people with learning disabilities, autism and mental health conditions at the time of the inspection. The service can support up to nine people. The care home accommodates people in individual self-contained apartments with ensuite bathrooms, kitchen and living area. Two apartments are in the main ‘farmhouse’ and the remaining accommodation is around an adjacent courtyard. There is communal outdoor space and a communal activity room.

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. Registering the Right support ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. At the Heathers there was a closed culture that did not support people to have maximum control, choice and independence and people using the service did not receive planned and co-ordinated person-centred support that was appropriate and inclusive for them.

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

People were not kept safe at the service. There had been a number of serious incidents that put people in the service at risk. Some of these incidents included abuse by members of staff in the service. The provider did not always report incidents. Neither did they always act in a timely manner to take action to safeguard people following incidents to ensure they did not happen again.

There was a closed culture at the organisation which did not encourage staff to raise concerns when they witnessed poor practice or abuse. There was no system to monitor the quality of care in the service or the actions of the manager. The provider did not have a regular presence in the service to provide support to the registered manager and the senior staff. The registered manager and deputy manager both worked regular shifts supporting people in the service which meant there was no oversight of the service and they did not have time to monitor the quality of care and ensure records were up to date. This meant audits were not always completed and action wasn’t taken following incidents to prevent things happening again.

Risk assessments and behavioural support plans did not always contain sufficient guidance for staff on how to keep people safe. There had not always been enough staff at the service which resulted in people sometimes sharing their one to one support. The provider had increased the number of staff available, but there was a high use of agency staff who weren’t always familiar with people’s needs. There were systems in place to ensure people received medicines as required. However, where people were prescribed medicines ‘as and when required’ this was not monitored or reviewed when people had these medicines on a regular basis. Other professionals told us they were concerned about a culture of ‘containment and medication’ rather than positive support for people. Fire procedures were inadequate. The provider reviewed these at our request following our first day of inspection.

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 and culture in the service did not support this practice. People were not deprived of their liberty in accordance with the law. Records and systems in place to support people with eating and drinking were inadequate and records contained contradictory guidance for staff. Some people did not always have care plans to provide guidance for staff on eating and drinking. Records of what people had to eat and drink for people at risk of malnutrition were not consistently maintained.

Staff training was not always effective and was not always put into practice. There was no system to monitor staff practice so the registered manager and provider could reassure themselves of staff competence. People were supported on a one to one basis in their own self-contained flats which did not provide opportunities for ‘open’ observation.

Staff were not always caring and respectful of people’s privacy and dignity. There were a number of incidents where people’s privacy and dignity had been compromised. People were not supported with their cultural needs. Care was not person-centred and care plans were not always reviewed when people’s needs changed. Plans to support people with their behaviour contained generic advice directly copied from a template and had not been sufficiently personalised to reflect people’s needs, and in some cases was contradictory to their needs. There were no activities on site and people were not supported to socialise with each other. High use of agency staff meant some people did not have the opportunity to go out into the community.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; there was a closed culture which did not always keep people safe, there was a lack of choice and control, limited independence, limited inclusion in the community and a lack of meaningful activity.

Prior to our inspection the provider had asked an external consultant to carry out an assessment of the service and they had put together an action plan based on their findings. This addressed some of the shortfalls but not all of the concerns we found at our inspection.

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 30 May 2019)

Why we inspected

The inspection was prompted by a notification of a safety incident at the service. The incident was subject to a police and safeguarding investigation. The information CQC received indicated concerns about the culture at the service. In addition, because the incident resulted in a number of staff being suspended, we were concerned about whether the service had sufficient staff to support people safely. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. After our first day of inspection we were concerned that standards fell below those expected in other the other key questions, so we widened the inspection to a comprehensive 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 improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

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

Enforcement

We have identified breaches in relation to safeguarding service users from abuse, safe care and treatment, staffing, need for consent, meeting nutritional and hydration needs, dignity and respect, person-centred care, good governance, duty of candour and notification of other incidents.

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 request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

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.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy. Details regarding conformity are detailed in the body of the report.

People’s experience of using this service:

People living at Heathers participated in activities and were involved in the local community. Staff showed kindness and compassion. They placed value on their caring role and involvement in people’s lives. People were offered a choice of meals and staff closely monitored people assessed to be at risk of poor food and fluid intake.

The service was working with people and their families to complete end of life care planning to ensure people received high standards of care and support. People were involved in the planning of their care at that stage of their life. The service had good working relationships with the local GP practice and learning disability healthcare professionals.

The service worked in partnership with people and encouraged feedback on the care provided. We received positive feedback from people about the staff and service received. Staff told us they enjoyed working at Heathers and spoke highly of the support and encouragement provided by the registered manager.

People had their care and support needs met by sufficient numbers of suitably trained staff, with use of regular agency staff or members of the management team to meet staffing shortfalls as required. The care environment was clean and comfortable throughout, with risk management plans in place. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice.

The service had good governance arrangements in place, and completed internal quality checks and audits. Findings from these were regularly reviewed by the registered manager and provider. The management team continued to drive improvement within the service to ensure people received consistent standards of care and support.

Rating at last inspection: Heathers was previously inspected 18 October 2018, rated as Requires Improvement overall, with Inadequate in well-led. The report was published 05 December 2018.

The service was in breach of regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and regulation 18 of the Registration Regulations 2009. There were conditions that remained in place on the service’s registration, and the service sent us monthly improvement plans on how those conditions were being met. Improvement plans were reviewed as part of this inspection.

Why we inspected: Services placed in special measures are inspected within six months of the publication date of the report to determine if sufficient levels of improvement have been made.

Enforcement: At the last inspection, we identified four breaches of regulation, and continued to take enforcement action.

At this inspection, we identified significant levels of improvement, with no breaches of regulation identified. The service was meeting the conditions placed on their registration and therefore no longer placed in special measures.

Follow up: We will continue to monitor this service and will reinspect in line with our schedule for those services rated as Good.

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

Heathers is a ‘care home’ providing residential care to people with learning disabilities, autism and mental health conditions. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy. Details regarding non-conformity are detailed in the body of the report.

The service is registered to provide care to a maximum of nine people. There were eight people living at the service at the time of the inspection. Each person lived in a self-contained apartment, receiving care and support from staff within their apartments.

The service’s manager had registered with the CQC since the last inspection. 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.

At our last inspection on 1 and 2 May 2018 we identified breaches of regulation in relation to safe care and treatment. The condition and cleanliness of the service. Low staffing levels per shift with poor training completion to meet the requirements of their roles. Staff did not consistently source people’s consent or adhere to the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. Governance and managerial oversight was poor. We also identified examples of incidents that had not been notified to CQC.

As an outcome of the last inspection visit, we put conditions on the home’s registration to encourage improvement. The provider was responsible for submitting an improvement plan and monthly updates to CQC. This information was reviewed during this follow up inspection.

During this inspection on the 18 October 2018, we identified that there continued to be poor governance procedures in place, particularly in relation to the management of risks. The management team were not fulfilling the requirements of their improvement plan from the last inspection. There continued to be non-compliance in relation to submitting notifications to CQC. Not all care records had not been reviewed and updated, this was an area of concern identified during the last inspection. Care records did not contain completed mental capacity assessments, or details of people’s deprivation of liberty safeguards status where applicable.

We did identify area of improvements since the last inspection. Staff morale had improved, with better working relationships between staff and the management team. There were improvements in the level of staff training completed since the last inspection. The cleanliness of the environment had improved. The service now had up to date fire, electrical and water safety checks in place. The management team had introduced community meetings had been introduced offering people an opportunity to raise concerns or give feedback on the service.

From reviewing the outcomes of the inspection, we made the decision was made for the conditions placed on the home’s registration to remain in place. This was to ensure the management team had the maximum amount of time for improvements to be made and embedded within the running of the service.

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for the service to remain 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.

Heathers provides accommodation and support to a maximum of nine people with a learning disability or autistic spectrum disorder. It does not provide nursing care. Accommodation is provided in nine self-contained apartments. Each apartment has a bedroom, living room, kitchen, and bathroom. On the day of our inspection there were nine people living at Heathers.

This type of care service should be developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy. Our inspection findings identified a lack of conformity with the Building the Right Support and Registering the Right Support guidance. Details regarding non-conformity are detailed in the body of the report.

There was a manager in post who was completing the registration process with the Commission. 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.

At our last comprehensive inspection on 12 July 2016 we found that the service was meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and rated the service as Good.

During this inspection we identified that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations for safe care and treatment, consent linked to the Mental Capacity Act, safeguarding people from abuse including depriving people of their liberty, good governance, staffing levels and training.

Full information about CQC's regulatory response to any breaches of regulation found during inspections is added to reports after any representations and appeals by the provider have been concluded.

From this inspection, on 1 and 2 May 2018 we identified areas of concern in relation to staff training in safe management of medicines, cleanliness of the environment and infection prevention control impacting on the care people received.

The service did not have robust governance processes in place for monitoring standards and quality of care provided. Staff did not complete clinical audits in areas such as medicines management and environmental condition and this was reflected in our findings during the inspection.

Staff did not consistently recognise the need to report safeguarding concerns or submit notifications relating to incidents to CQC.

Staff were not up to date with the provider’s mandatory training or annual performance appraisals.

Staff approach and people’s records demonstrated a lack of adherence to the Mental Capacity Act and Deprivation of Liberty Safeguards.

Low staffing levels impacted on people’s access to meaningful activities, particularly in the community. Planned staffing levels recorded on rotas were not an accurate reflection of actual staffing levels on each shift.

People had choice of food and fluids, with support in place to shop and participate in food preparation. Staff treated people with care and compassion.

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.

Heathers provides accommodation and support to a maximum of nine people with a learning disability or autistic spectrum disorder. It does not provide nursing care. Accommodation is provided in nine self-contained flats. Each flat has a bedroom, living room, kitchen, and bathroom. On the day of our inspection there were nine people living in the home

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.

People were safe living in the home. Medicines were managed safely and risks to people, including from the premises, were well managed. Staff had been successful in managing a number of risks that meant people’s quality of life improved. The registered manager encouraged staff to discuss and think about incidents that occurred in the home, so they could take action to reduce the likelihood of them reoccurring.

There had been some recent changes in the staffing team. This had been managed to ensure there were enough staff to meet people’s needs. Staff demonstrated an awareness of adult safeguarding and knew how to raise concerns.

Staff were supported to provide effective care through management support, good team work and effective training. New staff were provided with a detailed induction that gave them the skills and knowledge to undertake their new role.

The service worked within the requirements of the Mental Capacity Act (MCA). The registered manager understood the importance of providing the least restrictive care as possible and staff understood the importance of offering choice and supporting people to make decisions.

Staff understood people’s individual dietary needs and how to support them. They encouraged people to eat healthily and worked with health care professionals to ensure people’s nutritional needs were met. People were also supported to access other health care professionals when required.

People were supported by very caring and dedicated staff. Staff demonstrated they were committed to the people living in the home and their quality of life. They often went the extra mile to ensure people were happy and comfortable living in the home. Positive relationships had been developed between people living in the home and staff. This meant staff knew people well and were sensitive to people’s individual needs. Some people living in the home had complex communication needs. Staff had ensured they had learnt how to communicate with each person in their own individual way so the person could feel properly understood and were able to express themselves. Staff supported people to be involved in decisions regarding their care.

People were treated in a respectful manner and encouraged to be as independent as they could be. Support was provided to people in a way that met their individual needs, preferences, and routines. People’s care plans were written in a way that was individual to them and stressed their positive attributes and skills.

People were involved in writing and reviewing their care plans, so they reflected their needs and wishes. This included writing their activities plans. Activities were varied and tailored to people’s needs and preferences.

Leaflets on how to complain were written in an easy read format and kept in people’s flats, so people knew how to complain. Relatives told us they felt able and comfortable to raise concerns. The registered manager investigated concerns and took action to resolve issues raised.

Everyone we spoke with spoke highly of the home and the support provided. The service promoted a person centred and inclusive approach towards both people living in the home and staff. People and staff felt involved in the running and development of the service. We received positive feedback regarding the registered manager and the way in which they ran the service.

Some areas of record keeping could benefit from some small improvements in some areas. However there were effective quality assurance systems in place which had identified this area required further work. The registered manager ensured the service kept up to date with best practice so they could provide effective and good quality care.

We saw that staff spoke respectfully with the person we observed and included them in conversations and friendly banter. We also saw that, when staff provided any personal support, this was carried out in a discreet and dignified manner.

The person we interacted with indicated that they were happy and appeared comfortable and relaxed with the staff supporting them during our visit.

This person also showed us around their home and indicated that they liked their apartment and enjoyed spending time in the kitchen.

We determined that there were enough qualified, skilled and experienced staff to meet people's needs and the records we looked at were accurate, up to date and fit for purpose.

People told us that they liked the food that was provided and that they enjoyed going out to eat and helping to prepare their meals.

The home was a clean and welcoming environment that was maintained to a high standard. People were eager to show us their home and told us they were able to arrange their rooms as they wished.

We found that staffing levels in the service were sufficient to meet the needs of the people living there. Staff interacted well with them and clearly understood how individuals liked to be supported.

Complaints were managed appropriately and people using the service understood how to raise any concerns they may have.