The Orchard Trust - Sevenoaks

We found the following examples of good practice.

A variety of safe visiting options was available and thorough checks were completed before visitors entered the service. The service worked closely with people's relatives to assess and mitigate infection control and prevention risks associated with visits to people's family homes.

People were supported to maintain social distancing through effective use of communal and personal spaces, staggered activities and relaxation periods.

There had been no vacancies at the service during the pandemic. Staff had followed national guidance to ensure people returned from hospital safely.

Testing was carried out in-line with national guidance.

A deep cleaning and surface cleaning programme was followed by staff. Recruitment to a vacancy for a domestic/cleaner for Sevenoaks was in progress. A domestic staff member, usually employed at another of the provider's services, was allocated to support enhanced cleaning measures employed during a recent outbreak.

The service acted proactively to manage and limit outbreaks, including ongoing zoning and cohorting of Larch and Rowan, to reduce infection transmission risks within the service. Staff worked closely with external agencies and health professionals and were supported to isolate on full-pay when a risk was identified.

Management plans, policies and procedures reflected best practice to support staff in minimising transmission risks and responding safely to outbreaks. The provider kept relatives informed of changes to national requirements and subsequent changes to their polices.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 11 people. Ten people were using the service. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and other large domestic homes of a similar size.

The service was divided into two homes/areas known as Larch and Rowan, each with its own communal rooms and facilties. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when accessing the community with people.

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

People’s experience of using this service:

The outcomes for people using the service reflected the principles and values of Registering the Right Support in the following ways:

• Staff understood how to communicate with people effectively to ascertain and respect their wishes and preferences.

• People’s independence was respected and promoted. Staff prompted people during household tasks and activities, to enable them to do things for themselves and learn new skills.

• People's support focused on them having opportunities to be part of their community, meet others and maintain existing relationships.

We received positive feedback about the service and the care people received. The service met the characteristics of ‘Good’ in all areas.

• Risks to people had been assessed and plans were in place and followed by staff to keep people safe.

• Safe recruitment practices were followed to protect people from unsuitable staff.

• Staff were knowledgeable around safeguarding and understood provider policies and procedures in this regard. There were good links with local safeguarding bodies.

• Systems were in place to ensure people received appropriate support to take their medicines safely.

• Health and social care professionals guided staff to support people with their behaviour and epilepsy in accordance with national best practice guidelines.

• Staff received regular managerial supervision, felt supported in their role and received the training they needed to support people’s needs.

• All staff had a good understanding of the principles and application of the Mental Capacity Act. The Deprivation of Liberty Safeguards (DoLS) had been followed.

• Staff attitudes and behaviours were responsive, respectful and caring.

• People were supported through appropriate communication methods by staff that knew how to involve people in their own care.

• Interactions between staff and people demonstrated personalised, collaborative, action-oriented care planning and care delivery.

• There were processes in place to manage adverse incidents and complaints. There was evidence that learning from incidents and complaints was shared across the service.

• Effective quality monitoring systems were in place and regular audits and checks supported managers to identify concerns promptly to take action to improve the service.

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

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

Rating at last inspection: We last inspected The Orchard Trust – Sevenoaks on 9 November 2017. At the last inspection the service was rated Requires Improvement (this report was published on 19 January 2018). The provider had taken the required improvement actions and our rating of the service improved at this inspection.

Why we inspected: We inspected this service as part of our ongoing Adult Social Care inspection programme. This was a planned inspection based on the previous Requires Improvement rating. We also follow up on progress against agreed action plans to address the breaches in regulation we found at our previous inspection in November 2017. Previous CQC ratings and the time since the last inspection were also taken into consideration.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

At the last inspection on 25 and 26 August 2016 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not ensured staff received appropriate support or supervision to enable them to carry out their duties effectively. Systems to maintain accurate and contemporaneous records in respect of each person who used the service were not in place. The provider sent us an action plan telling us how they would meet these regulations by 18 November 2016. During this inspection, we found the provider’s improvement action plan had been completed and these requirements were met.

‘Sevenoaks’ is a care home which accommodates a maximum of 11 people in two connected units, with separate adapted facilities. People in care homes receive accommodation and nursing or personal care as single packages, under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection, 11 people with diverse and complex needs including learning disability, autism, sensory impairment and physical disability were living there.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, the registered manager resigned their post before our inspection was completed. The provider’s head of support and operations told us they would register with CQC as manager of the service until a new manager could be appointed for the service.

During this inspection we identified breaches against two of the Health and Social Care Act 2005 (Regulated Activities) Regulations 2014. Regulation 12 Safe Care and Treatment was not met. Improvements were needed to ensure people’s medicines were managed safely within the service. Temperatures in medicines storage areas were not monitored consistently, to ensure medicines were stored safely and staff did not always follow procedures in maintaining medicines records. The service was therefore again rated ‘Requires Improvement’.

The provider’s governance systems had not always been operated effectively and were not always sufficiently robust, to monitor and improve the safety of the service provided. Some managerial audits had not been carried out to monitor whether required standards were being met. Governance processes were not always robust enough to identify whether the systems in place were effective and to ensure external agencies had been informed of relevant incidents at the service.

You can see what action we told the provider to take at the back of the full version of the report. Following our visit, the provider sent us an initial action plan, on action already taken and actions they planned to undertake, to address the shortfalls we identified during our visit.

People benefitted from a service that worked closely with health and social care professionals to understand and meet people’s complex support needs. Staff understood how to protect people from harm and abuse. Risks to people's safety were identified and clear support plans were followed by staff. There were sufficient staff on duty and recruitment procedures were followed to protect people from the employment of unsuitable staff.

People were supported by staff who received on-going training and support to maintain or improve their skills and competency. People were supported to have maximum choice and control of their

lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to eat and drink sufficient amounts and their weight and intake was monitored as needed.

People received support from caring staff who valued and understood them. People's privacy was respected and they were treated with dignity and kindness. People were supported to maintain relationships with others who were important to them. They received personalised and responsive care which enabled them to live as full a life as possible.

People could raise concerns about the service and have their complaints listened to. People benefitted from a culture that was open and transparent where staff and the management team worked together to improve the service.

At the time of the inspection the registered manager had been promoted and had removed their registration from this location. 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. A new manager had been appointed and was going through the registration process with CQC.

People did not always have the support of enough staff to meet their needs and to ensure they could participate fully in their lifestyle choices. Staff had not received individual support meetings as scheduled and did not feel supported in their roles and responsibilities. People’s care records had not been kept up to date with their changing needs or reviewed as scheduled. During the inspection changes were made in response to our findings in medicines records, employment checks and submitting statutory notifications to CQC.

People’s care records were individualised and reflected their preferences and routines important to them. Staff had a good understanding of their needs and supported them with kindness, sensitivity and patience. When people were upset staff responded by offering reassurance or helping them to cope with their emotions by offering them a drink, music or space. Staff understood people’s preferred form of communication using sign language, music and objects to give them choices about they day to day lives. People’s personal space had been adapted to provide sensory environments which they could interact with. The gardens around their home also provided a stimulating space to spend time. People when able enjoyed going out to day centres, doing voluntary work or day trips. They used the provider’s swim gym and trampoline facilities.

People were supported by staff who had access to a range of training to maintain their skills and knowledge. They were able to complete training specific to people’s needs such as epilepsy and rebound therapy (trampolining). People’s rights were upheld. Staff had a good understanding of how to keep people safe and how to raise concerns. Accidents and incidents were closely monitored to make sure the appropriate action had been taken. A representative attended a Trust Our Voice Board which held managers to account and shared people’s experiences. People’s views were sought as part of the annual survey and during their reviews.

Quality assurance processes were in place which included feedback from people, relatives and staff. Visits by a representative of the provider had not been recorded and a new audit tool had been introduced to evidence any action being taken in response to their visits. Managers and representatives of the provider attended local networks ensuring they kept up to date with best practice and changes in legislation.

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.

We have followed up to make sure that the necessary changes have been made and found the provider is now meeting the standard included within this report. This report should be read in conjunction with the full inspection report.

We used a number of different methods to help us understand the experiences of people using the service. People using the service had complex needs which meant they were not able to tell us about their experiences in relation to cleanliness and infection control at the service.

When we visited the service on 20 December we found that the actions identified by the provider had been completed. Maintenance work was planned for one of the home's kitchens and some shower facilities which would make cleanliness in these areas easier to maintain. The provider was due to update their infection control policies in line with the current guidance.

The people within the home had complex needs and we were unable to communicate directly with them. We spoke with family members and a visiting professional who said that they were "impressed with the knowledge of staff." We saw that people's rooms catered to their individual needs with some bedrooms being decorated with their personal belongings whilst others were minimal.

We looked at people's individual files which incorporated their care plans, risk assessments and health care needs. We found that they encompassed the safety and well-being of people who used the service.

Relatives and staff told us that they knew how to raise a concern or complaint and felt confident in doing.

The home had recruitment procedures in place which ensured that people employed had the necessary qualifications, skills and experience to support people who used the service.

We reviewed the quality of the service and noted that this was not conducted systematically with the last survey being completed in 2011.

We looked at the cleanliness and infection control procedures and found that the provider did not have adequate systems in place to ensure the safety of the people who used the service regarding the control of substances hazardous to health.