The Ranch

The Ranch is a care home providing accommodation and personal care for up to three people with learning disabilities and/or mental health conditions. There were two people living at the home at the time of our inspection.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and 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 and autistic people and providers must have regard to it.

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

Right support

Staff supported people to have the maximum possible choice and control over their lives. Staff involved people in discussions about their support, including support to travel wherever they needed to go.

Staff focused on people’s strengths and promoted what they could do, which enabled people to enjoy meaningful, fulfilling lives. Staff supported people to pursue their interests in their local area.

Staff enabled people to access specialist health and social care support in the community. Staff supported people with their medicines in a way that promoted their independence and achieved the best possible health outcome.

Staff communicated with people in ways that met their needs. Staff supported people to make decisions about their day-to-day care and support. For complex decisions, staff ensured decisions were made in people’s best interests.

People lived in a clean, homely environment that met their sensory and physical needs.

Right care

People received kind and compassionate care. Staff respected people’s privacy and dignity. They understood and responded to people’s individual needs.

Staff understood how to protect people from poor care and abuse. The service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

People understood information given to them because staff supported them consistently and knew their individual communication needs.

People’s care and support plans were holistic and reflected their individual needs.

People received care that supported their needs and aspirations, and was focused on their quality of life.

People could take part in activities that were tailored to them. The service gave people opportunities to try new activities that enhanced and enriched their lives.

Staff had identified any risks people might face and put measures in place to mitigate these.

Right culture

People led empowered lives because of the values and behaviours of the registered manager and staff. Staff knew and understood people well and were responsive to their individual needs.

People were involved in planning their care. Staff listened to and acted on people’s feedback about the support they received.

The registered manager monitored the quality of support provided to people, involving the person, their family and other professionals as appropriate.

The registered manager and staff worked well with other professionals when necessary to improve people’s quality of life.

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 the service was requires improvement (published on 13 December 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 2 October 2019. Breaches of legal requirements were found. We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We assessed whether the service was 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. This included checking the provider was meeting COVID-19 vaccination requirements.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

The Ranch is a 'care home' which provides residential care for up to three people with needs such as learning disabilities and mental health conditions. The service is provided in a bungalow. Each person has their own bedroom and share communal areas such as the living room and kitchen. During our inspection, one person was in the process of moving to their own accommodation. Therefore, at the time of publication of this report, there are two people living at the service.

People’s experience of using this service

At our previous inspection in January 2019 we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. We found that the provider had made some improvements to the issues identified in areas but further work was required to fully embed new recording practices.

The registered manager was not always aware of the support staff required and relatives did not always find them approachable. The registered manager had been reluctant to implement the improvements identified at our last inspection, and there had been no internal audits to ensure improvements had been made. However, the deputy manager had worked hard to make some the improvements required, and further time was needed to fully embed new processes. Since our inspection, the registered manager has left the service and a new manager has been recruited. Feedback from people and relatives was sought on a regular basis. However, there had only been one staff meeting since our last inspection.

Risks were not always recorded and those that were recorded were not always done so in a dignified manner. Medicine competency checks were not being completed to ensure staff were safe administering and recording medicines. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Safe infection control practices were not always followed as areas of the service were dirty and unhygienic. End of life care plans were not always detailed and care plans did not reflect the person-centred care people received, but the impact to people from this was low as staff knew people well. Although there were enough staff to meet people’s basic needs, staff numbers did not always allow for personalised care. Staff were not up to date with their mandatory training and fed back to us that they would find some face to face training would be beneficial rather than just receiving e-learning. Referrals to healthcare professionals were not always made where required, but relatives and staff felt the communication within the service was effective.

Accident and incidents were recorded and actions were being taken to prevent reoccurrence. People’s nutritional and hydration needs were met through a varied and nutritious diet. The service was homely, and people had been able to personalise their rooms to match their decorative preferences.

People and relatives informed us that staff were kind and caring towards them. Staff respected people’s dignity and encouraged them to be as independent as individually possible. This had led to supporting one person to prepare to move in to their own accommodation. People and relatives told us they were involved in reviews around people’s care needs.

People were supported to participate in holidays and activities that were meaningful to them. This included maintaining relationships with their families. Although the service had not received any complaints since our last inspection, people and relatives informed us they felt able to raise any concerns if required. 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. For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection

At our last inspection we rated this service Requires Improvement (report published on 18 April 2019).

Why we inspected

We inspected this service in line with our inspection scheduling based on the service’s previous rating.

Enforcement

We identified four breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up

We will follow up on any breaches and recommendations made in this report. We will continue to monitor all information received about the service to ensure the next planned inspection is scheduled accordingly.

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 inspection took place on 11 January 2019 and was announced.

The service 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.

Risks to people were not appropriately recorded. There was no monitoring or analysis of accidents and incidents that had taken place to identify trends and reduce further risk. Care plans were not person-centred and did not include any detail around people’s end of life wishes or health diagnosis. Safeguarding procedures were not always followed and appropriate notifications were not made to the CQC and the local authority. People’s rights under the Mental Capacity Act 2005 (MCA) were not protected. The service did not follow the principles of the MCA and correct legal authorisation had not been sought to deprive people of their liberty.

Medicines had not always been stored at an appropriate temperature and people’s medicine profile did not include any information around allergies. There were no gaps in Medicine Administration Records (MARS) and protocols were in place for ‘as and when’ medication.

There was not a sufficient number of staff to meet people’s needs. Some staff did not receive adequate breaks between shifts. Recruitment practices were not robust. Staff were not up to date with their mandatory training. Staff told us that they were not receiving regular supervision and appraisals.

The service did not have robust quality assurance systems in place. Internal audits that had taken place had not identified the issues that we had during our inspection. The service had not notified the Commission of all reportable incidents. This included incidents where people living at the service had unexplained bruising.

People and their relatives were involved in the review of their care. However, this was not recorded in people’s care files. People were treated with kindness, respect and dignity. People and relatives told us they would feel comfortable raising a complaint if they needed to. People had a choice of foods, and their weight was monitored regularly. The premises was suitable to meet people’s needs effectively. People were able to personalise their rooms to suit their taste.

Staff and relatives felt that the registered manager and deputy manager were approachable. There was partnership working with a local day centre. Plans were in place to improve the service. However, the deputy manager felt they needed more staff to allow the time required to be able to implement these changes. We did not observe any pre-assessments as people at the service had been living there for many years.

People were being cared for by staff who were aware of and carried out safe infection control processes. People had access to a wide range of healthcare professionals, such as GPs, dentists and opticians. People were encouraged to take control of their appointments.

During this inspection we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

The Ranch is registered to provide accommodation with personal care for up to three people. At the time of our inspection there were three people living at the service all of whom had a Learning Disability. People required minimal support with staff encouragement and prompting as they were able to attend to most of their own personal care needs.

At the last inspection in 31 May 2016, the service was rated Good, however, we found the service was in breach of Regulation 18 (1) (2) (e) of the Care Quality Commission (Registration) Regulations 2009 (Part 4). The registered person had failed to notify the Commission of a safeguarding incident in relation to a service user. During this inspection we found the service was now meeting this regulation.

A registered manager was 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 and the provider undertook quality assurance audits to ensure the care provided was of a standard people should expect. Any areas identified as needing improvement were attended to by staff.

People and staff were empowered to contribute to improve the service. People and staff had regular meetings where they were able to put forward suggestions of how to improve the service. These were listened to and acted on. People, relatives and associated professionals had been provided with the opportunity to state their views about the care provided and how the home was run through an annual survey in 2016.

There was a set of values that included the aims and objectives, principles, values of care and the expected outcomes for people. This was displayed at the service. We observed staff putting these into practice.

Records of accidents and incidents were maintained at the service and the registered manager undertook monthly audits to identify any trends and took action as required to maintain the safety of people.

Further information is in the detailed findings below.

The Ranch is registered to provide accommodation with personal care for up to three people. At the time of our inspection there were three people living at the service all of whom had a Learning Disability. People required minimal support with staff encouragement and prompting as they were able to attend to most of their own personal care needs.

A registered manager was 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.

The registered person had not notified the Commission of a safeguarding incident in relation to a person living at the service.

People told us they felt safe living at the service. Staff had received training in safeguarding people and were able to describe how they would report and respond to any concerns.

Staff had received training and supervisions that helped them to perform their duties. New staff received a full induction to the service which included training.

Where there were restrictions in place, staff had followed the legal requirements to make sure this was done in the person’s best interests. Staff understood the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure decisions were made for people in the least restrictive way.

People were positive about the care provided and their consent was sought. People told us that staff treated them with respect and any help with personal care needs were done in private.

People’s care and health needs were assessed and they were able to access all healthcare professionals as and when they required.

People were supported by staff to have enough food and drink of their own choice. There were enough staff to ensure that people could undertake their activities and be supported with their assessed needs. Staff encouraged people to be independent and to do things for themselves, such as cooking and cleaning.

Documentation that enabled staff to support people, and to record the care and treatment they had received, was up to date and regularly reviewed. People had signed their care plans and were involved in writing and reviewing them. People’s preferences, likes and dislikes were recorded and staff were knowledgeable about the care needs of people.

Staff showed kindness and compassion and people’s privacy and dignity were upheld. People were able to spend time on their own in their bedrooms. People told us they would be able to raise concerns and make complaints if they needed to.

Staff at the service worked in line with these provider’s values that ensured people received effective care. Staff were also aware of the whistle blowing procedures and would not hesitate to report bad practice.

Quality assurance processes were in place to monitor and improve the service.

We found one breach 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.

All the people we spoke with said they liked living there. Staff were seen to interact well with people. For example by having conversations with them about how they were and the activities they had planned for that day. People appeared relaxed and happy.

People told us that they felt respected by staff. We saw that people were encouraged to maintain their independence, for example by preparing their own meals and drinks.

People who used the service and relatives had been involved in the planning of care. We saw that where risks of harm had been identified an assessment had been completed to protect the welfare and safety of people.

We looked around the house and saw that it was clean and tidy. People told us they were happy with the standards of cleanliness. There was a plan to replace the carpets in the house.

All the staff we spoke with felt supported in their role. New staff completed an induction process. This ensured they had the necessary skills to support the people who lived there.

Information about how to make a complaint was on display within the house. All the people we spoke with said they knew how to raise a complaint. They said that they had never felt the need to complain.

One person who lived there told us 'If I need help staff are there.' Another person said 'I love it here, staff help me a lot.' People were seen to interact positively with staff and were laughing and joking with them.

People we spoke with told us that their permission was asked before treatment or medication was given. People told us that staff helped them to understand decisions around their care and treatment.

We saw that people's individual needs had been assessed with them, and 'care protocols' had been put into place. These detailed the support people needed in their daily lives. People told us they received the support they needed.

The people we spoke with told us they felt safe living at The Ranch and staff supported them. We saw procedures were in place which gave guidance to staff on safeguarding vulnerable adults. Staff were able to describe what action they would take if they suspected abuse was taking place.

We looked at records of recruitment and training and spoke with staff to check their understanding of the training they had undertaken. We found that training and recruitment were appropriate to meet the needs of the people living there.

People told us they had the opportunity to express their views about the service, and that the provider took action where needed.