May Morning

May Morning provides accommodation and personal care for up to eight people who have a learning disability, autistic spectrum disorder and some physical disabilities. The accommodation is accessible and appropriate to meet the needs of the people living in the service. At the time of our inspection there were seven people living at the service.

The service had been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. The values that underpin the guidance such as offering choice, promotion of independence and inclusion were evident in the support people received from staff so that they can live as ordinary a life as any citizen.

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.

At the last inspection on 31 May 2017 the service was overall rated as requires improvement. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, responsive and well led to at least good.

At this inspection we checked that the action plan for the previous inspection had been implemented. We found that the previous breaches regarding completion of health and safety checks, an accessible complaints procedure and the effectiveness of quality assurance systems had now been fully met, and we have rated the service as ‘Good’.

There were enough staff to support people’s needs. Risks to people had been assessed and measures implemented to reduce these. Peoples medicines were managed safely and only trained staff administered these. Their competency to do so was assessed at regular intervals. People’s health and wellbeing was monitored by staff who were proactive in referring people appropriately to GP’s or for specialist support from other health professionals. Guidance was in place to inform staff how to support people’s specific health conditions such as epilepsy and recognise signs of deterioration.

People had care plans in place which detailed their needs and wishes. Where known people’s end of life choices and wishes were recorded to inform staff who would implement these if the need arose.

Staff were trained to recognise and respond to suspicions of abuse, they understood their responsibilities to act on their concerns. Staff knew how to escalate their concerns to protect people from harm. Staff understood how to report and act upon accidents and incidents. These were analysed and informed the development of strategies to reduce risk and avoid recurrence where possible.

Staff recruitment files showed that satisfactory processes were in place for the recruitment and selection of all levels of staff. Staff received the training they needed to ensure they had the right knowledge and understanding of people’s needs. Staff said that they felt supported and listened to, communication within the service between all levels of staff was good. New staff said they had felt fully supported by existing staff members and that there was good teamwork. Staff were given opportunities to express their views through staff meetings and one to one meetings. However, the delivery of an annual staff appraisal system needed improvement.

People lived in a clean safe environment that was maintained to a good standard. Equipment for the detection of fires and electrical and gas installations was tested and serviced at regular intervals. Staff were trained to take appropriate action in a fire. People had individual evacuation plans to inform staff what support they might need to affect a safe evacuation.

People were supported to make choices about their lives, including what social activities they wanted to do. Staff sought peoples consent to the everyday tasks they helped them with. Staff understood the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards DoLS. People were consulted about what they ate and drank, they were supported to make drinks and snacks for themselves. Where people showed a commitment to do so staff helped people to eat healthily and to lose weight.

A quality assurance system was in place this had been improved upon since the last inspection, this provided the registered manager with a good overview of service quality and where any shortfalls were identified. Relatives were surveyed for their comments, feedback from those received was universally positive with no comments for improvements.

An accessible complaints procedure had been developed for people and staff were proactive in supporting people to raise concerns. Relatives felt confident about raising concerns if they had any, and felt these would be acted upon.

We have made one recommendation in relation to staff appraisals.

At the previous inspection on the 18 & 19 October 2017 we found eight breaches of our regulations, and an overall rating of requires improvement was given at that inspection. As there were recurrent breaches in respect of the recruitment of staff and quality monitoring we issued enforcement notices for the provider to take urgent action in these areas. We issued requirement notices for other breaches because the provider had failed to ensure that medicines were managed safely, that some risks were appropriately assessed or that guidance in respect of some health conditions was in place. Applications for Deprivation of liberty authorisations had not been pursued to ensure restrictions in place were authorised. People were not provided with an accessible version of the complaints procedure. Service inspection ratings were not displayed in the service or on the provider’s website. New staff were not provided with appropriate induction training and supervision to ensure they could fulfil their role competently. The provider sent us an action plan following this inspection to tell us how they would improve. At this inspection we found the provider had made enough progress to meet the two previous warning notices in respect of regulation 17 for a lack of effective quality monitoring and regulation 19 for significant shortfalls within recruitment documentation. Minor shortfalls remain in some areas of staff monitoring and recording and we have issued a new breach for regulation 17, this is to ensure progress in this area continues and is maintained. Progress to address a previous breach of regulation 16 in respect of complaints had not been fully covered by the actions taken within the service and this remains a continued breach of regulation 16.

The service had a new registered manager in post that had been in post for three months at the time of inspection. A registered manager is a person who is 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. The registered manager was present throughout the inspection.

The service is a large detached house adjacent to another service May Lodge overseen by the same registered manager. People’s bedrooms were located on the ground and first floors, some bedrooms had en-suite facilities but the majority of people shared communal bathrooms and everyone shared living/dining room and kitchen facilities.

Although the new registered manager had been proactive in addressing many of the outstanding breaches, her influence on the service is still to embed. At the last inspection we highlighted that there was not an accessible complaints procedure for people in the service actions taken to address this had not been adequate to meet the needs of people in the service and this remains a breach.

Although the provider had taken action to address previous breaches and improve operational quality monitoring, improvements made were taking time to impact on the effectiveness of quality monitoring and there were still gaps in some of the safety checks made. We have issued a requirement notice for improvements to the quality monitoring system to be made.

Staffing was sufficient and flexible to meet people’s needs. New and existing staff had appropriate training and experience to support people well. Recruitment processes were in place to protect people and ensure staff employed were suitable for their roles. Staff felt supported and listened to and found the new registered manager ‘approachable’ and welcomed the open door policy they had adopted. Staff said they had more staff meetings and felt able to raise issues within these.

There were safe processes for the management of medicines. Staff knew how to keep people safe from harm, they were trained to recognise, and report abuse. Risks were appropriately assessed. Accidents were acted upon appropriately to ensure people received input from medical professionals if required. Incidents were analysed and where there were issues of concern advice was sought from health and social care professionals.

The premises were clean and well maintained. All tests checks and servicing of equipment was in date and staff practiced fire evacuations and understood where to take people in the event that the premises needed to be evacuated.

The registered manager demonstrated a clear understanding of the process that must be followed if people were deemed to lack capacity to make their own decisions and the Mental Capacity Act (MCA) 2005. They ensured people’s rights were protected by meeting the requirements of the Act.

People had choice around their food and drinks and staff encouraged them to make their own decisions and choices. People’s health and wellbeing was monitored by staff and they supported people to health appointments as and when required.

People moved freely in their home and were at ease in the company of staff. Staff demonstrated they understood people’s communication needs well and spoke to people in their preferred way. Staff were patient and respectful towards people and were mindful of people’s privacy and dignity in their everyday support.

Care plans contained specific detail so staff could understand people better and this information guided their everyday practice. People chose to participate in a variety of recreational activities inside and outside of the service. People were encouraged to develop their independence skills and were supported to maintain important links with family and friends.

We found two 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.

At our previous inspection of this service on 17 November 2015 we found the service was not meeting the required standards of quality, safety, protection from abuse and employment of suitable staff. There were breaches of regulations and we asked the provider to tell us what they were going to do to put the shortfalls right; they sent us action plans to tell us what they were doing and when this would be completed. This inspection was to assess whether the improvements they had told us about had been embedded and were now everyday practice.

A registered manager had not been in post since December 2015, although there was an on-going recruitment for this. A registered manager is a person who is 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.

Our inspection and feedback from relatives and care professionals indicated that whilst they felt that the day to day delivery of care people received from staff met their basic care needs, we found there were a number of areas where improvement was still needed, for example in regard to protecting peoples privacy and understanding and documenting better some peoples communication styles to inform staff engagement with them. Relatives said they were always made to feel welcome whenever they visited and that people were supported to maintain contact with the important people in their lives. Relatives said they felt they were kept informed about care and health issues.

The lack of oversight and settled management had meant that a number of important areas had lapsed or not been addressed at all including some of the previous breaches. The provider had not ensured that the previous inspection rating was visibly displayed in the service or on the provider’s service website. The inspection found that much of the operational knowledge for running the service had been invested in the previous registered manager, with the deputy manager having a fairly narrow role; the deputy manager was unaware of many of the tasks the previous manager undertook and as a consequence many of these areas had not been proceeded with for example there was a lack of awareness about previous action plans and what audits were undertaken to monitor service quality. Some information could not be found.

There were signs that incidents of abuse between people had reduced and staff were more alert to what would be considered abusive under safeguarding. Overall medicines were better managed and the previous shortfall had been adequately addressed, however, protocols for administering ‘as required’ medicines to people were generic and this could lead to inconsistency in the way these medicines were administered by different staff. There were enough staff to keep people safe but this was unsettled and supplemented each week by agency staff whilst recruitment was on-going to permanent posts. Recruitment documentation had deteriorated further and failed to demonstrate that all necessary checks were being undertaken before staff were employed.

A range of risk assessments were in place but some risks had not been identified and assessed or risk reduction measures in place for others managed well for example, people were at risk because staff were not receiving adequate fire drill training. Staff had received training in regard to the Mental Capacity Act 2005 and the use of Deprivation of Liberty safeguards authorisations (DoLS). Referrals for DoLS authorisations had previously been made but not progressed therefore restrictions placed on people were still be authorised albeit in place in the interim in their best interest.

There had been no complaints and relatives told us they felt confident of making a complaint should they need to do so. A previous recommendation in regard to providing accessible visible complaints information to people in the service had not been undertaken and people who could not complain for themselves were not accorded the right to have complaints made on their behalf for repeat issues that they experienced from other service users.

Staff felt well supported by the deputy manager and thought there was good teamwork and communication between staff, but systems in place for the induction, supervision and training of staff had lapsed. Staff said they felt listened to, and their views and opinions valued by the deputy manager, regular staff meetings had lapsed but staff said they found the deputy manager approachable at any time and they often got together for informal discussions when on shift together.

The premises were clean and relatively well maintained although there were some unnecessary delays in the provision of equipment or repairs and this needed review.

Staff engaged well with people and where possible protected their privacy and dignity, they encouraged healthy eating and were increasingly using pictorial menus to enable people to make informed choices about what they ate. Staff monitored peoples wellbeing and ensured they were referred to health professionals appropriately as and when required.

Staff support was guided by detailed plans of care, relatives were consulted about these and invited to attend annual reviews. Peoples interests were known to staff and individualised activity planners were developed for them. People went out on a regular basis if that was what they wanted to do and staff were available. They were also supported to help out with domestic tasks in the service to develop their skills and help increase their independence.

Updated policies and procedures were in place. Senior management staff understood their responsibilities to alert the Care Quality Commission to events in the service and had done so recently.

We have made two recommendations:

We recommend that the provider ensure that a competent person makes known to staff the business continuity arrangements and a copy of this is made accessible to staff in the service.

We recommend the provider appoint a competent person to review the current arrangements for ordering equipment and undertaking repairs and maintenance of services.

We found a number of 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.

People knew how to make a compliant if they needed to and had a range of opportunities to talk about their care and share their views. Staff and the manager knew what they needed to do to keep people safe from abuse and how to report any concerns appropriately.

People were treated with respect and dignity. They were supported to make decisions about their day to day lives and things that were important to them. They could choose when to get up and go to bed, what to do and what to each day and staff respected their choices. People told us they liked their rooms and had chosen the colour schemes for them.

Staff understood people's needs well and their individual preferred methods of communication. People had good relationships with staff and were comfortable spending time with them.

People were supported to be as independent as they could and to learn new skills. People could make their own meals if they chose and helped with their laundry and some household tasks.

There were enough staff on duty to support people safely and the organisation had processes and procedures in place to check on the quality of the service people received and to keep them safe.