Archived: The Merchant's House

The Merchants House is a care home providing support for up to six people over the age of 18. The house is a large Victorian building that fits in with other houses in the local area. People living there each have their own bedroom and share communal living space. There is off road parking available for several cars and an enclosed back garden people can access.

Improvements had been made since the last inspection in relation to supporting people in a person-centred way, supporting people to stay safe, minimise the risk of abuse, and maintaining a safe environment. Improvements had been made to the systems in place to monitor the quality and safety of the service and to sharing information with relevant organisations. Improvements had also been made to the training staff received and the providers oversight of that training.

Further improvements are needed to how people are supported with dignity and respect. We have therefore given a requirement related to this.

We have made three recommendations in relation to recruitment checks, training records and continuing to improve how they support people in line with the principles of Registering the Right Support.

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. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.

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

The service didn’t consistently 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.

Improvements had been made in the way people were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the polices and systems in the service supported this practice. This was an on-going process within the home with room for further improvement.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons: Although a number of improvements had been made to the environment of the home this was a work in progress with parts of the provider’s action plan still underway. Other aspects of the building such as the use of a staff toilet in a prominent position, a large menu board nobody used and labels on people’s furniture detracted from creating a homely environment as opposed to one which appeared institutional.

We saw an improvement in the culture amongst staff at the home. Staff were more aware of their body language and of the need to provide support as unobtrusively as possible. There was room for further improvement, particularly around ensuring written and spoken language was respectful and promoted people’s dignity.

People were protected from abuse and the risk of harm. Changes had been made to the staff team and to people living together at the home. This had created an opportunity for making improvements to the support individuals received and to the environment. Robust checks of the environment were undertaken to make sure it was safe. Risks to people were clearly identified and staff followed agreed procedures to support people to stay safe in as unobtrusive a way as possible. There had been no use of restraint with the home within the six weeks prior to the inspection.

Plans had been implemented and were underway to increase the opportunities people had for becoming more independent, make more choices and have more control over their home and their daily lives.

People received the support they needed with their physical and mental health and with their medication.

A settled staff team were available to support people. Staff had received training to enable them to understand people’s individual support needs. Recruitment checks were in place and generally followed. Staff felt supported by senior staff and the provider.

A registered manager was working at the home who was knowledge and enthusiastic about the service provided. They were open and honest with other agencies about how the home was operating and had clear plans for continuing to make improvements to the service.

Clear systems were in place to improve the quality of the service and check improvements were maintained.

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 (14 January 2019) 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 not enough improvement had been made in one area and the provider was still in breach of regulation 10. We found improvements had been made and the provider was no longer in breach of regulations, 9,12,13,17 and 18 and regulation 18 (Registration Regulations 2009)

This service has been in Special Measures since 19 January 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Caring section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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 Merchants House is a care home. 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 home is registered to provide support for up to six people. At the time of our inspection five people were living there.

The Merchants House is a large Victorian building that fits in with other houses in the local area. People living there each have their own bedroom and share communal living space. There is off road parking available for several cars and an enclosed back yard people can access.

The home does not have a registered manager. 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 manager had been appointed and had commenced the process of applying to register with CQC.

The last inspection of the service was carried out in August 2017 and the service was rated requires improvement. At that inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Regulation 19. This was because the service lacked a clear and robust system for monitoring and managing criminal records checks, known as Disclosure and Barring Service (DBS) records, and, where necessary, assessing any associated risks. At this inspection we found the service was no longer in breach of Regulation 19. This was because the manager was aware of information contained in DBS checks and where needed a risk assessment had been completed.

In June 2017 CQC published Registering the Right Support. This along with associated good practice guidance sets out the values and standards of support expected for services supporting people with a learning disability. At this inspection we assessed the service in line with this guidance.

During this inspection we found breaches in relation to Regulations 9, 10, 12, 13, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities). Regulations 2014. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Systems for keeping people safe were not robust. This was because the provider did not keep sufficiently detailed records of incidents when people were physically restrained. No robust system was in use for reviewing accidents or incidents, including the use of restraint. This meant it was not possible to ensure people received support in the least restrictive and safest manner.

Records relating to people living at the home were not detailed or accurate. This included records for supporting people with their behaviour and records relating to monitoring people so that their actions could be analysed and interpreted. We also found that records of people’s weight were duplicated and had not been completed in line with the provider’s review periods.

Other records relating to the operating of the home were not in place, accurate or up-to-date. This included records relating to staff training.

Assessments of people’s care needs had been carried out and comprehensive care plans were in place. We found that at times they lacked detail and had not been reviewed in a timely manner.

Not all parts of the environment had been safely maintained. A gas safety check that was due in August 2018 had not been undertaken by the time of the inspection. We also found that an external infection control audit of the service had highlighted a number of concerns. At this inspection we found that the provider had failed to implement effective changes to the way in which people’s laundry was managed to minimise infection control risks.

Staff did not always feel supported by the provider. They told us that at times particularly when supporting people who can challenge they had not felt sufficiently supported. The provider had undertaken an audit of the service in November 2018 and this had also highlighted that staff morale was low.

Staff had not always received training to help them understand and meet the care needs of people living at the home. This included training in areas the provider considered mandatory such as safeguarding people as well as areas specific to individuals such as the use of restraint techniques.

Although people received support to go out and about and to undertake activities at home this was not always consistently provided in the way the person preferred. One person had an activity they particularly enjoyed and liked to do around three times a week. Records showed that they had not been supported with this in the four weeks prior to the inspection.

The provider did not always meet the requirements of the Mental Capacity Act 2005. Care records did not always reflect people’s choices and opinions. A lack of records meant it was not possible to establish whether the least restrictive options had been considered for people. We also found that care plans that placed restrictions on people were not always reviewed in a timely manner and did not appear to have had a positive impact for the person.

A lack of oversight by the provider had led to potentially unsafe risks and care for the people living at The Merchants House. Systems for checking and improving the quality of care and support people received were not robust enough to identify concerns and affect change. As identified within the report we found a number of concerns relating to keeping people safe, minimising restrictions upon people, record keeping and oversight of the care and support people received to stay safe.

The Merchants House did not meet the values and principles of Registering the Right Support and associated guidance. These encompass the values of choice, independence, inclusion and living as ordinary a life as any citizen. This included staff wearing large bunches of keys and standing around when people living there were sitting down. This could create the feeling of a power imbalance between staff and people living there.

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.

You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The Merchant’s House is a large Victorian building where six people who have learning disabilities and mental health conditions live. Each person has their own room and shares communal living and garden areas. The service is situated near shops and public transport.

The service had a manager who was registered with the Care Quality 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.

We last inspected the service in June 2016 and gave it an overall rating of ‘requires improvement’. On that inspection we found breaches of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to medicines management, infection control and good governance.

During this inspection we found that the service had made significant improvements in many areas since our last inspection and it had complied with the requirement actions we made in our last inspection report. However, we found a breach of regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to ensuring staff are safely recruited and suitable to work with vulnerable adults. You can see what action we told the provider to take at the back of the full version of the report.

The local authority told us that it had some concerns about staff recruitment, staff files, disciplinary procedures and training at the service.

Most staff were safely recruited and were supported with an induction process. However, there was a lack of a clear and robust system for monitoring and managing criminal records checks, known as Disclosure and Barring Service (DBS) records and where necessary assessing any associated risks. Some staff files did not contain photographic identification and were cluttered with old and out-of-date information. The registered manager confirmed that an internal audit of staff files was being carried out and was due to be completed in September 2017 with an action plan for improvements. They also confirmed that they were committed to working with the local authority to improve in this area.

During our inspection staff training records at the service were not fully updated. However, shortly after our inspection the registered manager provided us with up-to-date and accurate training data. Staff were up-to-date on various essential and service-specific training, such as safeguarding, mental capacity and Deprivation of Liberty Safeguards (DoLS), autism awareness, epilepsy, diabetes, communication and mental health. We noted that there had been a marked improvement in staff training since the registered manager had taken up their post 12 months ago. The service had a system to record, monitor and schedule staff training.

The service had a disciplinary policy and procedure in place. The registered manager was supported to implement this by head office and senior managers.

Overall, medication was correctly administered, stored and recorded. We saw that there were policies and procedures in place to support staff. The service had also introduced a new electronic medication administration system since our last inspection, which appeared to have significantly improved medicines management at the service and reduced the risk of errors occurring. Staff gave us positive feedback about how this new system was working. Team leaders, as senior members of the staff team, were responsible for medicines administration. The team leader who showed us the medicines administration process was knowledgeable and confident carrying out this role. The registered manager had carried out competency checks on most of the team leaders and was due to complete this for all team leaders shortly after our inspection.

The new electronic system did not allow ‘as required’ (PRN) medication, such as pain relief, to be properly recorded. Whilst the system accurately recorded medication administration and gave prompts about safe intervals, there was no facility to record the reason for giving a PRN medication, as is good practice. During our inspection we also found a minor discrepancy in one medication stock level. The registered manager was able to review the system to find the recording error. The registered manger agreed to implement a system for PRN records and spot checks alongside the audit reports generated by the electronic system.

Staffing levels during our inspection were sufficient to meet the needs of the people living there. This included the introduction of a driver to assist with people’s transport and two chefs to provide fresh and nutritious food seven days-a-week.

The people we spoke with and their relatives told us they enjoyed the food and drink at the service and we saw there was a choice of suitable nutritious foods to meet their dietary needs. People living at the service were also supported to go out to buy and eat their own meals, as they enjoyed doing this.

We observed people looking relaxed and happy in a homely environment. We saw caring, friendly and upbeat interactions between the people living at the service and staff.

Staff encouraged people to maintain their independence and supported people to enjoy their hobbies and interests.

People living at the service had personalised care plans and risk assessments. The care plans we looked at were regularly reviewed by the registered manager and, where possible and appropriate, the people, their relatives and other relevant health professionals were involved in the process of reviewing this information.

The registered manager and other staff at the service regularly checked the safety of the premises and the quality of care provided through a range of audits.

We saw that there were policies and procedures in place to guide staff in relation to safeguarding adults. Staff told us that they felt people living at the service were safe, as the people living there and their relatives. They said that they would be confident raising a concern if necessary and they believed that the registered manager would listen to any concerns and take appropriate action.

There were policies and procedures in place to meet the requirements of the Mental Capacity Act 2005 and the associated DoLS. The care plans that we looked at showed that mental capacity assessments and best interests decisions had been appropriately considered, documented and made. The staff we spoke with demonstrated a basic understanding of the principles of the Mental Capacity Act 2005 and the associated DoLS and most staff were up-to-date with training on this.

The Merchants House is in a large, Victorian building and is a home where six people who have learning disabilities and mental health conditions, are resident. Each person has their own room and shares the communal living areas and garden area. The home is situated near shops and public transport.

The service requires a registered manager. 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 previous registered manager had left the service in the autumn of 2015 and at the time of our inspection there was a manager who told us they would be applying for registration.

We found breaches of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to concerns about medicines management, infection control and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We saw that the building and furnishings were, in places, dirty and in need of cleaning or refurbishment. This potentially put people at risk due to infection control procedures not being followed.

We found that medication processes were not always completed properly and the medication room was exposed to plaster dust.

People were cared for by supportive staff and supported in a person centred way. However, the staff themselves told us they were not supported by the management and that their training was sometimes not up to date. Scheduled training had been postponed because of staff shortages and overall there was no contingency for an additional staff member in case of emergency or other tasks to be done.

The management of the home had been erratic and at the time of our inspection, the new manager had just resumed their post at the service. We saw that the quality of the service had not been monitored over recent months and that the auditing processes had not been consistently completed. Relatives and health and social care professionals complained about a lack of information and communication to us.

During the course of the inspection and afterwards, the manager and the provider submitted action plans to us as they had already identified areas of concern which need addressing. They were aware of most of the issues we found at the inspection as they had just begun to identify the issues themselves and were open and transparent about the failings of the home and the plans to improve it.

We talked with three people who used the service and with three members of staff. We looked at various paper records including three care plans and four staff files.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

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

Is the service safe?

There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available or on call in case of emergencies.

Staff had been appropriately and properly recruited, ensuring that Criminal Records (CRB) or Disclosure and Barring Scheme (DBS) records had been checked.

Staff were trained in safeguarding principles and procedures and the people living in the home had been given information in easy read format to help them raise a concern if they were worried about anything. The home had a safeguarding policy which was regularly monitored.

The building and equipment was well maintained by a dedicated handyperson. The home had a friendly, clean and well maintained feel about it.

Appropriate risk assessments had been carried out and action plans put into place for safe practice. A person living in the home told us, 'I feel safe'.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One person using the service told us, "I feel the staff are good to me'.

Staff had received training to meet the needs of the people living at the home.

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Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us '[My staff member] is great. He's my mate".

People had been involved in the creation of their care plans and continued to be involved throughout their stay in the home. We noted that peoples preferences about, for example, activities, room layouts or clothing choices, were respected by the staff. The people who used the service people were supported, where necessary, to make these choices and decisions. One relative had written in a feedback form, 'His health and well-being is always at the top of the list with staff'.

Is the service responsive?

People's needs had been assessed before they moved into the home and frequently re-assessed whilst they lived there.

People had key workers who related to them specifically, but they were also happy with other team members and spoke well of them. Records confirmed that people's preferences, interests, aspirations and diverse needs had been recorded. Care and support had been provided that met their needs and wishes. Other professionals, such as speech and language therapists and physiotherapists, were involved in peoples care when necessary.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. People, staff and other professionals had been asked for their feedback on the service. This also confirmed that respondents were listened to and as a result, some changes had been made. Comments made on relatives and professional's feedback commended the manager's leadership. One said, 'The manager is a very approachable professional and is willing to go the extra mile'.

The home completed various other audits throughout the year, which contributed to an annual audit. An action plan had been produced to address any areas of concern raised through all of the audit and feedback processes.

The provider had a number of premises and homes and for all, used the same IT package for much of its record keeping and policies. The manager was able to demonstrate effective knowledge of this and show us that she had acted according to policy regarding such things as recruitment, safeguarding procedures and CQC notifications.

We spoke to and observed four of the people who used the service. We asked them if they felt comfortable, safe and well cared for. Comments included "Yes, I am happy, I feel safe", "Yes, this is a good place", and "Yes, the staff are good and kind to me". A relative we spoke with said "My relative has been in a few places but this is by far the best". We saw from care records that advice about people's nutrition was sought from GPs, dieticians and the speech and language therapists and this advice was acted upon to ensure that people's weights remained stable and healthy. There was an up to date infection control policy in place and people who used the service were protected from outbreaks of infection.

We saw copies of the staff rota which showed that all shifts were covered appropriately and that the required number of staff were available for the level of need within the home.

Comments and complaints people made were brought to a satisfactory conclusion and all records for the service were held securely and kept for the appropriate periods.