About the service: Adjuvo Essex Care Limited – Brightlingsea provides accommodation and personal care for up to nine people with a learning disability and autism. At the time of the inspection five people were living at the service.

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

The service had been developed and designed in line with the values that underpin the CQC Registering the Right Support policy 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.

People’s experience of using this service:

Staff understood the risks to people and the measures in place to keep them safe. Systems were in place to ensure people’s medicines were managed safely and to reduce the risks associated with the spread of infection.

Sufficient numbers of staff were employed to meet people’s needs and ensure they had maximum choice and control in their lives. This included supporting people to access a wide range of activities in the community that reflected their specific needs and interests.

The recruitment, induction and training processes in place ensured staff had the right skills and experience, and were suitable to work with people who used the service.

Staff were intuitively caring, and were observed treating people with dignity and respect.

People were receiving personalised care responsive to their needs, including access to health care services. The registered manager and staff worked well with other agencies to ensure people received high quality joined up care. People had access to food and drink based on their individual choice and preferences.

People’s communication needs had been assessed and were meeting the requirements of the Accessible Information Standards. This set of standards sets out the specific, approach for providers of health and social care to identify, record, share and meet the communication needs of people with a disability, impairment or sensory loss.

Staff felt supported in their roles and had confidence in the registered manager. There was an open culture of learning from mistakes, concerns, incidents and accidents and other relevant events. Staff understood how to raise concerns and felt comfortable doing so.

Rating at last inspection: Requires improvement (Report published 24 October 2017)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: Our previous inspection in August 2017 (published October 2017) identified improvements were needed in relation to the overall management of the service. The service was rated requires improvement. This was because there had been a lack of oversight of the service by the provider and the registered manager to ensure the service delivered was of a good quality, and safe. They did not have systems in place to identify what was working well and what needed to improve.

During this inspection we found the required improvements had been made. We will continue to monitor all intelligence received about this service to ensure that the next planned inspection is scheduled accordingly.

The service provides accommodation and personal care for up to nine people with a learning disability and autism. At the time of our inspection, there were five people using the service, one of whom was on a week’s respite.

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.

Our previous inspection undertaken on 29 and 30 December 2016 identified serious concerns regarding the management and leadership of the service and the quality of the care delivery. We asked the registered provider to make improvements to ensure staff were suitably trained and supported to respond to people’s complex needs, make the environment safe and ensure infection control risks were managed.

At this inspection, we found improvements had been made to the quality and safety of the service provided. Where staff had lacked supervision, appraisal and basic training, action had been taken to rectify this. Improvements had been made to ensure the premises were safe and the interior had been completely refurbished. However, we remained concerned about the registered persons overall management and leadership of the service. We identified that further work was needed to increase the service's overall rating and ensure that people are provided with good quality, safe care at all times.

There continued to be insufficient staff available to ensure people’s safety and provide additional care support hours, provided as part of their care packages, to access activities. The addition of people for respite care, with no additional staff, further impacted on staff’s ability to provide one to one support. Staff expressed frustration about the lack of staff and at times felt this placed them and people using the service at risk of harm. The service manager was in the process of recruiting new staff for when a new person was admitted to the service at the end of August 2017, increasing occupancy to five. However, neither the registered manager nor service manager were able to show or tell us how the staffing ratio had been calculated to ensure there was always sufficient staff available.

Consultants had been used to provide advice and guidance to staff with regards to managing people’s behaviours in a positive way. Individualised support plans had been developed providing staff with strategies for managing challenging behaviours and distress. These included step by step guidance on physical intervention and verbal de-escalation techniques to be used. Staff had received conflict management training and demonstrated how these techniques would be used. Debriefing sessions were held following incidents of challenging behaviour to discuss and agree what could be done differently to avoid incidents from reoccurring.

People’s care records and information shared with us from relatives confirmed people were receiving personalised care. Individual risks to people had been assessed and actions for staff to address these were clear and coordinated. Systems were in place, which showed staff managed people’s medicines consistently and safely.

Staff understood their responsibility to report any concerns to the manager, but were not familiar with the local safeguarding protocols and access to local authority safeguarding team. However, both the registered manager and service manager were aware of their responsibility to liaise with the police and local authority if safeguarding concerns were raised. Such incidents had been managed well. A robust recruitment and selection process was in place. This ensured prospective new staff had the right skills and were suitable to work with people using the service. A formal supervision process had been implemented and recor

The inspection took place on 29 and 30 December 2016 and it was announced. We last inspected this service in February 2016 and found that overall the service was rated ‘requires improvement’.

The service provides accommodation and personal care for up to nine people living with learning disabilities and autism. At the time of our inspection, there were six people using the service.

The home has 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 & Social Care Act and associated regulations about how the service is run.

Our inspection identified serious concerns regarding the management and leadership of the service, and the quality of the care delivery. People were being placed at risk of physical and emotional harm and there was insufficient governance in place to make improvements within acceptable timescales.

The service was not safe. Staff did not receive appropriate training to understand the complex needs of people using the service. Behaviour which may have impacted negatively upon people was not managed correctly, and forms of restraint were being used which placed people at risk of harm. There was insufficient monitoring and reporting of incidents which meant that poor practices had become embedded into the service. There were risk assessments in place for people, but these did not account for the management of this type of behaviour.

People had care and support plans in place but these were not always updated or reviewed with involvement from the person or their relatives. People had their dietary and healthcare needs assessed but some relatives reported missed appointments and had been since assumed responsibility for the healthcare needs of their family member. People did not always have access to activities which were stimulating or kept them occupied. The limitations with transport and staffing hindered people’s ability to live a full and active life.

Staff were not supported through regular supervision or appraisal and did not have sufficient opportunities to contribute to the development of the service. They only received basic training which was unfit for the nature of the roles they were employed to perform. Staff did not feel able to share issues or views and did not feel supported by the management team.

The leadership and management at provider level was absent which meant that the registered manager was performing his role beyond the scope of his remit. This had led to a decline in the standards of the service and the registered manager did not have sufficient time to make improvements. There was little quality assurance in place to identify issues and take remedial action. Some complaints were dealt with but others were not recorded or resolved and some relatives and staff felt that their concerns were not listened to. There were inconsistencies in the maintenance, design and decoration of the service which had an impact on the safely and effectiveness of the environment for people. Elements of the environment were poorly maintained and presented an infection control risk.

This inspection identified that there had been breaches of a number of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014 and the overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we

The inspection took place on 12 February 2016 and was unannounced.

The service provides accommodation and care for up to nine people with the learning disabilities and autistic spectrum disorder. Some people also have a physical disability. The service also takes people for respite breaks.

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.

Staff had received training in administering medicines but medicines were not always well managed as poor stocktaking procedures made it difficult to be sure that people had received their medicines as prescribed.

Staff were trained in safeguarding people from abuse and systems were in place to protect people from abuse. There was a lack of clarity over some financial procedures which could have left people open to financial abuse.

Risks were assessed but action was not always taken to minimise these risks. Systems were not in place to ensure the safety of the service vehicles.

Staffing levels meant that people’s needs were met, although some feedback indicated that sometimes people were not able to take part in certain activities due to staffing constraints.. Recruitment procedures were not always robust and references had not been sought for one person.

Training was provided for staff to help them carry out their roles but a structured induction was not in place. Staff were not well supported by the manager as regular supervision and appraisal were not in place.

People, and their relatives or legal representatives, gave their consent before care and treatment was provided. Staff had not been provided with training in the Mental Capacity Act (MCA) 2015 and Deprivation of Liberty Safeguards (DoLS). The MCA and DoLS ensure that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. Where people’s liberty needs to be restricted for their own safety, this must done in accordance with legal requirements. Appropriate DoLS applications had been made.

People were supported with their eating and drinking needs and staff helped people to maintain good health by supporting them with their day to day physical and mental healthcare needs.

Staff were caring and treated people respectfully making sure their dignity was maintained. Staff were positive about the relationships they had built with the people they were supporting and caring for.

People, and their relatives or legal representatives , were involved in planning and reviewing their care and were encouraged to provide feedback on the service. Care plans identified people’s particular preferences and choices but plans and risk assessments had not always been appropriately reviewed. People were supported to play an active part in their local community and follow their own interests and hobbies.

Formal complaints were not logged but informal issues were dealt with appropriately and to people’s satisfaction.

Staff were not always well supported by the management of the service. Staff were not clear about management roles and lines of accountability were not evident.

Quality assurance systems were in place and audits were carried out regularly to monitor the delivery of the service but these were not robust.

We identified several breaches of regulation during this inspection, and you can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 12 November 2014 and was unannounced.

The service provides accommodation and support for up to 9 people with learning difficulties and autistic spectrum disorder. Two rooms are set aside to be used as a respite service. These were unoccupied at the time of our inspection and six people were living permanently at the service.

The service had not had a registered manager in place since June 2013 but the newly appointed manager has made an application to become registered 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.

Staff knew how to recognise the signs of abuse. Some staff were not clear about raising a concern directly with the appropriate authorities. Risks were assessed and actions taken to reduce them.

We were concerned that staffing levels were not always enough to support people and keep them safe. Sometimes levels dipped below those set by the management of the service. Several relatives expressed their concerns about the staffing levels and one felt this had contributed to their relative suffering a seizure when they should have had one-to-one supervision.

Although systems for administering medicines were in place, medication audits and stocktaking procedures were not robust which could have placed people at risk of receiving too much or not enough of their prescribed medicines.

Staff received the training they needed to carry out their roles and were positive about the quality of the training

The requirements of the Mental Capacity Act 2005 had not been followed in order to assess people’s capacity to consent to have a flu vaccination. The service had not yet made any applications to the local authority under the Deprivation of Liberty Safeguards even though an application of this type would be appropriate for some of the people who used the service in order to keep them safe.

People were supported to have a balanced diet and were appropriately referred to dieticians. Other healthcare professionals were involved in people’s care but some of their advice had not been followed.

We found that staff were caring and demonstrated that they had built up good relationships with the people they were supporting. Staff knew people well and were patient and treated people with dignity. The people who used the service were supported to follow their hobbies and interests and were introduced to new interests by staff.

We found that comments and feedback raised by relatives did not always bring about change and some concerns had been raised multiple times without them being resolved. Formal complaints were not always responded to promptly and to people’s satisfaction.

Record keeping at the service was incomplete and several records could not be located. This had the potential to place people at risk. Quality assurance systems were in place but it was not always clear to whom concerns would be escalated.

At this inspection we found that there were breaches of three regulations of the  Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

The people living at Futures Care Home had complex needs and were unable to discuss their care with us which meant they could not tell us their experiences. People communicated with gestures, facial expressions or signing and this showed us that they were happy.

Relatives who completed surveys as part of the home’s quality monitoring process made positive comments about the care. They said: “Our young adult is very happy at the home and always comes home immaculately dressed and obviously well cared for.” and “We are happy with the way things are going.”

Staff knew people well and they understood specific needs. We saw that there were respectful and caring interactions between members of staff and people living in the home. Staff listened to people and provided care and support in ways that met their needs and took into account their individual preferences.

The service co-operated with other agencies, such as health services, to ensure people received the care and support that best met their needs.

There were systems in place to support staff and provide them with the training they needed to ensure they had the skills and knowledge to provide safe and effective care.

Futures Care Home Care Home was well run by a competent manager and there were effective processes to monitor the quality of the service. They consulted with people and took their views into account to make improvements.

People using the service had complex needs which meant that many were unable to tell us their experiences. We gathered evidence of people’s experiences of the service by observing how people spent their time and noting how they interacted with other people living in the home and with staff. One person communicated with us using signs and we could see that they were happy.

Relatives who completed surveys as part of the home’s quality monitoring process made positive comments about the home. One relative said “On the whole we are very pleased with [our relative’s] placement.” Positive comments were also made about the staff and management of the home. One relative said “[The management team] have been very supportive” and another said they were pleased “With the staff and management who work very hard to give the residents a comfortable home and a good life.”

We saw that people smiled and were relaxed and comfortable with staff and others living in the home. We also saw friendly and patient exchanges between staff and people living in the home.

During our inspection we saw that people received good care and that staff treated them with respect.

The management team and staff were able to demonstrate a good understanding of people’s needs, likes, dislikes and preferences. People had a variety of ways of communicating their needs and we saw that staff understood people’s individual ways to communicate.

Most of the people living at Futures were unable to communicate with us verbally. However, they shared their views through gestures, facial expressions and body language wherever possible.

We saw people were relaxed and comfortable with staff and other people using the service.

Relatives who completed surveys as part of the home’s own quality assurance process made positive comments about staff and the service provided at Futures. One person said, “I’m impressed by the enthusiasm and energy of the staff. They seem keen to take on board suggestions, indicating reflective practice which is always good to see” and another stated, “I’m very happy with the present arrangements.”

When asked in surveys what improvements the home could make one person said, “None that I can think of” and another said, “Can’t think of any.”