This inspection took place at the service on 11 and 14 September 2018 and was unannounced. We made telephone calls to speak with relatives on 17 and 25 September 2018.

All Saints Vicarage 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. All Saints Vicarage is registered to provide residential care and support for up to six adults with a learning disability or autistic spectrum disorder. At the time of our inspection four people were living at the home.

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.”

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection, the service was rated requires improvement. We found some supervisions and essential training were overdue; team meetings were not taking place and relatives told us communication was poor.

During this inspection we found improvements had been made. Regular team meetings were held with full staff involvement. The registered manager had introduced a plan for supervisions and appraisals and we saw evidence of these taking place. Relatives told us communication had improved.

There was a positive atmosphere at the service, staff were passionate about ensuring people received quality care and support. People were at the centre of everything and the staff team worked well together.

The provider had systems in place to safeguard people from the risk of abuse and discrimination. Sufficient experienced and skilled staff were deployed in the service to support people in line with their assessments and preferences. The provider had a robust recruitment procedure in place which included ensuring appropriate checks were undertaken before staff started work.

People lived in a safe environment. Health and safety checks were completed regularly. Interiors were designed to ensure people remained safe. Identified risks were assessed and managed to reduce the risk to people who used the service and others.

Medicines were managed safely. People were supported to access health professionals when required, including opticians, dentists, GPs and nurses. The service was proactive in obtaining the correct support and challenged potential poor care on behalf of people living at the service.

People were provided with meals and drinks they enjoyed and were supported to make healthy nutritional choices. Staff supported people to maintain family relationships and links with the local community.

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

Relatives and external healthcare professionals we spoke with told us staff were kind and caring. Staff we spoke with had extensive knowledge about the people they were supporting. We observed staff treating people with dignity and respect.

People were supported to follow a range of activities they enjoyed. Staff worked with people and Positive Behaviour Support (PBS) practitioners to develop new goals to work towards.

Care plans were detailed and reflected people’s individual needs. Information was displayed in accessible formats throughout the service.

The provider had systems to monit

All Saints Vicarage is a residential home that provides care, support and accommodation to a maximum number of six people who have a learning disability or autistic spectrum disorder. At the time of the inspection there were six people living at the home.

At the last inspection on 1 July 2015, the service was rated Good. At this inspection we rated the service as ‘Requires Improvement.’

Relatives gave us mostly positive feedback and confirmed they were happy with their family member’s care. They said there had been some difficulties at the home particularly in relation to staff turnover, management and communication. However, they also acknowledged these had improved and the home was now more settled. They also felt a recent change of ownership for the provider was positive for future development of the home. Some relatives felt communication could be improved further.

Relatives and staff told us they felt the service was safe. We concluded from speaking with staff and our own observations that there were sufficient staff deployed to meet people’s needs.

Staff showed a good understanding of safeguarding and were aware of the provider’s whistle blowing procedure. They also knew the process for reporting concerns and said they would not hesitate to raise concerns if required. Previous safeguarding concerns had been dealt with appropriately.

The provider had effective recruitment procedures in place to ensure staff were suitable to work at the service.

We found medicines were usually managed safely. Records confirmed only trained staff administered people’s medicines. We found a recent medicines audit had not identified minor gaps in one person’s medicine records.

The provider carried out regular health and safety checks and had procedures to deal with emergency situations.

Staff told us they received good support and the training they needed. However, records showed some supervisions and training were overdue.

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

People were supported with nutrition and accessing healthcare in line with their individual needs.

People’s needs had been assessed to identify the support they needed and the information used to develop personalised care plans. These had been reviewed following a recent audit to ensure they reflected people’s current needs.

People had opportunities to participate in their preferred activities, such as walking, dancing, painting and crafts

Although relatives gave positive feedback about their family member’s care, they also knew how to raise concerns if required.

Relatives and staff described the registered manager as approachable and supportive.

We did not find evidence of regular team meetings having taken place.

The provider carried out internal and external quality assurance checks to help ensure people received good care.

We inspected All Saints Vicarage on 1 July 2015. This was an announced inspection. We informed the provider at short notice (the day before) that we would be visiting to inspect. We did this because the location is a small care home for people who are often out during the day; we needed to be sure that someone would be in.

This service is a residential home that provides care, support and accommodation to a maximum number of six people who have a learning disability or autistic spectrum disorder. All Saints Vicarage is set in its own grounds and has a large enclosed garden. The home is set in the small village of Hetton-le-Hole, which is outside of Sunderland. It is walking distance to local shops and Hetton Country Park.

The service has 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.

People’s nutritional needs were met, with people making decisions about what they wanted to eat. At the time of the inspection, staff at the service were closely monitoring people and what they had to eat. However, nutritional screening had not been undertaken. We spoke to the registered manager about this and after the inspection they sent us information to confirm that nutritional screening had been undertaken for all people who used the service.

Accidents for people who used the service were infrequent as such did not need monitoring. Incidents were not always analysed to reduce the risk of reoccurrence.

The staff understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the right action to take if they were concerned that abuse had taken place.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

Staff told us that they felt supported. There was a programme of staff supervision in place. Records of supervision were detailed and showed that the registered manager had worked with staff to identify their personal and professional development goals.

Staff had been trained and had the skills and knowledge to provide support to the people they cared for. There was enough staff on duty to provide support and ensure that their needs were met. We found that one person who used the service had a designated staff team; this helped to provide consistency to people.

The registered manager and staff that we spoke with had a clear understanding of the MCA principles and their responsibilities in accordance with the MCA and how to make ‘best interest’ decisions. We saw that appropriate documentation was in place for those people who lacked capacity to make best interest decisions in relation to their care. We saw that a multidisciplinary team and their relatives were involved in making such a decision and that this was clearly recorded within the person’s care plan.

We looked at the arrangements that were in place to ensure that staff were recruited safely and people were protected from unsuitable staff. We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Appropriate systems were in place for the management of medicines so that people received their medicines safely. We saw that medicines had been given in accordance with the person’s prescription.

There were positive interactions between people and staff. We saw that people were supported by staff who respected their privacy and dignity. Staff were attentive, showed compassion, were encouraging and caring.

People visited their doctor, dentist and optician. Staff told us how they supported and accompanied people on hospital appointments to manage their physical and mental health needs. To reduce anxiety the doctor visited people in the service to do their annual learning disability review. This meant that people who used the service were supported to obtain the appropriate health and social care that they needed.

Assessments were undertaken to identify people’s health and support needs as well as any risks to people who used the service and others. Plans were in place to reduce the risks identified. However some plans and risk assessments would benefit from further detail. Person centred plans were developed with people who used the service to identify how they wished to be supported.

Peoples independence was encouraged and their hobbies and leisure interests were individually assessed. Staff encouraged and supported people to access activities within the community.

The provider had a system in place for responding to people’s concerns and complaints. The one person we spoke with during the inspection told us they knew how to complain and felt confident that staff would respond and take action to support them.

There were effective systems in place to monitor and improve the quality of the service provided. Staff told us that the service had an open, inclusive and positive culture.

People who were using the service had complex needs which meant they were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

Below is a summary of what we found:-

Is the service caring?

We saw that staff were caring and people were treated with dignity and respect. We saw that staff were confident when carrying out their roles and there were enough of them, so that care of people was never rushed or pressured. This was important as some people living at the service had autism and required stable routines and a calm atmosphere. We saw that these needs were met. A health professional told us, “It really is a nice place.”

Care was individualised and centred on each person. Staff communicated effectively with people using the service, no matter how complex their needs. Their care and support was provided by staff who knew and understood their needs and preferences and responded promptly and consistently to these. A relative told us, “My son has his own team. He knows them all. I can’t say enough what a great team they are.”

The provider carried out checks to ensure people were treated well. Relatives were asked for their feedback and felt confident their views were listened to.

Is the service responsive?

We found that people were treated with respect. We observed that staff provided personalised care and support and they respected people’s wishes and their agreed plan of care. People and their families were encouraged to be involved in making decisions about their care and treatment.

Relatives participated in regular reviews of their relative’s care and felt that the service responded to any concerns or issues. Relatives also told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. Their comments included, “If there was anything I wasn’t happy with, I would not wait; I would speak to staff but I haven’t had to do that.”

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, we found 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.

We saw that risks to people’s safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe.

Staff had been given relevant training and there were effective procedures in place to ensure that food was handled safely, which ensured people had a choice of suitable and nutritious food. We saw that staff provided appropriate support to people at mealtimes and understood about who may be at risk at mealtimes.

Staff had been trained to manage medicines safely. We saw that medicines were correctly stored and records were accurate. Suitable arrangements and guidance were in place where people might need specific medicine in a medical emergency. Staff had been trained about this and knew what they had to do.

Staff ensured people’s medicines were reviewed regularly. Relatives we spoke with told us they were confident about the way staff managed people’s medicines. A community nurse who visited one person regularly told us, “They always do the medicines in twos, with one person checking. They must be doing the right thing as X’s blood sugars are always fine and they wouldn’t be if his medication wasn’t managed well.” This showed that medicines were handled safely.

The provider ensured that people’s needs, safety and wellbeing were taken into account when determining the skills and numbers of staff on duty. A relative told us, “My son has seizures. He can have three in one day. If the staff think he will have another one, they will put on an extra member of staff. They more or less stay in his room.”

The provider had implemented effective audit processes, to ensure the service was safe and to identify ways to improve.

Is the service effective?

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We found that people who used the service were receiving the care and support they needed. The staff we spoke with could describe how they met people’s assessed needs. A community nurse, who regularly visited the service, told us, “They take great care and provide good care.”

Relatives of two service users told us that their sons’ wellbeing had improved considerably after they moved to the service. One said, “It’s wonderful; the best placement he’s ever had. They know him inside out.” Another said, “He is a changed lad. He is very happy.” This showed that the care and support provided had changed people’s lives for the better.

People were supported to eat healthy, balanced diets, which helped ensure their wellbeing. Relatives were confident that their relatives’ nutritional needs were being met and their weight was carefully monitored. One told us, “He’s a healthy weight for his height. They know what he likes. He has a really balanced diet. He eats much better than he used to.” This showed people were supported to be able to eat and drink sufficient amounts to meet their needs.

Relatives we spoke with told us they were confident about the way staff managed people’s medicines. One told us, “I think they manage it quite well. It is reviewed every six months to make sure his medication is right for him. The staff are good about making sure he sees the doctor (about this).” People’s care records showed their medication had been reviewed by their GPs or consultants to ensure it remained appropriate and effective.

Is the service well led?

Communication and care of people was tailored to their individual needs. Effective systems were in place to communicate with people who had complex needs. Relatives of people using the service felt they were regularly involved and were consulted about the service, which helped to drive improvement. One relative commented, “They ask what we want to change. We don’t want anything to change. I am more than happy.”

Quality assurance systems were effective. Audits were carried out to check people were cared for appropriately.

Medication systems were audited. Staff were trained to handle medication safely and checks were made to ensure they were following safe procedures.

There was a culture of openness. Relatives told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. Their comments included, “There are open lines of communication. If I thought something was wrong, I would contact Sandra (the manager) or X (the operations manager).” Another said, “If there was anything I wasn’t happy with, I would not wait; I would speak to staff but I haven’t had to do that.”

The home had been managed by the same person since it opened approximately sixteen years ago. The manager had established efficient systems and provided good leadership to ensure that the service operated effectively at all times. There was good staff morale and many of the staff had worked at the service for a considerable number of years. This meant people benefited from stable and consistent care. A relative told us, “The majority of the staff have been there for years. I think they do their job very well. They’re always cheerful and diligent.”

Some of the people using the service had complex needs which meant they were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences.

The service planned and delivered care and support so that people’s needs were met and their privacy, dignity and independence respected. A relative we spoke with said “We couldn’t wish for him to be anywhere better.”

Staff had been fully supported in meeting people's needs because they received regular supervision sessions and their training was up to date. A relative told us “The staff are always friendly and helpful.”

The manager had systems in place to regularly check the quality of the care and was aware of their responsibilities to respond to any allegation of abuse or potential abuse. Another relative told us that they were ”Very happy with the manager and the team.”

We were unable to speak to people who use the service due to their physical disabilities however we observed people being treated with respect and taking part in activities during our inspection.

We found that the premises were comfortable and warm with space for people to be alone if they wished. People were given appropriate levels of support and encouraged to complete tasks independently where appropriate.

We viewed results from a recent satisfaction survey sent to relatives of people who lived within All Saints Vicarage. Comments from relatives included, "My son is well cared for at All Saints" and "the home has provided a consistently high standard of care".

We spoke with the relatives of four of the people who lived at All Saints Vicarage. They were all very positive about the care their family member received.

One mother said “staff are brilliant and are gentle and kind. He likes to sit in a corner chair in the lounge and see right through to the kitchen and he enjoys going out in the minibus. He enjoys walking backwards in the garden and plays with footballs while members of staff observe him at a distance through the lounge window.” She told us that his care plan was reviewed every six months and that she always took part in this process.

There were appropriate staffing ratios for activities and good observation of people by members of staff. Staff had been trained in how to use restraint and records showed that it had been used appropriately. Parents were able to visit at any time providing they check first that people were not out.

None of the families we spoke with had any concerns about the safety of their relatives.

We were unable to communicate effectively with people living at the home.