About the service:

Ballater House is a care home for people who require nursing or personal care. The service accommodates up to 16 people who have a learning disability, such as autism or epilepsy or behaviour that may challenge. At the time of our inspection, 14 people were living at the service.

People’s experience of using this service:

We found the service was not always meeting the characteristics of a good service. Although the service was working towards the principles that underpin the Registering the Right Support and other best practice guidance, there was further work to do to ensure people could live fulfilling lives with full autonomy. The values of Registering the Right Support include choice, promotion of independence and inclusion, ensuring people with learning disabilities and autism can live as ordinary a life as any citizen. For more details and a copy of the full report, please see the full report which is on CQC website at www.cqc.org.uk

Medicines management processes were not robust. People’s consent to their care was not always sought in line with the legal requirements of the Mental Capacity Act 2005 and although people had access to sufficient food and drink, staff did not always adhere to people’s individual dietary wishes.

People told us they felt safe living at Ballater House and that there were enough staff.

People told us they liked living at Ballater House and staff were kind. However, we found incidents when staff were not as respectful towards people as they could be. We also found that people were not always given the opportunity to participate in individualised, meaningful activities.

Individual staff did demonstrate kind attention towards people and it was clear from speaking to staff that they knew people well. There was good guidance in people’s care plans for staff to follow and people told us they could make their own decisions.

People had access to healthcare involvement when needed and they could make their wishes known through regular meetings. Staff told us they felt well trained and that they supported each other. They also had the opportunity to meet regularly.

Staff worked with other professionals to help to improve the service for people and they monitored the level of the service that was being provided.

We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around medicines and the Mental Capacity Act 2005. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: We last inspected this service in August 2016 when we awarded it a Good rating overall. The report was published on 2 September 2016.

Why we inspected: This inspection was carried out in line with our inspection methodology in that we scheduled the inspection based on our previous rating.

Follow up: We will continue to carry out ongoing monitoring on this service and we will ask them to provide us with an action plan to demonstrate to us how and when they will address the shortfalls we have identified at this inspection. A further inspection will be carried out within a 12 month period to check that appropriate action has been taken to improve the service.

Ballater House is a large detached property located in a residential area of Chipstead. The service is registered to provide nursing care for up to 16 people who have a learning disability, autism and for people living with a behaviour that challenges. Accommodation is arranged in three units one of which is a designated female unit. Each unit has its own kitchenette, lounge and dining facilities. On the day of our inspection 14 people were living at the service.

At our previous inspection on 15 April 2015 the home was judged as requiring improvement in four domains and had an overall rating as requires improvement. The provider sent us an action plan telling us how they were going to make improvements. Since then the provider appointed an experienced registered manage who had made a significant impact to the quality of care people received and the overall management of the service.

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 and associated Regulations about how the service is run.

Medicines were managed in a safe way and recording of medicines was completed to show people had received the medicines they required.

People had risk assessments in place for identified risks. These were detailed and provided good guidance for staff to follow to keep people safe.

The registered manager logged any accidents and incidents that occurred and had put measures in place to reduce reoccurrence of any further accidents or incidents.

If an emergency occurred or the home had to close for a period of time, people’s care would not be interrupted as there were procedures in place.

Appropriate checks, such as a criminal record check, were carried out to help ensure only suitable staff worked in the home. Staff were aware of their responsibilities to safeguard people from abuse and were able to tell us what they would do in such an event. They also had access to a whistleblowing policy should they need to use it.

Staff met with their line manager on a one to one basis to discuss their work. Staff said they felt supported by the registered manager who they said had good management oversight of the home.

Staff supported people to keep healthy by providing people with a range of nutritious foods. Everyone had a food preference plan which involved choosing food from the menus and planning meals to suit their activities which included eating out.

People’s health care needs were met and people had access to external health care services and professional involvement was sought by staff when appropriate to help maintain good health.

People were encouraged to take part in a range of activities which were individualised and meaningful for people. We heard people chose what they wished to do on the day.

Staff had followed legal requirements to make sure that any decisions made or restrictions to people were done in the person’s best interests. Staff understood the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS).

There were a sufficient number of staff on duty to meet people’s needs and support their activities. People and staff interaction was good. It was evident staff knew people well and understood people’s physical and emotional needs. One to one support was in place for people when they were assessed as requiring this. Staff were caring to people and respected their privacy and dignity.

Staff received a good range of training specific to people’s needs. This allowed them to carry out their role in an effective and competent way.

The registered manager and staff undertook quality assurance audits to ensure the care provided was of a standard people should expect. Corporate quality audits were also undertaken to drive improvement. Any

Ballater House is registered to provide accommodation for people who require nursing and personal care for a maximum of 16 people who have a learning disability, and people whose behaviour may challenge. The accommodation is on two floors of a large house arranged over three units named Mercury, Pluto and Saturn. There were 13 people living in the service during our inspection

The inspection took place on 15 April 2015 and was unannounced.

The home did 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 responsibilities for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. On the day of our inspection the appointed home manager assisted us with support from a company director.

People were not always protected from abuse as the staff were not always able to recognise abuse.Staff had undertaken training in safeguarding adults and told us action they would take if they saw abuse taking place but were not always clear about the actions they should take or who they should report concerns to.

People were not always protected from avoidable harm because risk assessments for people had either not been carried out or not fully completed.

Care was provided to people by staff who did not always have up to date training in the management of people’s behaviour and we saw some staff lacked the skill to interact well with people which affected the quality of care that people received.

Staff did not fully understand their responsibilities in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Some mental capacity assessments and best interest meetings had not been undertaken for people who required them.

People received their medicines on time and safely from staff who had been trained to undertake the task however people were not provided with their medicines in a dignified way. Medicines were stored securely and a clear record of them was available.

There were sufficient staff employed to meet people's care needs which included one to one support where appropriate. The provider followed safe recruitment procedures which ensured that staff were suitable to work in the home.

People’s health care needs were met and people had access to health care professionals when they needed them.

People were able to take part in a range of activities that they enjoyed and had to access community facilities if they wanted this. Family links were encouraged and maintained and visitors were made welcome in the home.

People were not always provided with enough food and drink to meet their nutritional needs. People had access to small kitchens in their individual units where a variety of snacks and drinks were available throughout the day.

A complaints procedure was provided and some people were able to make a complaint or voice their concerns. We saw no complaints had been received however people and relatives told us they knew how to do so if they needed to.

Whilst systems had been developed to monitor the quality of the care provided to people these were not always effective as they did not highlight the breaches of regulations that we identified. Quality audits of care, medicines and the health and safety of the environment were completed.

The manager in post had a good understanding of people’s needs and was making progress in developing a consistent staff team. People and healthcare professionals spoke well of the management arrangements in place at the service.

There were several breaches of regulations which impacted on the quality of care that people experienced. You can see what action we have asked the provider to take at the back of the full version of the report.

During our inspection we set out to answer our five questions; Is the service safe?, Is the service effective?, Is the service caring?, Is the service responsive?, Is the service well led?

Below is a summary of what we found. The summary is based on our observations during our visit, discussions with people who used the service, the staff supporting them and looking at records.

Is the service safe?

Safeguarding procedures were in place and staff understood their role and responsibility in safeguarding the people they cared for. We saw that staff had recently undertaken training regarding the safeguarding of vulnerable adults and they praised the quality of the training during our discussion with them.

We saw staff were recruited according to the home's recruitment policy and had all the required security checks in place. This ensured the welfare of the people they were supporting. We noted that despite the recent wave of staff recruitment the service was still not providing sufficient staff with the appropriate skills and qualifications to meet people's needs.

Is the service effective?

People's health care needs were assessed with them whenever possible and written in a care pan. Arrangements were in place for people to see their GP when necessary to monitor their individual health care needs. People also had effective psychological support to manage their emotional needs. Other support for example from the chiropodist, dentist, optician, dietician and a psychiatrist was provided on a regular basis and records were maintained in people's care plan.

Is the service caring?

People who were able told us the staff were caring and always treated them well. We saw the staff on duty were kind and caring and spoke with people who used the service in a polite and respectful manner. People told us that staff enabled them to have a recent holiday which they enjoyed and appreciated. We saw people were supported to choose their meals and eat their meals in a dining room of their choice. We also saw staff took the time to enable people to be as independent as possible.

Is the service responsive?

The service was responsive to the needs of people who used the service. For example when a risk had been identified the provider responded with an action plan to minimise the risk but allowed the individual to be as independent as possible. This included the management of challenging behaviour. Management guidelines provided staff with a specific plan of action on how to deescalate an aggressive situation and how to protect people who used the service from harm.

The service also provided staff with up to date training in response to people's changing needs, for example managing aggression, and using PRN medication. (As required medication)

Is the service well led?

Since our last inspection on 24 March 2014 the registered manager resigned their position at the service. The provider appointed two senior manager/consultants in July 2014 to oversee the home in the absence of a registered manager.

We met with the manager/consultants on 7 August 2014 to discuss the action plan submitted to us outlining how the service was going to meet the non- compliance actions made at our last visit. Reasonable steps were being taken to recruit a registered manager and the service has kept us updated regarding this.

There were regular health and safety audits undertaken to ensure the health and welfare of people who used the service and to promote a safe working environment. Issues identified have been submitted to the clinical governance committee by the consultant management team for immediate action. A refurbishment plan has also been submitted to the providers that requested essential work to be undertaken to ensure people who used the service to live in a home that promotes their dignity and welfare.

Complaints and accidents were monitored and the provider discussed the management of these in order to reduce their reoccurrence.

People we spoke with told us that staff were "Friendly", "Helpful" and "Always polite". They told us that staff always asked before they helped with any care.

People told us they had been able to visit the service before they moved there and were involved in deciding what care was to be provided.

People said that they were encouraged to be independent. One person said "I like the independence that is offered" and "You can come and go as you please".

People said they felt "Safe" and had no concerns about the care provided.

We found the provider had taken action to improve infection control processes.

The property was found to be in a good state of repair and there was evidence of on-going maintenance work to ensure the property was fit for purpose and safe.

We spoke with staff who said they received regular training, supervision and felt "Supported". However, we found that there were gaps in some people's knowledge and have asked the provider to make improvements.

We found that the service had improved their quality assurance processes and were responding to complaints and comments. The provider had implemented and updated new and existing policies to reflect current best practices in areas such as infection control and health and safety.

We reviewed care plans and staff records and found that these were fit for purpose and secured in a safe area.

People who use the service told us they receive their medicines at the right time and said they would speak to the manager or their key worker if they were unhappy about anything in the home.

Overall, people told us they were happy in their home, and three people told us that "this is the best home they had lived in".

This is because they were involved in their care and take part in review meetings to discuss aspects of their care and support. People who were able to go out independently told us about where they go and what they do.

People told us they liked the meals that were provided and that they always had a choice. They said that if they did not like the meal which was being prepared or served, they could request something else.

We were also told of the support people receive from others outside of the home. People spoke of their appointments with doctors, with a dietician, a psychologist and the dentist.

If they had any problems, concerns or complaints, people told us they would talk to the manager, deputy manager or their link worker. They said they felt sure they would be listened to and would be taken seriously.

People who use the service told us they help to keep the home clean by looking after their own rooms. They said they were able to keep their rooms private because they have a key to keep them locked if they wish.

We were told that enough staff were provided to help people who use the service when needed.

People told us they had been given copies of their care and support plans to keep in their bedrooms. Some people have kept a copy in their rooms but others told us they did not wish to and their choice was respected.

At our last inspection, which was carried out in July 2013 in response to us receiving information of concern, we found that the service was failing to meet the national standards that people should expect to receive. As a result, we issued formal warning notices to the provider, Mr Gordon Phillips, telling them that they must improve in a number of areas within a specified period of time.

The provider wrote to us on 24 January 2014 to advise us that a number of improvements had been made to the overall governance structure of the service and that changes had taken place with regards to the internal management structure of the organisation. The provider informed us that an external organisation had also been commissioned to review Ballater House to ensure that the service was now meeting the national standards.

The people who lived at Ballater House had been assessed as having a range of learning disabilities, complex needs and challenging behaviour. They had varied methods of communication, some people were able to express their views clearly and others were not able to tell us their experiences of using the service. Overall, people spoke positively about the service. One person said "I love it here, I really do not want to leave". Another person said "It is ok, I keep to myself and do not really mix with others". A third person said "I like it here; some of the staff are very kind".

We found that a number of improvements had been made to the overall quality of the service. However, we found that further improvements were required to ensure the service met with national standards.

Care plans had been revised to ensure that they provided staff with an accurate record and guide of people's needs. However, staff were not always delivering care and treatment which was consistent with people's assessed needs. Improvements were required in relation to the pre-assessment of people who were being considered for a placement at Ballater House.

The provider ensured that the care and welfare needs of people, whose care was shared with external agencies, was met. This was because the clinical lead and home manager took action to implement any new or amended treatment pathways.

Staff had received training around safeguarding of vulnerable adults. However, the provider did not have an effective system in place for ensuring people were protected from the risks associated with excessive restraint. This was because staff were not routinely following local policies and guidance.

There had been improvements to the overall maintenance of the premises. However, we found that the layout of the premises did not always ensure that people's privacy and dignity was maintained.

Although the number of staff working during each day had increased since our last inspection, we found that some of the staff employed by the service did not always have the appropriate skills, experience of knowledge to care for people with challenging behaviours.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not being maintained.