Beeches is a residential care home for 12 young people and adults with autism and learning difficulties, often accompanied by complex needs and behaviour that can challenge.

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.

At our last comprehensive inspection in June 2015 we rated the service as good. In addition the areas we inspected at a responsive focused inspection in December 2016 were good; this was undertaken in response to concerns about the safety of people living at the service.

This is the second comprehensive inspection of the service. The inspection took place on 6 March 2018. We found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Systems and processes were in place to safeguarding people from abuse; these covered staff recruitment practices and staff training and knowledge on safeguarding procedures. Systems also ensured accidents and incidents were recorded and analysed and steps to improve and learn were identified. Risks, including those risks from medicines and infection were identified and steps identified and taken to reduce known risks to people. Staffing levels were kept under review to ensure people received sufficient staff support.

People’s care was provided in line with the MCA and staff understood the importance of seeking appropriate consent for care and treatment. Staff were supported and trained to have the skills and knowledge in areas relevant to people’s needs. Assessments of people’s needs were in place and included assessments of any health related needs as well as any diverse needs including those in relation to a person’s culture or belief. People’s needs for a balanced diet were met and any specific dietary needs were identified and met. Where people required healthcare from other professionals this was arranged and help to ensure good on-going healthcare support for people. The premises had been changed to meet people’s needs and reflect their hobbies and interests.

The staff team demonstrated a caring approach in their work and understood how to reduce people’s anxieties. Staff were mindful of promoting people’s independence and respecting their privacy and dignity. People were supported to be actively involved in decisions about their care.

People’s care and support reflected people’s preferences and interests and identified what was important to them. People and when appropriate, their relatives, were involved in making decisions about their care. Staff understood how people communicated and they worked in ways to promote people’s involvement by ensuring appropriate methods of communication were used. Systems were in place to ensure complaints could be made and investigated.

Sufficient arrangements were in place to cover the absence of the registered manager. Systems and processes were in place to assess, monitor and improve the quality and safety of services. The service was focussed on achieving good quality outcomes for people using the service and worked in partnership with other health and social care professionals to ensure people received appropriate care. People, relatives and staff had opportunities to engage and be involved in the development of the service.

Further information is in the detailed findings below.

We carried out an unannounced comprehensive inspection of this service on 2 June 2015. After that inspection we received concerns in relation to the safety of people living at the home. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those/this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cambian Beeches on our website at www.cqc.org.uk.

The service had 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.

Staff worked to protect people from the risk of abuse and appropriate action was taken following any incidents to try and reduce the risks of incidents happening again. Risks to people’s health and safety were assessed and plans put into place to reduce risks.

People were supported by a sufficient number of staff and staffing levels were flexible to meet people’s needs. Effective recruitment procedures were operated to ensure staff were safe to work with vulnerable adults. People received their medicines as prescribed and they were safely stored.

We performed the unannounced inspection on 02 June 2015. Cambian Beeches is run and managed by Cambian Learning Disability Midlands Limited. The service provides 52-week residential care for up to twelve people aged eighteen and above, with autism and severe learning disability, often accompanied by complex needs and challenging behaviour. On the day of our inspection 7 people were using the service.

The service had a registered manager in place at the time of our inspection. 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.

At our last inspections performed on 8 September and 19 November 2014 we found improvements were required in relation to the quality of service provision. Following these inspections the provider sent us action plans telling us how they would address the areas of concern. At this inspection we found the required improvements had been made.

People were protected from the risk of abuse as staff had a received training in safeguarding people and had good understanding of their roles and responsibilities if they suspected abuse was happening. The registered manager also shared information with the local authority when needed.

People received their medicines as prescribed and the management of medicines promoted people’s safety.

Staffing was maintained at appropriate levels to provide people with effective support. Staff had received appropriate training, professional development and supervision to maintain their competency.

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when needed.

People’s care plans were holistic and person-centred to ensure people received support in a planned and responsive way. People who used the service, or, when required, their representatives, were encouraged to contribute to the planning of care packages.

People had regular and unrestricted access to their family and their friends. They also had opportunities to participate in a variety of social and leisure activities to help them lead a fulfilling life.

People benefited from a service which was well led and systems were in place to monitor the quality of service provision.

People residing at the home, or those acting on their behalf, felt they could report any concerns to the management team and would be taken seriously.

This inspection was arranged to follow up on two warning notices issued for Regulations 10 and 11 after our previous visit in September 2014.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with seven care workers, a housekeeper, a cook, an administration officer, the acting manager and the operations manager. We looked at some of the records held in the service including the care files for two people, audit reports and staff training records. We did not speak with people who used the service or observe the care and support they received. This was because we were looking at management systems to see what improvements had been made to these and the guidance provided to staff.

The most recent registered manager left the service in September 2014. A new manager had been recruited and the operations manager told us they would apply to become the registered manager once they take up their position. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

This is a summary of what we found-

At the previous inspection we issued a warning notice for Regulation 11 of The Regulated Activities Regulations 2010, Safeguarding service users from abuse and for Regulation 10 of The Regulated Activities Regulations 2010 Assessing and monitoring the quality of service provision.

We found at this inspection some improvements had been made, however there were further improvements needed. Staff had been informed how they should pass on any concerns they had, however we found none of the managers had not been made aware of a concern within the timescale expected to ensure prompt action was taken.

Staff had been informed on what restraint was permitted, however bank staff were not clear about this.

Staff we spoke with understood the policies and procedures about how to keep people safe from harm and knew how to respond to any concerns about people’s safety. Staff had been able to reduce the number of incidents of restraint through following alternative ways to keep people safe.

People’s support plans had been rewritten so they gave clear guidance about what support people needed and how this should be provided.

When bank staff were used they did not receive the information they needed about events in the service or changes to people’s support plans.

There were improvements needed to how shifts were organised. It was not always made clear who was in charge of the shift and there were not planned breaks for staff incorporated into the 12 hour shifts. As a result some staff did not have a break in that time.

The acting manager had made improvements to how the service was run and provided staff with the leadership they required. The acting manager ensured any actions identified in audits of the service were taken.

We used a number of different methods to help us understand the experiences of people using the service, because the people had complex needs which meant they were not able to tell us about their experiences.

We reviewed all the information we had received from the provider. We spoke with the relatives of two people who were using the service. We spoke with the registered manager, the chef and three support staff. We also looked at service information, support plans and performed a partial tour of the building.

We found that comprehensive assessments were undertaken prior to people gaining residency at the home to determine if their needs could be met.

Systems were in place to ensure that consent was sought from people’s relatives and they told us they felt fully involved in the decision process.

We saw that people were provided with varied, appetising and nutritionally balanced meals and any specialist diets that were required due to pre-existing medical conditions or cultural needs could be supplied.

We found that the premises were maintained to a very good standard of hygiene and were comfortable and well maintained.

There were sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the individual needs of people.

We saw that systems were in place to enable people to complain or make comments about the quality of the service they received.

Because people using the service had complex needs they were not able to tell us about their experiences of living at the home. We therefore used a number of different methods to help us understand the experiences of people residing at the home. These included telephone conversations with the relatives of two people who were using the service and interviews with the homes deputy manager and two members of the support staff.

Relatives of people who were using the service told us that they were extremely satisfied with the quality of service provision. Comments included, “The staff are excellent, it really shines through. They all go that extra mile for the residents.” Another person said, “The attitude of the staff is very good, they are professional, and it’s a beautiful home”

Systems had been initiated to ensure that support staff were provided with comprehensive details about peoples’ individual needs and preferences in relation to the type of support provided.

Effective recruitment processes were in place to ensure suitable staff were employed at the home and staff had received a thorough training package.

Effective quality auditing procedures were undertaken and appropriate systems were in place for gathering, recording and evaluating information about the quality of the service provided.

We found that all areas throughout the home were maintained to an exceptionally high standard of hygiene and décor.

Prior to our visit we reviewed all the information we had received from the provider. The inspection took place over two days. All the people who used the service had complex needs and required a high level of support. We used a number of different methods to help us understand their experiences when we undertook our visit. We were able to speak briefly to one person who used the service and asked them for their views. We also spoke with support workers, the deputy manager, a service manager and the nominated individual. We looked at some of the records held in the service including the support files for five people. We observed the support people who used the service received from staff and carried out a tour of the building.

There was a registered manager in post who was on leave at the time of our inspection.

The inspection team who carried out this inspection consisted of two inspectors and a specialist advisor. We carried out this inspection to answer five key questions; is the service safe, effective, caring, responsive and well-led. Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found-

Is the service safe?

We found there had been problems obtaining the correct equipment to support someone to have a bath. This meant staff had had been supporting the person with their bathing without the correct equipment needed to do so safely.

Although staff we spoke with demonstrated they understood the safeguarding policies and procedures and knew how to respond to safeguarding concerns, we found this had not happened in practice. We found allegations of abuse had not been responded to correctly. We found examples where allegations of inappropriate physical force and inappropriate use of restraint had been made, and these policies had not followed. We also found not all staff had received planned supervision about keeping people safe and how to respond to any allegations of abuse, or completed the safeguarding training they were expected to have.

We found the position about what was, and what was not, acceptable forms of restraint to use were unclear. Staff received training in the use of pressure holds, which may inflict pain, and these were referred to in some people’s support plans. However the deputy manager said staff should not use these.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider had followed the correct process to submit applications for a DoLS where it was identified a person needed to have their liberty restricted in order to care for them safely, and that this was in their best interests.

There was a locked door policy at the home which restricted people who used the service from moving around all areas of the home freely. There was no information in people’s support plans to show that the effect of this was considered for each person.

Is the service effective?

Any new person coming to use the service had an individual programme for moving to the home developed to help them with the transition from their previous placement.

We saw meetings designed to review and plan people’s care did not always discuss issues of need and did not follow up on discussions from previous meetings.

Staff felt the induction for new staff was good and prepared them for their work. However, we found the intended support after this to support staff in their new role was not provided. Staff had not undertaken all the training they required and did not receive ongoing supervision or support. Staff meetings had stopped taking place since April 2014.

Is the service caring?

We found staff responded to people in a caring and respectful manner. We saw there were staff available to give assistance where needed.

One person who used the service told us they were, “Aright.” They also said that staff were, “OK.” No one else was able to share their views with us verbally so we spent time in communal areas observing daily routines and people’s interactions with staff. We saw that staff were caring and offered compassionate support.

Is the service responsive?

Staff told us where someone did not have the capacity to make a decision they would make that decision for the person in their best interest. Staff told us their training included how to determine if someone had the capacity to make a decision and if they did not, how a decision should be taken in the person’s best interest.

We saw that support plans were well organised and detailed, although some information was contradictory and this could lead to confusion about what support people may require. We also found some support plans were not up to date so could not be relied on to describe people’s current needs and the support they required. Additionally some support plans did not reflect people’s individual health and mobility needs, which would influence the support the person needed.

Staff made referrals to health and social care professionals when people’s needs changed and people who used the service were supported to attend health appointments. We found staff were knowledgeable about people’s health and social care needs.

Is the service well-led?

Managers at the home did not have sufficient time to complete all their management responsibilities. The deputy manager said, “There is a lot more we need to do, but we haven’t the time to do it.”

There were internal and external audits that had highlighted a number of improvements that were needed but there was no system in place to effectively implement these. As a result a number of recommended improvements had not yet been made. Quality assurance programs had not been properly maintained so information the provider used for monitoring the service was not available, and this had not been recognised. The nominated individual said, “The robust company systems have not been kept up.”

We found the policies and procedures in use were used by a number of other services operated by the provider and were not always relevant to this service. For example the medication policy had references to a registered nurse when there was not one employed at this service.