The inspection took place on 21 March 2018 and was unannounced. At the last inspection on 8 November 2016 we asked the provider to take action to make improvements around building maintenance and cleanliness. We issued a warning notice in relation to maintenance of the building. Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions safe, and well led to at least good. At this inspection we checked to see whether improvements had been made and found the registered provider was meeting all the regulatory requirements.

Clarence House provides accommodation and personal care for up to 11 people who have a learning disability and complex behavioural or mental health related support needs. It is divided into two units for men and woman. At the time of this inspection there were nine people living there.

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 not in place as they had recently left the service, and applied to de-register as 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 regional operations manager was currently managing the service.

People who used the service told us they felt safe at Clarence House. Building maintenance and cleaning had improved, with some minor issues still apparent, which were dealt with straight away.

Staff had a good understanding of how to safeguard adults from abuse and who to contact if they suspected any abuse and safe recruitment and selection processes were in place.

Emergency procedures were in place and people knew what to do in the event of a fire. Risk assessments were individual to people’s needs and minimised risk whilst promoting people’s independence.

Detailed individual behaviour support plans gave staff the direction they needed to provide safe care. Incidents and accidents were analysed to prevent future risks to people.

We saw medicines were administered in a safe way for people. Staff had training in safe administration of medicines although not all staff competency checks on the administration of medicines had been refreshed in the last year. The regional operations manager said these were a priority for completion.

The required number of staff was provided to meet people’s assessed needs.

Staff told us they felt supported. Staff had received an induction and role specific training, which ensured they had the knowledge and skills to support the people who lived at the home. The overview of staff training needs was not up to date, although we saw training certificates to show staff had received the relevant training. A new training matrix was forwarded to us following our inspection.

People were supported to eat a balanced diet, and meals were planned around their tastes and preferences.

People were supported to maintain good health and had access to healthcare professionals and services. They were supported and encouraged to have regular health checks and were accompanied by staff to health appointments. The area operations manager promoted partnership working with community professionals and responded positively to their intervention and advice.

The service was adapted to meet people’s individual needs, with specialist furniture and fittings.

People were supported to have maximum choice and control of their lives and staff supported them in the least restricti

The inspection of Clarence House took place on 8 November 2016. The inspection was unannounced. We previously inspected the service on 12 January 2015 and at that time we found the provider was not meeting the regulations relating to premises safety. On this inspection we checked and found some improvements had been made, however the registered provider was still not meeting the regulations related to premises safety.

Clarence House provides accommodation and personal care for up to 11 people who have a Learning Disability. The service is divided into two units for men and women.

The service is required to 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. The service had a registered manager.

Since our last inspection the registered provider has made a number of improvements to the cleanliness and maintenance of the home. However, during our inspection we saw evidence the registered provider had not ensured the safety and dignity of all people who used the service and building maintenance was still required. This was a continuing breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations.

People who used the service told us they felt safe at Clarence House. Staff had a good understanding of how to safeguard adults from abuse and who to contact if they suspected any abuse. Risk assessments were individual to people’s needs and minimised risk whilst promoting people’s independence.

Effective recruitment and selection processes were in place and medicines were managed in a safe way for people.

There were enough staff to provide a good level of interaction, although some staff told us they worked long hours to cover for absence..

Staff had received an induction, supervision, appraisal and role specific training. This ensured they had the knowledge and skills to support the people who used the service.

People’s capacity was considered when decisions needed to be made. This helped ensure people’s rights were protected in line with legislation and guidance.

People were supported to eat a balanced diet and meals were planned alongside people.

Staff were caring and supported people in a way that maintained their dignity and privacy.

People were supported to be as independent as possible throughout their daily lives.

The service was led by each individual’s goals and aspirations. Individual needs were assessed and met through the development of detailed personalised care plans and risk assessments, although one file we sampled contained contradictory information about medicines.

People and their representatives were involved in care planning and reviews. People’s needs were reviewed as soon as their situation changed.

People engaged in social activities which were person centred. Care plans illustrated consideration of people’s social life which included measures to protect them from social isolation.

Systems were in place to ensure complaints were encouraged, explored and responded to in good time and people told us staff were always approachable.

The culture of the organisation was open and transparent. The manager was visible in the service and knew the needs of the people who used the service.

People who used the service, their representatives and staff were asked for their views about the service and they were acted on.

The registered provider did not provide formal supervision to enhance the professional development of the manager and support them in their role; however they completed regular monitoring visits and were available to provide advice on the telephone.

The registered provider had an overview of the service. They audited and monitored the service to ens

The service had a registered manager in place. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Since our last inspection the registered provider has made a significant number of improvements to the cleanliness and maintenance of the home. However, during our inspection we saw evidence that the registered provider had not ensured the safety and dignity of one person who lived at the home.

Staff had all received training in safeguarding adults and were confident to report any concerns to their manager. The registered manager kept a log of all incidents which resulted in a safeguarding referral being made. On the day of our inspection we observed staff de-escalating a number of situations in a calm and appropriate manner.

Pre-employment checks were completed to ensure people were safe and suitable to work with vulnerable adults. There were enough staff on duty to support people in a timely manner.

People’s medicines were managed and administered safely. Medicines were kept securely and the medicines room and trolley’s were kept locked when not in use.

Although staff we spoke with told us they had received regular training we were unable to clearly evidence from the registered providers training matrix that this training was up to date. We saw evidence that new staff were supported and that all staff received regular supervision with their manager.

The registered manager and the staff we spoke with were aware of how their role in complying with the Deprivation of Liberty Safeguards (DoLS). The registered manager understood the procedure for requesting an authorisation and under what circumstances a referral may be required.

We saw people were offered a choice of food and drink and were supported by staff to purchase and cook meals.

Staff treated people with kindness and compassion and responded to people in a timely manner. During our inspection we saw staff resolve situations that had the potential to escalate into more challenging exchanges Staff approached these situations in a manner which enabled the situation to be resolved without causing conflict. Staff were able to verbalise how they maintained people’s dignity and privacy.

Peoples care and support records were person centred and were reviewed regularly. People took part in a range of activities and were supported by staff to take personal responsibility for aspects of their daily lives including planning the activities they wanted to participate in.

The service had a policy for ‘management and prevention, restrictive physical interventions’ which was evidence based and easy to follow. Following any episodes of physical intervention, staff told us they had a de-brief session to evaluate the incident.

The registered manager completed a number of audits each month which assisted them to monitor and assess the quality of the service provision.

The registered manager supported people who lived at the home to be involved in making decisions about their care, support and the environment in which they lived. This was achieved with resident meetings and quality surveys.

You can see what action we told the provider to take at the back of the full version of the report.

This visit was carried out by an inspector and a specialist advisor in relation to learning disability. We spoke with the operations manager, the home manager and three staff. We also spoke with six people who lived at the home. Following the inspection we also spoke with a professional from the Community Assessment Team.

The inspector and specialist adviser, also through observation and looking at records used the information they were given to answer the five questions we always ask;

• 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.

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

Is the service safe?

People were not cared for in an environment that was clean and hygienic.

The premises were not adequately maintained.

Is the service effective?

The service had an induction programme in place to support new members of staff.

Three staff we spoke with said they felt supported.

We saw from the training matrix that annual training was generally not up to date.

Is the service caring?

Five service users we spoke with said they liked living at Clarence House. One service user said, “This is the best house that I’ve lived in”. Another service user said, “Staff treat me well”.

Is the service responsive?

We spoke with a visiting professional from the Community Assessment Team. They described staff as ‘accommodating and willing to listen’. They said they had access to peoples support plans and incident reports.

One service user we spoke with told us, “I see Dr X every few months”.

Is the service well led?

Three staff we spoke with told us they had received regular supervision.

There was not an effective system in place to regularly assess and monitor the quality of service that people receive.

There was no evidence that learning from incidents / investigations took place and appropriate changes were implemented.

We spoke with one person who used the service and an Independent Mental Capacity Advocate (IMCA) to help us understand the views of the people who used the service. Comments included:

“Yes, get to do lots of activities.”

“They [registered manager] are very clear in relation to advocacy. Very on the ball and empower clients.”

We found that the staff we spoke with understood the needs of the people they cared for.

We observed staff to be caring and supportive towards the people in their care.

We saw that the provider had effective processes in place to monitor quality and these included audits and analysis of incidents and complaints.

At the time of our visit, we were able to speak with three people who use the services and they told us they were happy and that staff looked after them very well. They felt comfortable and safe living at the home. One person using the service told us she has completed training in Health and Safety whilst living at the home and attends the service committee meetings. We also heard positive feedback from one person about a recent holiday that she had been taken on with staff from the home. We saw evidence of people using the service personalising their bedrooms choosing colours and soft furnishings. One person we spoke to told us that staff had helped her save money for the items she wanted. We were also told that people were assisted in opening bank accounts and obtaining passports at their request.

We spoke with three people who live at Clarence House. Each expressed their satisfaction with the service and told us they had good relationships with the staff.

People said they were supported to make choices, and that staff treated them with respect and understanding.

Each person said they were happy with their care. One person told us that they liked their keyworker because she listened to them and tried to help sort out their problems.

People we spoke with told us that staff were good at helping them and arranging things that they enjoy doing.

Two of the people we spoke with knew about safeguarding procedures and their right to be kept safe from abuse. They knew who to report any concerns to and said they were comfortable talking to staff about the subject.