This inspection took place on 15 May 2017 and was unannounced. Dovetail house is run and managed by Step Forward (Nottingham) Ltd. The service provides care and support for up to 20 people with mental health and learning disabilities resulting from brain injury. On the day of our inspection 10 people were using the service.

The service had a registered manager who was also the registered provider of the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered providers and registered manager 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. As well as a registered manager the service employed a home manager to manage the running of the service.

People who used the service were safe as the provider had systems and processes in place to protect them from risk to their safety. They were supported by suitably trained staff who had an understanding of their responsibility to protect people from abuse.

The numbers of staff were reflective of the needs of the people who lived at the service and the provider followed safe recruitment process when employing staff to ensure they were suitable to support people. People were supported to receive their medicine as they required them.

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’s nutritional needs were well managed and people received the support they required. There was good collaboration between the staff and health professionals to ensure people’s health needs were met.

People received care from staff who were kind and respectful and people were encouraged to contribute to the planning of their care.

People received individualised care from staff who know their needs. They were supported to undertake social activities of their choice and maintain relationships with people who mattered to them.

People who used the service, or their representatives, were encouraged to be involved in decisions and systems were in place to monitor the quality of service provision. People also felt they could report any concerns to the management team and felt they would be taken seriously.

We carried out this unannounced inspection on 15 & 16 March 2016. Dovetail is run and managed by Step Forward (Nottingham) Ltd. The service provides care and support for up to 20 people with mental health problems and learning disabilities. On the day of our inspection 11 people were using the service.

The service had not had a registered manager in place since September2015. 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 and associated Regulations about how the service is run. The unregistered manager in post had not yet applied to the CQC for registration.

People who used the service were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The unregistered manager shared information with the local authority when needed. Action was taken following any incidents to try and reduce the risks of incidents happening again. People received their medicines as prescribed and the management of medicines was safe.

People were not always protected against the risk of infection. The lack of cleaning schedules meant robust monitoring was not in place and as a result there were issues relating to cleanliness in some areas of the service.

Staffing levels were sufficient to support people’s needs and people received care and support when required. Staff were provided with the knowledge and skills to care for people effectively and felt supported by the management team

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. 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 who used the service, or their representatives, were encouraged to contribute to the planning of their care.

People were treated in a caring and respectful manner and staff delivered support in a relaxed and considerate manner. Positive caring relationships had developed between staff and the people who lived at the service.

People felt they could report any concerns to the management team and felt they would be taken seriously. People who used the service, or their representatives, were encouraged to be involved in planning their care.

Quality monitoring systems were in place to monitor the some aspects of the service but some environmental auditing had not been carried out by the management team.

We performed the unannounced inspection on 6 May 2015. Dovetail House is a care home for up to 20 men and women with an acquired brain injury or Huntingdon’s Disease. On the day of our inspection 13 people were using the service. The service is provided across two floors with a passenger lift connecting the floors.

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.

When we last inspected the service in July 2014 we found there were improvements needed in relation to protecting people from the risk of abuse. Staff had not received training to recognise and report abuse and there were insufficiently qualified, skilled and experienced staff with the knowledge, skills or training to support people safely. We found plans of care did not always detail how care and support should have been planned and given to meet people’s individual needs. We also found people were not always protected as systems for monitoring and assessing the quality of the service were not effective. The provider sent us an action plan on 22 July 2014 telling us they would make these improvements by 22 September 2014. We found at this inspection that the required improvements had been made.

Staff had received training in protection of vulnerable adults to ensure people were protected from the risk of abuse. We found staff had a good understanding of their roles and responsibilities if they suspected abuse was happening and found the manager shared information with the local authority when needed.

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

Staffing levels were sufficient to support people’s holistic needs and they received care and support when it was required.

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 and fluid intake. Specialist diets were provided when needed and referrals were made to health care professionals when required.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care. People’s care plans described in detail how they were to be supported and they contained risk assessments which were reviewed on a regular basis.

People were treated in a respectful and caring way and staff delivered support in a relaxed and considerate manner.

People who used the service were encouraged to be involved in decisions about the service provision. Effective systems were in place to monitor the quality of service provision.

People felt they could report any concerns to the management team which they felt would be taken seriously and acted upon.

Although we had planned to inspect Dovetail House, we bought the visit forward after we received concerns about the service.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information 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. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records. We also spoke with the newly appointed manager and the person responsible for overseeing the management of the home (the nominated individual).

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

Is the service safe?

We spoke with four of the people who lived at Dovetail House. They told us that they were, “Ok”. Not everyone was able (or willing) to share their views about the service verbally. We therefore spent time observing staff interactions with people. We saw that people were relaxed in staff’s company although interactions were minimal.

We spoke with staff on duty who told us that there was not enough staff on duty to meet people’s care and support needs effectively or consistently. We saw records that reflected people were entitled to one to one support. The manager could not demonstrate to us that people received these hours. The records we saw showed that, although some one to one activities took place, they were limited. Staff told us that support depended upon staffing levels. We found that staffing levels were inadequate to meet the assessed needs of the people who received a service.

We spoke with staff who told us that they did not always feel well trained to carry out their roles effectively. The manager acknowledged that training was an area where improvements were needed.

Is the service effective?

We found that people who received a service were not getting all of the support that they were assessed as needing. Although we did not observe anything to suggest people’s basic care needs were not met, staff told us that people often had to wait for support. Opportunities to access the local community or take part in in-house activities were limited. We saw that care plans were in place however some staff told us that they did not know what information was contained within them. They told us that in order to know how to support a person they watched other staff. We saw that one person was not getting appropriate support to have their lunch. This showed that this informal approach was ineffective as people were not getting the right support.

We saw that care plans and assessments of risk did not always match. Some areas of risk were identified and there was no record of how to reduce the risk. On other occasions interventions were recorded that staff were unaware of. This confusion could lead to people who received a service (or staff) at risk of being harmed.

Inadequate staff on duty meant that people’s needs could not be met in a timely manner or in ways that people preferred. People were not getting the support that they were entitled to. Opportunities to live full and active lives were restricted.

Is the service caring?

People were supported by staff who were committed to meeting their needs. Staff however were worried that they did not have the time needed to meet people’s needs effectively or in ways that they preferred. Staff told us of concerns that they had had in relation to how some staff spoke to people. They had shared these concerns with the manager who had passed on the information to the local authority safeguarding team. They had then agreed a joint response.

Staff told us about activities that people enjoyed and shared their frustrations that these did not always take place. Staff told us how they worked extra hours and flexibly to try to ensure people got to enjoy planned activities. They acknowledged that there were shortfalls in this area.

Is the service responsive?

We saw that when people’s needs increased the manager made appropriate referrals for them to be seen by health care professionals. This meant that they could maintain people’s good physical health. They also told us how they supported one person with increased support needs.

The manager told us how they had followed up on poor practice by taking the appropriate action. For example they had started disciplinary action against one staff member following an allegation of suspected abuse.

The manager and the person with overall responsibility for the service (the nominated individual) told us how they were actively recruiting staff to address the current shortfalls. We saw that three staff had started working at the home on the day of our visit. Staff were very positive about the increase in staff.

Is the service well-led?

We found that there had been issues with the leadership of the service that had led to staff feeling demotivated and deskilled. Staff told us that they were hopeful the new manager would offer them effective leadership and support.

We found that there had been communication issues between the previous manager, the nominated individual and the owner. This breakdown in communication had negatively affected the quality of the service provided. As a result the nominated individual had taken a more active role within the home. Staff told us that this had had a positive impact on morale.

Prior to our inspection we reviewed all the information we had received from the provider. We spoke with three people who used the service for their views. We also used observation to help us understand the experiences of people using the service, because some people had communication needs which meant they were not all able to tell us their experiences.

We spoke with three members of staff and the registered manager and deputy manager. We also looked at service information, care plan files for three people and did a tour of the building.

People we spoke with told us they were involved in discussions and decisions about their care. Comments included, “My keyworker (name) is great, she’s the best, we talk and plan things together.”

We looked at the menu and spoke with the cook and saw that people’s nutrition and hydration needs were met. A person we spoke with told us, “I like the food, we get a choice.”

The home had good infection prevention and controls in place that protected people from the risk of infections. We saw the home was clean and well maintained.

People were supported by sufficient numbers of staff with appropriate skills and experience. The people we spoke with told us they felt there was enough staff around to meet their needs.

We saw the home had up to date internal quality assurance systems in place that monitored the service provided.

The last inspection of Dovetail House was in August 2012. This was a follow up inspection to check on compliance.

As part of this inspection we spoke with the registered manager and three staff. We also looked at people’s care plans records and service information.

We did not speak with people who used the service direct at this inspection. We looked at surveys the provider had sent to people who used the service and their relatives and representatives in October 2012. This information told us what some people’s experiences and views were about the service they received.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

As part of our inspection we spoke with a number of people who used the service,

care staff and the registered manager and deputy. On the day of our inspection there were 16 people living at Dovetail House.

We went out to the service in response to some information we had received raising concerns about the home.

We spoke with four people on the day of our inspection. The people we spoke with talked positively about the support and accommodation provided. Most people told us they would like more to do.

Comments included, “It’s nice here and you get treated well.” And, “We have residents meetings monthly, you can raise anything. I said I wanted to go on holiday and I’ve been away with staff.” And “I like the food, you get a choice, it’s tasty.” Another person told us,” I’m happy and content with what’s on offer but would like to go out more on trips.”

We saw there was a lack of routine, structured and stimulating activities. People’s independence was promoted, some people were supported with developing their daily living skills.

The home was in need of redecoration and required some additional equipment to meet people’s needs.

We saw staff communicated well with people, appropriate language, tone of voice and eye contact was used. Humour was used in a caring and appropriate manner. We saw staff communicate with people in different ways demonstrating a person centred approach.

The staff we spoke with talked positively about the registered manager and deputy. One person told us, “I can’t praise the new manager enough, they have an open door policy, are supportive, listens and has a have a go approach.” And, “The deputy is fantastic.”

We spoke with two people who live at Dovetail House. We asked if people were happy living at the home, and if they thought their needs were being met. We were told: “It’s alright.” “The staff are OK.” We were also told: “I’ve got a nice bedroom and my family come to see me every week.”

We were told that the care that people were receiving was very good. We were told: “I like the staff, they are very good to me.” “I go out in to town, I like to go shopping.”

We spoke with two people about their experiences of living at Dovetail House. We asked each person if they felt safe, and they both said that they did. None of the people we spoke with were able to tell us about the policies that the home had for keeping them safe, or give any insight into staff training in safeguarding procedures.

We asked people who live at the care home if they thought there were enough staff employed and working at the home. Everyone we asked said that they thought there were.

We asked about staff training. Neither person was able to give any insight into what training the staff had received, although one person commented: “The staff seem to do a lot of training.”

None of the people we spoke with were able to give us any insight into how Dovetail House was monitored or assessed by the provider, although both of the people we spoke with knew that there was a new provider, and they knew who he was.