About the service:

This service is a residential care home. It provides personal care to adults living with a learning disability, some of whom also have physical disability and/or sensory impairment. The service is known both as ‘The Byre’ or ‘Footsteps’.

This service was registered to support up to five people with learning disabilities and/or autism, physical disability and/or sensory impairment. Five people with complex needs were using the service. The service is an extended bungalow in a residential area and was in keeping with other domestic homes of a similar size in the area. Staff wore regular clothes when supporting people, both at the service and while out in the community.

People’s experience of using this service:

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The outcomes for people using the service reflected the principles and values of Registering the Right Support in the following ways:

• People’s wishes and preferences were ascertained by staff who understood how to communicate with them effectively and people’s wishes were respected.

• People's support focused on having as many opportunities as possible for them to gain new skills and become more independent.

• People were supported to get out and about, be part of their community, meet others and maintain existing relationships.

We received highly positive feedback about the service and the support people received. The service met the characteristics of ‘Outstanding’ in the key question ‘Is the service Caring?’ and ‘Good’ in all other key questions. A health professional said about people living at Footsteps, “They are out all the time. They do everything”.

• The service was outstandingly caring and demonstrated a strong, visible person-centred culture.

• People were supported by exceptionally caring staff who often “went the extra mile” for them and told us doing this was “a pleasure”.

• People were placed at the centre of the service and benefitted from staff who knew how to communicate with them to ascertain their wishes. People’s relatives were informed, involved and consulted on every level. Relatives told us their views were “listened to”.

• People received exceptionally personalised care and support specific to their needs and preferences. Staff were creative and proactive to ensure people’s needs were met in the community, removing potential barriers to community based activities.

• Risks to people were regularly assessed and the related support plans were followed by staff to keep people safe.

• Safe recruitment practices were followed to protect people from unsuitable staff.

• Staff were knowledgeable about safeguarding and understood provider policies and procedures in this regard. Staff knew when and how to involve external agencies.

• People received appropriate support to take their medicines safely. People’s medicines were reviewed regularly in line with best practice guidelines including STOMP.

• People’s heath related needs and risks, such as epilepsy, were managed in accordance with national guidance and with appropriate support from health care professionals.

• People were encouraged to live healthy lives. They were supported to maintain a healthy weight, eat a balanced diet and exercise regularly.

• People benefitted from a stable staff team who “loved” their role and were happy in their workplace. Staff felt exceptionally well supported and had completed further and specialist training to enable them to suppor

This inspection took place on 26 and 29 February and was unannounced. Footsteps Medical Limited provides personal care for up to five people with a learning and physical disability. At the time of the inspection there were five people living there. They share a bungalow which provides individual bedrooms with en suite facilities, a shared lounge and kitchen diner.

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 2008 and associated Regulations about how the service is run.’

People received individualised care which reflected their likes, dislikes and lifestyle choices. They were supported by staff who understood them well and were able to communicate with them effectively. When people’s needs changed staff responded quickly by involving health care professionals. People were supported to stay well and maintain a diet which reflected their individual dietary needs. Medicines were managed safely and they were reviewed to make sure people’s medicines were effective. People enjoyed a range of activities including trips out to places of interest, the gym, reading, skittles and baking. Sensory activities such as music, hand and head massage and the use of sensory equipment were also offered. People were kept safe and their rights upheld.

People benefitted from staff who had the knowledge and skills to meet their needs. They had access to training to keep their skills up to date. They felt supported in their roles and had individual and group meetings with the registered manager to reflect on the service they provided and their professional development. Staff treated people with dignity and respect. They were kind and caring.

People’s experience of their care and support was audited through a range of quality assurance processes. Relatives were positive about the care people received praising the staff and registered manager for the way they supported and cared for people. They were confident any concerns would be addressed. Relatives and staff found the registered manager open and accessible.

During this inspection we checked that the provider was meeting requirements and had completed their action plan in relation to four compliance actions issued at our last inspection. On 11 February 2014 we served a fixed penalty notice to Footsteps Medical Care Limited for providing accommodation with personal care in an unregistered location. A fine of £4,000 was paid.

This inspection was completed by an adult social care inspector. We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke with the relatives of two people and observed staff as they supported all four people living at The Byre. We spoke with the registered manager and three care staff. We reviewed two care plans, behaviour and communication plans, assessments of people's capacity to make decisions, incident and audit records. The focus of the inspection was 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 representatives of people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were safe because risks were assessed and managed effectively. Risk assessments had been carried out and were updated regularly to ensure risks to people were managed. Care plans included pictures and detailed descriptions which described how staff should support each person in different situations. Daily records and our observations demonstrated that care plans had been followed. Staff worked with a range of external health professionals to ensure people’s health needs were met. Appropriate arrangements were in place to manage foreseeable emergencies.

The systems in place to manage people’s medicines were safe. This included appropriate staff training, checks of staff competency and medicines checks. The checks carried out ensured that any shortfalls could be identified and managed promptly. Clear guidance was available to staff in the use of prescribed ‘as required’ medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff were trained to understand when an application should be made and how to submit one.

Is the service effective?

The service people received was effective because people's individual needs, choices and preferences were reflected in their care plans. It was clear from our observations and by speaking with staff that staff understood what was important to people and knew how to support them in making choices. For example, they checked what people wanted to eat and if they agreed to the care or activity planned for them. When people were unable to give consent for their care or treatment the appropriate people had been involved in making decisions in their ‘best interests’.

People were supported to access a range of health professionals and their advice was taken into account when planning and delivering care.

Is the service caring?

The service was caring because people and their representatives had been enabled to express their views about what was important to them and they had been listened to. For example, one person’s relative told us that moving to the home had been daunting for their relative. They said, “They all (staff) listened to what I said, they were very good at looking out for the signs (they had shared with staff to recognise how their relative was feeling)”. Another person’s representative told us that staff were caring and supported them. They said, “These girls here (staff) are as good as I could find. She (registered manager) has looked after me more than I’ve ever been looked after in my life”.

Is the service responsive?

The service was responsive because when people’s need changed appropriate action was taken. For example, when a person became unwell, advice from a health professional was sought promptly. One person’s representative said, “They (staff) will always call. When (name of person) was ill they phoned me and got the doctor up quickly. Straight away they do it”.

Staff recorded information about people’s day to day health which enabled external health professionals to monitor how well they were responding to individual treatment plans. This meant that people got the appropriate treatment to meet their needs.

Is the service well-led?

The service was well-led because effective quality assurance systems were in place and where the need for improvement had been identified, timely action had been taken. Staff were clear about their roles and responsibilities. They felt well supported and were confident that if they raised any issues or concerns, these would be managed effectively and in confidence. People, or their representatives, met with staff regularly to give feedback about the service provided.

We carried out this inspection in response to information of concern raised by commissioners and the representatives of people who used the service. Information the provider shared with us also indicated that potential breaches of our regulations and the provider’s conditions of registration had occurred.

We have not been able to speak to people using the service because they had profound learning disabilities which meant we were unable to communicate effectively with them. We gathered evidence of people’s experiences of the service by reviewing their records, observing how they were supported by staff and by taking into account the views expressed by their representatives.

We found that people who used the service for respite care had not always been involved in decisions made about them. When people were considered as lacking capacity to consent to more complex aspects of their care, the provider did not have appropriate systems in place to ensure that legal requirements were met. The provider had addressed the majority of shortfalls identified by commissioners. However, the planning and delivery of care had not always been provided in a way that met people’s needs or ensured their welfare and safety. The service was not meeting standards for medicine management. We are taking action against Footsteps Medical Care Limited for providing accommodation for persons who require nursing or personal care (a regulated activity) in an unregistered location.

Staff demonstrated confidence in their interactions with people and in understanding their needs and feelings. Communication passports had been developed by staff to describe how people communicated their feelings, wishes, likes and dislikes. This was an ongoing process but appeared to be working well as people living at The Byre looked settled and happy.

We saw that food was regularly home cooked from fresh ingredients. A selection of fresh, frozen and tinned fruit and vegetables were used including locally produced farm goods. One member of staff said "they have brilliant meals". Another said, "the menus are great, there's good variety".

Staff demonstrated good knowledge of infection control procedures and knew how to minimise infection risks to people. One of the newer members of staff we spoke with said they “love it” at The Byre and they found communicating with people and seeing them enjoy themselves especially rewarding. They said it had taken them a while to get to know the people they supported, but said “all the staff were brilliant” during this time. All staff had completed training appropriate to their role.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences.There were no family or friends visiting during our inspection to ask about their experiences.

We used a number of different methods to help us understand the experiences of people using the service, because people had complex needs which meant they were not able to tell us about their experiences. We spent time with people using the service, observed the care and support they were receiving and reviewed care records and quality assurance systems. We spoke with the family of one of the three people who uses the service and looked at feedback that other relatives and external health professionals had given. We spoke with staff, looked at staff supervision and training records and the provider’s quality assurance systems.

Feedback about the service was largely positive. However, people’s independence was not always promoted and their representatives were not always involved in making decisions on their behalf. People had equal access to health care, but they were not always protected against the risks of cross infection. The environment was safe but some fixtures and fittings were worn or damaged. Staff had successfully undertaken a variety of training but had not completed all the training required to support people with complex needs. The provider had an effective quality monitoring system in place; some shortfalls had been identified and were being addressed.