This comprehensive inspection took place on 23 and 24 April 2018 and was unannounced. The last comprehensive unannounced inspection of Kingarth took place in September 2016 when we found it was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations, Good Governance. This was because improvements were needed in relation to quality monitoring to ensure that risk assessments, staff training and supervision were up to date.

We carried out an announced focused inspection on May 2017 when we found that although some improvement had been made there was a continuing breach in good governance at the service.

At this inspection we found the breach was met.

Kingarth is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Kingarth provides support for up to seven people who have a learning disability who may at times present behaviour, which can challenge others. At the time of our visit, six people were using the service with a seventh person visiting with a view to move into the home.

The service offered by Kingarth is consistent with the aims of Building the Right Support. The bespoke environment and specialist skill set of the staff team enable people with learning disabilities and very complex needs to live in a community setting.

A registered manager was 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. The registered manager was also one of the registered providers for the home.

People told us they had no concerns about their safety in Kingarth. People were cared for in a safe and clean environment.

The people who used the service and staff felt safe and there were clear processes in place for safeguarding people from abuse.

Staff had been safely recruited and there were enough staff to meet people’s needs.

Detailed risk management plans were in place to guide staff on the action to take to mitigate the identified risks, which were kept under regular review.

Systems were in place to help ensure the safe administration of medicines, including where people who used the service took responsibility for their own medicines.

People were supported to make their own decisions and choices within any restrictions that were in place.

People were encouraged to eat a healthy diet. People chose what they wanted to eat and bought, prepared and cooked their own meals.

The property was large and spacious, whilst retaining a homely feel.

Staff closely monitored people’s physical health and wellbeing. The staff team worked closely with other health and social care professionals to help maintain this.

People spoke positively about the relationships they had with the staff team. The atmosphere was relaxed, calm and friendly.

People were involved in developing their care plans, which were person-centred and kept under reviewed.

Staff received positive behavioural support training to help them support people effectively.

People had busy and active lifestyles with support from the staff team. Independence was promoted. People were involved in all household activities, for example, cleaning the home, cooking and laundry.

People lived closer to their families and relationships with them were encouraged wherever possible.

There was a system in place for managing complaints in the service. We saw that people’s views had been taken seriously and acted upon in order to improve their experience in the service.

There were processes in place to ensure regular audits and governance of the service.

This was an announced focused follow up inspection, which took place on 2 May 2017. At our last inspection, which took place in September 2016, we found that the service did not have a manager who was registered with the Care Quality Commission (CQC). This is a condition of the services registration with us. Because there was no registered manager in place at the service and we were yet to receive an application from the registered provider we placed an automatic limiter on the well led section of the report of requires improvement.

We also issued a requirement action that related to shortfalls identified in the management of the service. We found that the service was in breach of the regulations because there was a lack of robust monitoring of risk and quality relating to the service being provided, which included action being taken to make identified improvements to service delivery. This included a review of people’s individual risk assessments and ensuring that staff had signed that they had read and understood them, as well as some outstanding training mainly for bank staff and supervision. This report only covers our findings in relation to this topic. You can read the report from out last comprehensive inspection by selecting the ‘all reports’ link for ‘Kingarth’ on our website at www.cqc.org.uk.

Following the inspection the acting operations manager, sent on behalf of the registered provider, an action plan which informed us of what action the registered provider would take to make the necessary improvements required.

This service is registered to provider 24 hour nursing and personal care support for up to seven people with learning disabilities and associated mental health needs, that might present as behaviours that are challenging to others. There were five people living at the service at the time of our inspection. Two people were also accessing the service during their assessment period to see if Kingarth was a suitable place to meet their needs.

At this inspection, we found that the service had a manager who was registered with the Care Quality Commission so the condition of registration previously applied was met. 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.

We looked at what action had been taken to make improvements to the shortfalls identified at our last inspection.

We saw that the registered provider had undertaken an online quality assurance review since our last inspection. This gave people who use the service, their families and relevant health and social care professionals the opportunity to give their views and opinions about the service. However, only two people responded to the online quality assurance request. The registered manager told us that plans were in place to send out paper versions of the quality assurance review survey.

The registered provider’s quality monitoring form, the operations manager’s monthly quality monitoring reports and other records we saw showed that the required improvements had not yet been fully made or sustained.

You can see what action we have asked the provider to take at the end of this report.

This unannounced inspection took place on 20 and 26 September. We had previously carried out an inspection in September 2014 when we found the service to be compliant with all the regulations that were in force at the time.

The service is registered to provide 24-hour nursing and residential support for up to seven people with learning disabilities and associated mental health needs. During our inspection, there were five people living at the home with a sixth person visiting.

Kingarth is in a residential area of Radcliffe and has good transport links to Bury and Manchester.

The service did not have a manager who was registered with us. 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. We were aware that the home manager had recently left the service and that recruitment process for a new manager had begun.

We found one breach of the Regulations relating to good governance.

There had been no recent external quality assurance review of the service. This would give the service the opportunity to seek feedback from people who use the service, their families and relevant health and social care professionals about the quality of the service.

Systems were in place to assess and monitor the quality of the service however, we found that there were outstanding actions to be undertaken in relation to updating risk assessments as well as some training and supervision.

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

People told us that they felt safe at the home. Staff said they felt safe and comfortable working at the home and were able to demonstrate good understanding of safeguarding and whistle-blowing procedures. They knew what their responsibilities were and what action to take if an allegation of abuse was made to them or if they suspected that abuse had occurred.

Staff had been recruited safely and there were sufficient numbers available to meet people’s required needs.

Medicines were managed safely and staff authorised to administering medicines had received training and had their competency to carry out the administration assessed.

We saw that the home was clean and tidy throughout and well maintained.

Although there were some shortfalls noted staff received the training and supervision they needed to carry out their roles effectively. Staff spoke positively about working within the staff team and were very complimentary about the acting manager.

People were able to tell us about the progress they had made in managing their behaviours whilst living at Kingarth. Staff had received training and had access to professional guidance on how to support people when they presented behaviour that might challenge others. People had access to health and social care professionals who worked in partnership with staff to help support them.

Independence was promoted and people were involved in undertaking daily living skills which included shopping for food and cooking meals for themselves and others. Maintaining a healthy diet was encouraged by staff.

People who used the service and staff spoke positively about Kingarth. They told us that management team was very approachable and supportive. We observed that interactions between people and staff were respectful and friendly and the atmosphere was calm and relaxed.

People participated in activities within the community with support where required. They were also able to pursue their own hobbies and interests.

People had the opportunity to influence the day-to-day running of the home and told us they could speak with any of the staff if they had any worries or concerns.

The service had notified CQC of any accidents, serious incidents and safegua

Before people came to live at Kingarth a thorough assessment was undertaken to ensure that people's needs and risks could be fully and safely met.

We saw that people were involved in many activities for example, gardening, playing football and cricket, watching and collecting DVDs, outward bound courses and trips out.

People took responsibility for shopping and preparing and cooking the main meal of the day. People decided what they were going to cook. On the day of our visit it was decided to have a barbecue outside due to the hot weather.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The house was large and spacious. People had well equipped bedrooms with en suite bathrooms.

Appropriate checks were undertaken before staff began work and there were enough qualified, skilled and experienced staff to meet people’s needs.

Despite close support from staff with people using the service we saw that there were frequent and friendly interactions and the atmosphere was very relaxed. The manager said that the staff team had a shared value base and worked well together.

People we spoke with told us that they if they had any concerns, problems or worries they could speak to any of the staff. They said they were confident that staff would listen and try their best to sort the problem out.

Some people living at Kingarth were unable to talk with us but could express themselves using gestures or were able to show us what we needed to see for example their bedrooms and en-suites, with staff support were necessary. We spent time watching what was happening throughout part of the day. One young person confirmed some of the activities they had been involved in recently by gesture and it was clear that going out to the pub for lunch was one of their favourite pastimes. During our visit they had been out shopping to a local supermarket and helped to put the items they had bought away and had been helped by staff to do their washing. A relative we spoke with said that their son was now “Completely relaxed and a lot happier” and that Kingarth had “Done very well and that they were very pleased.”

Two people showed us their bedrooms and en suite bathrooms. We saw that the en-suite for one person with physical support needs had appropriate facilities to meet their needs. Two people had separately attended dental appointments and also been to the hairdressers. We saw that people’s appearance was well kept and age appropriate.

People told us that the staff team were “nice” and “alright.” Staff we spoke with confirmed the staff team worked well together and there was a low staff turnover. They said that members of the staff team came from a variety of backgrounds and had different skills and experience that were used to the benefit of people using the service.

During our inspection we spoke with all the people who lived at the home, the registered manager, two senior team leaders and three support workers. We also spoke with a visiting healthcare professional, observed how people were supported, looked at parts of the home and records.

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 to people’s needs? Is the service well-led? Below is a summary of what we found.

Is the service safe?

People we were able to speak with told us they felt safe. They said they were encouraged to speak to a member of staff if they had any worries or problems.

The registered manager was fully aware that the staff team were required to support people within the law, which included the Mental Capacity Act 2005 (MCA) and to use least restrictive practices. We saw records that showed a MCA assessment had recently been carried out by an appropriate professional.

Before coming to live at the home a thorough assessment was carried out, which involved a multi-disciplinary team to discuss any potential risks. A person who we spoke with told us they had been involved in the assessment process and had visited the home before they moved in.

We were told that compatibility with the needs of the established group was always considered before agreement was reached to admit a new person to the home.

The home was seen to be clean and tidy throughout and no malodours were detected. People were protected from the risk of infection because appropriate guidance had been followed in all areas of the home.

Is the service effective?

People had access to the treatment they needed to help them with any behaviours that challenged. People told us about the progress they thought they had made in developing strategies to manage their own behaviours in a more acceptable way.

Some people told us about the arrangements that were in place to move to more independent environments which would give them the opportunity to learn new daily living skills such as budgeting.

The building was large and welcoming. Internally there was plenty of space for people to use which included two lounges, a dining room and a large conservatory. The garden area to the rear was well used.

Is the service caring?

People who used the service appeared appropriately dressed and well cared for. We saw that the interaction between people who used the service and the staff supporting them was frequent and friendly.

Despite close one to one support the atmosphere was calm and relaxed. We saw members of staff were able to communicate well with people with good eye contact, a ready smile and humour.

We saw that because staff knew people well, they were able to recognise any triggers and behaviours that could lead to increased anxiety and agitation and used de-escalation techniques to prevent any further escalation.

New support staff who had recently joined the staff team said they had been made to feel welcome and supported by more established staff.

Is the service responsive to people’s needs?

We saw that prior to an admission being agreed a thorough assessment was carried out by the registered manager and/or one of the senior team leaders.

We spoke with a visiting healthcare professional who spoke positively about the treatment and support provided by the home. They said that staff at the home treated people as individuals and had a good understanding of their needs and risks which enabled them to provide effective support within a homely environment.

People we spoke with confirmed they were treated as individuals and all the activities they were involved in were what they wanted or liked to do.

Staff had received training in positive behavioural management. A support worker we spoke with said, “It is about knowing each individual person’s triggers, managing and minimising potential risks and building up trust.”

Is the service well-led?

The home had a manager who was registered with the Care Quality Commission (CQC). The registered manager was present during our inspection visits. The registered manager was in almost daily contact with the nominated individual for the service to help ensure they were kept up to date with what was happening at the service.

The registered manager was supported by two senior team leaders who were both nurses. To ensure their continued professional development they had recently completed an applied behavioural analysis and intervention degree.

Everyone we spoke to told us that the management team were very approachable and supportive. The staff team said they were encouraged and could be ‘open and honest’ and give their views and opinions about the running of the home.

The home was monitored by the provider. A monthly audit was carried out and an annual quality assurance visit, were carried out by managers external to the home.

Prior to our visit to the home we contacted the local authority commissioning, quality assurance and safeguarding teams. We were informed there were no concerns at this time.