This inspection took place on 20 December 2017 and was unannounced. At our previous comprehensive inspection in November 2015 the service received an overall rating of ‘Good’.

Living Ambitions Limited - 63a Victoria Avenue provides personal care for up to seven adults with a learning disability. There were seven people living in the service at the time of our inspection. Living Ambitions Limited - 63a Victoria Avenue 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.

The care service was 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.

The service had 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 were supported by staff to be safe at the service. People’s risks were assessed and reduced by the plans put in place and staff understood how to protect people from abuse and improper treatment. People received their medicines safely and there were sufficient numbers of safely recruited staff available to deliver care and support. Staff routinely checked the home environment for cleanliness and safety and the service was prepared to respond quickly in the event of an emergency.

People’s needs were assessed and they were met by trained and supervised staff. People accessed healthcare services whenever they needed to and were supported to eat healthily. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were upheld and they were supported with planned transitions into the service.

Staff were caring and kind towards people. Accessible information was available to support people to make decisions and people were supported to be independent. Staff supported people to maintain relationships and relatives were made to feel welcome when they visited.

People contributed to the planning of their personalised care. People were supported to have assessments of their communication needs and were supported in line with them. People’s bedrooms were personalised. Staff supported people to engage in a wide range of activities.

The registered manager led a staff team which felt supported and able to contribute their views. The quality of the service was the subject of on-going auditing and review. The service worked collaboratively with external organisations to secure positive outcomes for people.

The last Care Quality Commission (CQC) inspection of this service was carried out on 19 November 2015 when we found the provider was not meeting all the regulations we looked at. Specifically, the provider had failed to ensure staff who worked at the home always received the support, supervision and appraisals that were necessary for them to carry out their role and responsibilities.

After the home’s last comprehensive inspection, the provider wrote to us to say what they would do to meet their legal requirements in relation to the breach described above. We undertook an unannounced focused inspection on 8 June 2016 to check the provider had followed their action plan and now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Living Ambitions Limited - 63a Victoria Avenue’ on our website at www.cqc.org.uk’.

Living Ambitions Limited - 63a Victoria Avenue is a residential care home that provides accommodation, personal care and support for up to seven people. The service specialises in supporting adults living with a learning disability and complex health and physical needs. There were seven people living at the home when we inspected.

At the time of our inspection, the service’s registered manager had gone on an extended leave of absence for the next 12 months. In the interim the service’s acting manager will apply to become the registered manager for the service. 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.

During our focused inspection, we found that the provider had followed their action plan. We saw legal requirements had been met because the provider ensured staff received the support and supervision that was necessary for them to carry out their role and responsibilities. The meant the needs of the people living at the home were being met by appropriately supported staff.

This inspection took place on 19 November 2015 and was unannounced. The last Care Quality Commission (CQC) inspection of the home was carried out on 16 September 2014, where we found the service was meeting all the regulations we looked at.

63a Victoria Avenue is a care home that can provide accommodation and personal support for up to seven adults living with learning and physical disabilities. There were seven people living at the home at the time of our inspection.

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

People who lived at the home were at risk of not having their health and welfare needs fully met because staff were not always properly supervised and appraised by their line managers. This was a breach of the Health and Social Care (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This point notwithstanding we saw staff looked after people in a way which was kind and caring. Our discussions with people using the service and their relatives supported this. People told us they were happy living at 63a Victoria Avenue and felt safe there. People’s rights to privacy and dignity were also respected.

Staff knew what action to take to ensure people were protected if they suspected people were at risk of abuse or harm. Risks to people’s health and wellbeing had been assessed and staff knew how to minimise and manage these risks in order to keep people safe. The service also managed accidents and incidents appropriately and suitable arrangements were in place to deal with emergencies. Regular service checks were carried out at the home to ensure the building was appropriately maintained.

There were enough suitably competent staff to care for and support people. The home continuously reviewed and planned staffing levels to ensure there were enough staff on duty to keep the people using the service safe.

Staff were suitably trained and knowledgeable about the individual needs and preferences of people they supported.

People were supported to maintain social relationships with people who were important to them, such as their relatives. There were no restrictions on visiting times.

People participated in meaningful social, educational and vocational activities that interested them both at home and in the wider community. We saw staff actively encouraged and supported people to be as independent as they could and wanted to be. We saw people could move freely around the home.

People were supported to keep healthy and well. Staff helped people were able to access community based health care services quickly when they needed them. Staff also worked closely with other health and social care professionals to ensure people received the care and support they needed.

People received their medicines as prescribed and staff knew how to manage medicines safely.

There was a choice of meals, snacks and drinks and staff supported people to stay hydrated and to eat well.

Staff supported people to make choices about day to day decisions. The manager and other staff were knowledgeable about the Mental Capacity Act (2005) and best interests meetings were held in line with the Act to make decisions on behalf of people who did not have the capacity to make decisions themselves.

Deprivation of Liberty Safeguards (DoLS) had been applied for to protect people’s safety, and the staff were aware of what this meant and how to support people appropriately. DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

The service had a clear management structure in place. They checked the quality of service provision and ensured appropriate action was taken when concerns were identified.

The views and ideas of people using the service, their relatives, professional representatives and staff were routinely sought by the provider and used to improve the service they provided. The provider had arrangements in place to deal with people’s concerns and complaints appropriately.

The inspection was carried out by one inspector.

We considered our inspection findings to answer 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 and information from records. These included policies and procedures, minutes of meetings, care records, staff files and records related to quality monitoring and quality assurance systems. At the time of our visit seven people used the service and all were home for parts of the day. We spoke with two people and two relatives, also with staff, a health professional, the home’s operations manager and registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

Is the service safe?

A person who used the service told us, "I like living here, this is the best home I have lived in. I feel safe here and want to live here forever. I like the staff; they are really nice to me. They give me choices and don’t tell me what to do, I decide for myself”.

People living in the home had a range of needs. These included profound learning disabilities, mental health disorders, physical disabilities and complex health needs.

Of the seven people accommodated, two used verbal communication to express their wishes. Other people had minimal or no verbal communication. We saw staff demonstrate significant skill in their understanding and interpretation of people’s individual methods of communication. They used observations to determine whether people were happy or upset. Staff explored and reported any concerns, ensuring people's safety.

Staff treated people with respect and dignity, providing consistency of their care and support. We saw people react to staff contact in ways that showed no obvious signs of distress when receiving support. People's needs had been fully assessed and their care and support was provided in accordance with their personal support plans.

A range of risk assessments had been undertaken, for example, related to moving and handling, prevention of pressure sores, nutrition and management of behaviours that challenged. Risk management plans had been produced and staff followed them. Care plans and risk assessments had mostly been reviewed each month and updated, as necessary. This meant changes in needs had been identified and responded to, ensuring people were not exposed to unnecessary risk.

Suitable arrangements were in place for obtaining and acting in accordance with people’s consent in relation to their care and treatment. Where people did not have capacity to consent the provider had acted in accordance with legal requirements.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had policies and procedures in relation to the Mental Capacity Act and DoLS, although to date, no applications had needed to be made. Records showed mental capacity assessments had been carried out for some people. These had been specific to decisions made in their best interest. These had been made by professionals, involving people and others including relatives acting on their behalf. There was an on-going programme of staff training. This helped ensure staff understood their responsibilities under the Mental Capacity Act and DoLS. The registered manager was clear in what circumstances a DoLS application should be made. We were told consideration was being given to submitting DoLS applications for people specific to the use of gates at the top and bottom of the stairs. Risk assessments showed the use of stair gates had been considered necessary to ensure people’s safety.

The environment was clean, hygienic and well- maintained. A range of audits had taken place to ensure the safety of the environment.

Systems were in place to make sure staff learned from events such as accidents, incidents, practice shortfalls, complaints and concerns. This minimised risks to people and promoted continuous service improvements.

Procedures for dealing with emergencies were in place and staff trained to competently implement them.

Is the service effective?

Records showed people’s health and care needs had been assessed and support plans reflected their current needs. The plans took account of people’s diversity, rights and preferences. People and/or those acting on their behalf had been involved in the care planning process. People had access to health and therapeutic services and had equipment to meet individual needs.

People’s needs had been taken into account in the design and layout of the premises, enabling safe movement around their home.

Staff had received essential training to ensure they had relevant skills and competencies to meet people's needs.

The registered manager, deputy manager and operations manager were accessible to staff for advice, guidance and support.

Is the service caring?

We received positive feedback from people’s relatives during the inspection. Comments included, “I feel x receives wonderful care, I am happy with everything and feel the home should have five stars”. Also, “I think the home is very good and x is very happy there. I feel the carers are very loving”.

We found staff to be knowledgeable about people’s preferences and lifestyle choices. They were attentive to people, with high levels of engagement. We observed staffs' interactions with people and found their general approach to be friendly, cheerful, caring and respectful. When speaking with staff it was evident they genuinely cared for the people they supported. They showed commitment to enhancing people's life experiences, assisted them to make the most enjoyable and beneficial use of their time.

Is the service responsive?

People and those acting on their behalf had been informed of the procedure for making a complaint or expressing a concern. A relative told us, “Nothing is 100% as a parent would do things but the home is very good. When I have had a concern about something the manager and deputy manager have quickly dealt with the problem to my satisfaction”. This showed the home had effective systems for investigating and responding to complaints.

Systems were in place for analysing incidents, complaints and safeguarding alerts. Learning from these events had been constructively used to promote continuous service improvement and developments.

Is the service well-led?

The home manager was registered to manage two care homes, spending time in both during the week. The operations manager spent time at the home throughout the week and was frequently there when the registered manager was at the other home. The registered manager told us both homes had well-established deputy managers who showed initiative and possessed strong management and leadership skills. The management arrangements ensured staff received the necessary support to deliver services in compliance with essential standards of quality and safety.

The registered manager, operations manager and deputy manager monitored and assessed quality within the home in various ways. Staff demonstrated they were clear about their roles and responsibilities. They felt supported by management and had a good understanding of the home's ethos and quality assurance processes. This helped ensure people received a good quality service.

During our inspection we spoke with two people who lived at the care home and one of their visiting relatives. They told us they were happy with the standard of the care provided at 63a Victoria Avenue and felt the staff that worked there were kind and compassionate. One person told us “this is the best place I have lived. This is my home” and “all the staff care for me here”. Another person said “my daughter is happy here and she is definitely safe” and “the staff are helpful and always make me feel welcome when I visit”.

We saw staff respected people’s dignity and were familiar with the individual needs, abilities, preferences and daily routines of the people they supported. People also received effective care that met their needs because staff were suitably trained and supported to deliver care to an appropriate standard.

However, although staff were suitably trained and supported to effectively carry out most of their duties the provider may wish to note that none of the current staff team had received any formal training on preventing and managing pressure sores or had had their overall work performance appraised by the registered manager in the last twelve months.

Due to the complex needs of most of the people who use this service we were unable to communicate with everyone in a meaningful way. So in order to help us understand the experiences of all the people who lived at 63a Victoria Avenue we used a number of different methods, including: the Short Observational Framework for Inspection (SOFI), which is a specific way of observing care to help us understand the experience of people who could not talk with us; reviewing various records the provider is required to keep; and, talking to the homes management and staff on duty at the time of our visit.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care and support. The feedback we received from the few people who we could have a meaningful conversation with was on balance very complimentary about the standard of the care and support they received from staff that worked at the home.

It was clear from all the evidence we gathered during our review that the provider had taken appropriate steps to ensure that there were now always sufficient numbers of staff on duty in the home with the right mix of knowledge and skills to meet the needs of the people using the service. People we met told us they were happy with the overall attitude of the staff that worked at the home and felt there was usually enough of them around to meet their needs. Typical comments we received, included: “Staff always knock on my bedroom door before they come in, even when it’s open”, “Most of the staff are alright here and treat me well”, and “I like my key-worker very much”.

It was also clear from the comments we received from the few people we spoke with that they felt the staff that worked at this home listened to what they had to say and usually took their views into account. Feedback we received included: “I help the managers run the place and interview new staff sometimes”, “I feel like I am part of the team here”, and “I can choose what I have for my lunch and what I am going to do every today”.

We observed all the managers and staff interact with the people who use the service in a very courteous and respectful manner throughout the course of our visit. For example, we always heard staff using appropriate voice tones and language when speaking to people who use the service and during lunch observed staff appropriately support people who required assistance to eat this meal.

The atmosphere in the home remained relaxed and congenial throughout the course of our visit.

This review was carried out to follow up concerns raised by an anonymous whistle blower who alleged there was not always enough staff on duty at Victoria Avenue during the day to meet the health and welfare needs of the people who lived there.

Most people using the service are unable to communicate their needs and wishes verbally and therefore we were unable to speak at length to anyone who currently resides at Victoria Avenue. Nonetheless, we were able speak with a few people using the service about what it was like to live at the home, as well as observe how care staff on duty at the time of our visit interacted with everyone.

The limited feedback we did receive from people using the service was on balance quite positive about the standard of care they were receiving, especially regarding the attitude of care staff that worked at Victoria Avenue. People we met told us staff always treated them well and with the utmost respect. Typical comments we received, included: “Staff are nice” and “I like most of the staff here”. During our visit we observed care staff treat people using the service with kindness, and always take their time to listen to what people whom lived at Victoria Avenue told them.

However, all these positive points made above notwithstanding, it was also evident from comments made by people using the service and care staff that worked at Victoria Avenue that everyone was concerned about staffing levels at the home. Typical feedback we received from all the stakeholders we met, included: “There’s not enough staff to talk to me”, “Staff are nice, but too busy to see me sometimes”, “Sometimes we are down to two staff here, which is very dangerous”, and “community based activities and medical appointments are always being cancelled either because we do not have enough staff to take people or we do not have a driver”.

It was also concerning to note that when we first arrived at Victoria Avenue the service was operating without its full compliment of early morning staff and as a direct consequence of this staff shortage a prearranged appointment with a community based healthcare professional had to be cancelled by the service at short notice. Staff duty rosters we looked at indicated that staff shortages, absenteeism and lack of temporary cover were not uncommon occurrences at Victoria Avenue during 2012.

The feedback we received from the people who use the service was in the main very positive:

People we met told us they were staff always treated them well and listened to what they had to say.

Typical feedback, included: - “I get up when I want and staff are always taking me out”, “staff ask me where I want to go and they always come with us”, “if I'm not happy about something I always talk to my keyworker”, “staff are ok…they look after us” and “I feel safe living here…better than the last place I lived”.

People told us they liked the food and drink they were provided.

Typical comments, included - “I like the food here and you can always choose what you want”, “the food is all right and I sometimes have my meals in my bedroom”, and “staff help me to make my own drinks”.

People told us staff look after all their medication, which they manage well.

Typical feedback, included – “I'm happy for staff to look after my medication… I think I would get confused if I had to do it myself”, “I don’t want to look after my medicines… staff do that” and “staff always give me my medication on time… never had any problems”.

People told us they liked they way their bedrooms were decorated and everyone we spoke to, including staff, said they were pleased work to redecorate all the communal areas was now underway.

Typical comments, included – “my bedroom is great…I've got everything I need”, “I don’t like the colour the kitchen is painted, but I like my bedroom”, and “it’s great to see the painters in redecorating the place… its well overdue”.

People told us there were ‘usually’ enough members of staff around to take them out and talk too. Typical comments, included - “its good there’s more staff about these days to take us out” and “staff sit and talk with me in my bedroom every morning, which I like”. In addition to these comments, staff also told us -“the mornings are always the busiest times, so having more staff working on early shifts means we can take more people out” and “it use to be a real problem getting people to their day centres on time because the mornings are so hectic, but it’s a lot easier now there’s more staff about”.

People who use the service told us they liked the staff. Typical comments, included - “I don’t like living here, but the staff are nice”, “staff help me a lot… they’re all great”, and “staff always listen to what you have to say“.

We also observed staff interacting with the people who use the service in a very kind, respectful and professional manner throughout the course of this visit.

Finally, we were reassured by many of the comments made by the services managers who acknowledged the service was far from perfect and that there was room for further improvements to be made. We are confident the service is capable of achieving this aim as we feel they have the necessary will, resources and knowledge to make the improvements we discussed during this visit.