About the service: Middlefield House Nursing Home is a nursing home that provides personal and nursing care for up to 18 people with learning disabilities, autistic spectrum disorder or associated physical needs. At the time of this inspection, 17 people were using the service.

The provider's quality assurance systems were not always effective at monitoring and improving the service people received. They had not identified issues we found during our inspection, and parts of the service provision were not monitored. These included the mealtime experience, and whether support provided to people was in line with current best practice guidance. Records were not always kept up to date, and some had not been completed.

Staffing levels did not always meet people's needs. People had not always received personalised care due to staffing levels. Staff had not received supervision in line with the provider's policy. Staff training was not up to date.

In June 2017, The Care Quality Commission published 'Registering the Right Support'. This, along with associated good practice guidance, sets out the values and standards of support expected for services supporting people with a learning disability. At this inspection, we assessed the service in line with this guidance. The care service has not been developed and designed in line with the values that underpin ‘Registering the Right Support’. These values include choice, promotion of independence and inclusion, and people with learning disabilities and autism using the service can live as ordinary a life as any citizen.

People’s experience of using this service: As a larger care home catering for up to 18 people, Middlefield House does not meet current best practice guidance for supporting people to live as ordinary a life-style as possible. The Department of Health states that best practice is for people with a learning disability to live in 'small, local, community based settings.' The size, layout and staffing arrangements at Middlefield House meant that it did not feel or operate as people's own home. Staff wore uniforms and a large sign outside the service advertised the service. People who required support to learn or retain everyday living skills were not always provided with individualised support.

We have made a recommendation that the provider follow best practice for people with a learning disability to ensure the principles of choice, independence, inclusion and living as ordinary a life as any citizen are implemented throughout the service they provide.

The provider had systems in place to protect people from the risk of harm and staff knew how to keep people safe. Risk assessments were in place, which provided staff with guidance on how to maintain people's safety. The provider followed safe recruitment procedures and processes.

Staff knew people and their needs well. People were cared for by kind and caring staff. Relatives gave consistent, positive feedback about the service and said they were happy with the care their family member received.

Care plans were detailed and were developed in line with people's preferences. These were in accessible formats and included information from external healthcare professionals.

People's health was well managed and the service maintained positive links with healthcare professionals. Medicines were managed safely and people's dietary needs were met.

Some adaptations had been made to the premises to support people with their moving and handling needs. People had access to communal spaces which included a sensory room.

Complaints were managed in line with the provider's policy. People and their relatives were provided with information on how to complain.

Staff told us they were supported by management and felt able to raise concerns.

Rating at last inspection: Good (date published 3 June 2016)

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Enforcement: We identified two breaches

This inspection took place on 27 April 2016 and was unannounced.

Middlefield House specialises in the care of people who have a learning disability. It provides accommodation for up to 18 people who require personal and nursing care. On the day of our inspection there were 17 people living at the home.

At the time of our inspection 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.

On the day of our inspection we found that staff interacted well with people and people were cared for safely. The provider had systems and processes in place to safeguard people and staff knew how to keep people safe. Risk assessments were usually in place, where people received their medicines in food risk assessments had not been completed. Medicines were administered and stored safely. Accidents and incidents were monitored and recorded.

The provider acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).If the location is a care home Care Quality Commission is required by law to monitor the operation of the DoLS, and to report on what we find.

We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals such as a dietician and GP. Staff were kind and sensitive to people when they were providing support. Staff had a good understanding of people’s needs. People had access to leisure activities and excursions to local facilities.

People had their privacy and dignity considered. Staff were aware of people’s need for privacy and dignity.

People were supported to eat enough to keep them healthy. People had access to drinks during the day and had choices at mealtimes. Where people had special dietary requirements we saw that these were provided for.

There were sufficient staff available to care for people appropriately. Staff were provided with training on a variety of subjects to ensure that they had the skills to meet people’s needs.

Staff felt able to raise concerns and issues with management. We found relatives were clear about the process for raising concerns and were confident that they would be listened to. The provider recorded and monitored complaints.

Audits were carried out on a regular basis and action put in place to address any concerns and issues.

Due to the complex needs of some of the people living at Middlefield House we used a combination of methods during our inspection. This included talking to the manager, four members of staff and two relatives of people using the service.

We looked at the care plans of three people, toured the building and looked at records which demonstrated how the provider was monitoring the quality of the service provided.

Relatives we spoke with told us they were involved in decision making about the care and support they received. One relative we spoke with told us, “I think Middlefield House is absolutely brilliant. My family member is always happy and the care staff always consider our input which involves us as a family.” Another relative told us, “All the staff are very friendly, very caring and always treat you with respect.”

We saw the food was prepared using fresh ingredients, was well presented and people were offered a variety of choices.

We saw Middlefield House was adapted to meet the needs of the people who lived there. The gardens around the house were accessible, well maintained and contained a patio area for service users and their families to use.

We saw there was an adequate number of staff to support people and extra staff were on duty to support people to go out on a trips out. One member of staff told us, “I enjoy my job and I stay here because of the people”.

The provider had systems in place to monitor and assess the quality of the service.

Due to the complex needs of the people using the service we used a number of different methods to help us understand their experiences. We spoke with and observed staff working with people who were undertaking their daily routines, eating their meals, undertaking activities and going out into the community with support.

We also looked at records. These included care plans, minutes of meetings, and quality assurance reports completed by the manager using feedback from a survey undertaken by the home owners in 2011.

We observed that staff provided sensitive support using special equipment when people needed support with moving safely, during meal times and when people were undertaking individual or group activities.

We also observed how people enjoyed the food that the home provided and the social activities that the home had organised. We saw there was a range of things for people to take part in as well as opportunities for them to go out into the community with support from staff and their relatives when they chose to.