This unannounced inspection took place on 14 November 2018. At the last inspection on 23 August and 08 September 2017 there was a breach of Regulation 17. This was because the provider did not have effective systems in place to manage risks relating to the health, safety and welfare of people using the service. During this inspection, we found the provider had made some improvements, however they had not been completely effective or consistent therefore the service has remained in breach of Regulation 17.

Natalie House is a care home registered to accommodate up to five people who have a learning disability. The home is not purpose built or modified. At the time of our inspection four people were living at the home. People in care homes receive accommodation and nursing or personal care as a 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 has been 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.

There was a registered manager in post at the time of the 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 2008 and associated Regulations about how the service is run.

There was some further improvement required to the systems and processes in place to monitor the safety and quality of the service provided. We found the provider was not meeting the regulations around the overall governance of the service. You can see what action we told the provider to take at the back of the full version of the report.

Relatives were involved, alongside healthcare professionals, to ensure that any decisions made in respect of their care and support needs, were done so within their best interests and in accordance with the Mental Capacity Act 2005. However, this was not always practiced consistently by the service and required some improvement.

People were protected from the risk of abuse and avoidable harm because staff knew what action to take and the provider had safeguarding systems and processes in place to keep people safe. People were supported by sufficient numbers of staff who were kind and respectful and had the knowledge they required to care for people safely.

People were also protected against risks associated with their health and care needs because risk assessments and associated care plans were in place and had been reviewed within the last 12 months. People received support from staff to take their prescribed medicines. Systems and processes were in place to ensure medicines were managed safely. People received their medicines from staff who had undergone training and were permitted to administer medicines.

Where people were assessed to lack the capacity to consent to the support they received, the provider followed key processes to ensure the care being provided was in the least restrictive way possible. Applications had been made to safeguard people against the unlawful deprivation of their liberty, where necessary. People’s privacy, dignity and independence were respected.

People were supported to maintain a healthy diet with choices of different foods available and all their health needs were met with the support from staff and healthcare professionals. Staff knew people very well. There was a complaints process in place although there had been no complaints since the last inspection. People engaged in interests in an environment that was suitable for people living with learning disabilitie

Natalie House is registered to provide accommodation and support for up to five people with a learning disability. On the two days of our inspection visit there were four people living at the home. This was an unannounced inspection.

At the last comprehensive inspection on 9 August 2016 the service was rated as requires improvement and we identified a breach in the legal regulations (Health and Social Care Act 2008). This related to there being ineffective quality monitoring systems in place to monitor the quality of the records, recruitment processes, and the training needs of staff. We also found that improvements had not been made in response to the previous inspection report. We undertook a focused inspection on 18 May 2017 to check that they had followed their action plan and found that the provider had met the legal requirements.

At the inspection on 23 August and 08 September 2017 there was a registered manager in place. 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.

Regular audits were completed by both the registered manager and a representative for the provider. However, these checks had not ensured that the service was meeting people’s needs and all of the fundamental standards. You can see what action we told the provider to take at the back of the full version of the report.

At the time of our inspection two safeguarding concerns had been reported to the local authority. These included concerns about medicine practices, staff allegedly pulling and grabbing a person and poor pressure care. These were under investigation by the local authority and the provider.

Risks relating to people’s healthcare needs and lifestyle had been assessed but the action needed to manage and reduce the risk had not always been identified or planned. Staff we spoke with gave different accounts of how they supported people and the support was not always consistent with good practice guidelines.

People required the support of staff to manage their medicines. Some improvements were needed to ensure people could be confident their medicines would be administered safely and as prescribed. The registered manager took some actions during the inspection visit to rectify issues we identified.

People were supported by sufficient numbers of staff to ensure their needs were met. Records were available to support the recruitment checks that had been undertaken on new staff members employed to work at the home. Improvements were required to ensure any gaps in staff employment would be identified and explored.

The staff we met knew people well, and were able to tell us about people including their needs, preferences and things and people who were important to them. In our discussions staff demonstrated that they cared about the people they supported and many of the interactions we observed supported this. However some of the care we observed did not always protect and promote the person’s dignity.

Staff demonstrated that they knew about the signs of possible abuse and they knew the action they should take should they suspect abuse. At the time of our inspection two safeguarding incidents had been reported to the local authority and these were under investigation by the provider.

New staff received suitable induction training. Training was provided to ensure staff had the knowledge and skills needed to support people. Where gaps in training had been identified we were informed plans were in place to schedule this.

People received care and support with their consent where possible, and the staff ensured that people were supported in the least restrictive ways in order to keep them safe. When restrictions on people’s liberty were necessary the registered man

We carried out an unannounced comprehensive inspection at this service on 09 August 2016. We found the service was in breach of a regulation. This related to there being ineffective quality monitoring systems in place to monitor the quality of the records, recruitment processes, and the training needs of staff. We also found that improvements had not been made in response to the previous inspection report. After the inspection, the provider wrote to us telling us what action they would take to meet the legal requirements in relation to the breach.

We undertook this focused inspection to check that they had followed their action plan and to confirm that they now meet the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Natalie House on our website at www.cqc.org.uk.

Natalie House is registered to provide accommodation and support for up to five people with a learning disability. On the day of our inspection there were five people living at the home. This was an unannounced 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.

The provider had taken action and the legal requirements had been met. We found that sufficient improvements had been made to monitor the quality of the service.

People were supported by sufficient numbers of staff to ensure their needs were met. Although a formal system was not yet in place we were told the staffing levels were reviewed on a regular basis by the registered manager. Risk assessments for people were being reviewed, and this work was on-going. The risk assessments that had been reviewed were detailed to ensure staff received clear guidance on how to support people to reduce any identified risks to their well-being.

Records were available to support the recruitment checks that had been undertaken on new staff members employed to work at the home. Improvements were required though to ensure gaps in employment were explored and assessments of risks were completed around specific issues relating to their suitability for their role. Action was taken by the registered manager to address these issues. We saw records were in place to show new staff had induction training. A training plan was now in place to ensure staff had access to training to enable them to fulfil their role.

Audits were now completed by both the registered manager and a representative for the provider on a regular basis. Where shortfalls had been identified action plans were in place to address these.

We last inspected Natalie House on 04 September 2015. At that inspection we found that the provider was meeting all the regulations but needed to make some improvements. This included ensuring that the local authority were informed of all allegations of abuse and ensuring that systems used to drive improvements and the management of risk were effective. We rated the service as Requires Improvement. At this inspection we found that the provider had not made all the improvements needed and had not demonstrated that they had effective systems in place to monitor the service and drive up improvements.

Natalie House is registered to provide accommodation and support for up to five people with a learning disability. On the day of our inspection there were five people living at the home. This was an unannounced inspection.

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.

Systems in place to monitor and improve the service had not been effective in making the required improvements. Systems in place for record keeping were not robust and could not demonstrate safe requirement practices and risk management. You can see what action we told the provider to take at the back of the full version of the report.

Staff had not received sufficient training and supervision to ensure they had up to date knowledge and skills to provide safe care.

The staffing arrangements did not ensure that safe levels of staffing were provided at all times of the day.

People were protected from the risk of abuse because the provider ensured that staff had received the training they needed so that they could recognise and respond to the risk of abuse.

People were supported by staff that were kind and caring and who took the time to get to know people. People were cared for by staff that protected their privacy and dignity and respected them as individuals.

People received care and support with their consent where possible, and the staff ensured that people were supported in the least restrictive ways in order to keep them safe.

People’s dietary needs were assessed and monitored to identify any risks associated with their food and fluid.

People were supported to maintain good health because staff worked closely with other health and social care professionals when necessary.

People were supported to receive their medication as prescribed because the provider had systems in place.

We last inspected Natalie House in June 2014. At that inspection we found the provider was meeting all the regulations.

Natalie House is registered to provide accommodation and support for up to five people with a learning disability. There were five people living at the home when we inspected.

Natalie House is required to have a registered manager. 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 the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A registered manager was in post.

Staff had received training in how to safeguard people against the risks of abuse. They were able to describe with confidence what constitutes abuse and the reporting procedure they would follow to raise their concerns. Whilst the provider took action to protect people from abuse they had not informed the local authority of all allegations as required. People’s relatives and staff said the registered manager was approachable and available to speak with if they had any concerns.

Not all care plans and risk assessments for keeping people safe were accurate and up to date. These risks were reduced because staff knew people well. We reviewed the systems for the management of medicines and found that people received their medicines safely.

We received some mixed opinions from staff about the staffing arrangements in the home. Whilst staff did not raise any concerns about people’s safety in relation to staffing levels some staff told us that it was difficult to provide the level of care needed when only two staff were on duty.

We saw that people who used the service were treated individually and that staff were considerate towards them. Most staff had worked at Natalie House for a long time and told us they enjoyed caring for the people who lived there. There was evidence that staff training was provided and including specific training relevant for the needs of the people who lived at the home.

People had been supported to stay healthy and to access support and advice from healthcare professionals when this was required.

Some records required for the effective running of the service were not available or up to date. Systems used to quality assure services, manage risks and drive improvement were not as effective as they could have been.

We visited Natalie House and carried out an inspection there. On the day of our inspection, the registered manager told us that five people lived there. We met all five people. However, none of the people were able to share with us their views about their care due to their individual needs. Most people that used the service had limited verbal communication skills so we also observed their interactions with staff and their body language to understand their view of the support they received. We looked at recorded information for four people to gain a balanced overview of the quality of the care and support people who lived there experienced. Following our inspection we spoke with two relatives. We considered all of the evidence that we had gathered under the outcomes that we inspected. We used all the information to answer the five questions that we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We observed that people were treated with dignity and respect by the care staff. We saw that people were given choices about their care. All relatives that we spoke with told us that they were very happy with the care at the home. One relative said, “They are wonderful. My relative has a busy life. They go away on holiday every year. They are very well cared for. My relative is safe in their hands at all times.”

Records sampled showed that the provider had systems in place to establish whether people had capacity to give their consent to receiving care and were able to make informed decisions. We spoke with staff and the registered manager about Deprivation of Liberty Safeguards (DoLS). This applies to all care homes. All staff spoken with told us and records sampled showed that all staff had received DoLS and Mental Capacity Act (MCA) 2005 training and which meant that they understood their responsibilities and ensured that the rights of people were protected.

The provider had policies and procedures in place to protect people from harm. Some people had complex support needs, with some difficult to manage behaviour. All staff spoken with understood what safeguarding people meant. All staff had up to date training on how to protect vulnerable adults and how to support a person when they displayed behaviours that may harm themselves or others. This meant that the safety of people who lived there and of others was promoted and protected.

We saw that people had an assessment of their needs and associated risks. A plan of care was completed which enabled staff to offer care and support to people in a safe way. Staff told us and records sampled showed that they had received training and support to enable them to deliver care safely.

We saw that systems were in place to make sure that learning takes place from accidents, incidents, complaints and investigations. This reduced the risks to people and helped the service to continually improve.

Is the service effective?

Both of the relatives that we spoke with confirmed that they could visit throughout the day. We saw that facilities were available so people could meet in private if they wanted to.

We saw that staff asked for peoples consent before care and support was given and that their responses were listened to and their choices respected. Where people did not have mental capacity to consent, care was provided by staff in their best interests. Records sampled showed that the provider had appropriate systems in place to ensure that people’s mental capacity to consent to their care was documented. This meant that people could influence the care they received.

We saw that relatives were involved with people’s care. A relative told us, “They always ensure that my relative’s health care needs are well met, they involve other health professionals and inform me of what is happening.”

All staff spoken with were able to give us good detail about the support they provided to people. People’s health and care needs were assessed and care plans told staff what people’s care needs were so they could support people consistently. Referrals had been made to external professionals so people got the support they needed to maintain their health and wellbeing and we saw that staff followed their advice.

Records sampled showed that people were encouraged to eat a healthy and nutritious diet. We saw that they had a choice of what to eat and enjoyed the food provided. Their weight was recorded regularly. This is important as a significant loss or gain of weight could be an indicator of an underlying health need. This meant that people were supported to eat and drink sufficient amounts to meet their needs and ensure their health and wellbeing.

Is the service caring?

We saw that staff treated people with dignity and respect. We saw that were patient and caring they took their time and did not rush people. Staff were seen to be attentive and interacted well with the people they supported. We saw that people responded positively to staff.

People, their relatives and other professionals involved with the service had completed an annual satisfaction survey. We saw that relatives had made positive comments in the surveys we looked at. A health professional visiting on the day of our inspection said, “The staff have worked very closely with our team to assess and establish my client’s communication support needs. We have seen a big improvement in their ability to express themselves since they moved here. Staff have consistently followed our advice with patience and commitment.”

People’s preferences, interest and aspirations and diverse needs had been recorded in their care records.

Is the service responsive?

We saw that people were supported to take part in a range of activities at home and in the local community. We saw that staff responded to people’s positive responses to individual activity choices and used positive or negative responses to help inform future activity choices. This enabled people to do activities, or to spend their time in a way that they preferred. People had also been supported to go on holiday.

We saw that when needed staff had requested the involvement of other health professionals in people’s care and their advice was followed.

Is the service well lead?

The home had a manager who was registered with us, CQC. They were experienced and knowledgeable about the needs of the people that lived in the home.

We found that robust systems were in place to regularly assess the quality of the service that people received. Records showed that regular spot checks on staff skills and work practices were by carried out by the manager. We sampled the findings and saw that they were detailed and feedback was provided to staff following these checks. Supervision and training records showed that supervision and staff training was regular and up to date. This ensured that people received care from staff that were suitably skilled to deliver care and feedback was continuously given on their performance.

All staff that we spoke with were clear about their role and responsibilities. They had a good understanding of the ethos of the home and the systems in place to monitor quality assurance. This ensured that people received good quality of care.

When we inspected, five people lived at the home. We met all five people. However, none of the people were able to share with us their views about their care due to their individual needs we used different ways to evidence their experiences. We observed their care, looked at their records and spoke with four staff. Following our inspection we spoke with two relatives.

Staff asked for peoples consent before care and support was given. Where people did not have mental capacity to consent, care was provided by staff in their best interests. Records sampled showed that the provider did not have appropriate systems in place to ensure that people’s mental capacity to consent to their care was documented.

Care was planned and delivered to ensure people's safety and welfare. External health professionals such as, consultants, community nurses, physiotherapists and dieticians were involved in their care so that people's health care needs were monitored and met. One relative spoken with said, “They are simply wonderful. My relative has a busy life and has just been on holiday. They are very well cared for.” We saw that people were involved in a variety of interesting activities such as bowling, swimming and visits to local attractions.

People were cared for by a stable staff team who knew them well, who were supported, supervised and trained to deliver care to an appropriate standard and were suitable to work with vulnerable people.

People received their medicines as prescribed by their doctor to ensure their health needs were met.

There were systems in place to monitor the quality and safety of the service to ensure that people were experienced good quality care.

There were four people living at the home when we visited. We observed how people were cared for to understand their experiences. People were not able to tell us what it was like to live at Natalie House.

Staff interacted well with the people who lived there. We saw they treated people with dignity and respect. People were relaxed and happy with the staff supporting them. Attention had been given to their appearance and personal care and they were dressed in individual styles.

We saw people enjoyed going shopping or to other places. One person’s relative said, “My relative goes somewhere interesting nearly every day. The staff here are wonderful and do as much as possible to make life good.”

Care plan records were up to date and provided staff with all the information they needed to be able to meet people’s needs safely and appropriately. People were referred to other health care professionals and staff followed their advice to ensure that people's health needs were met.

Before staff started working, appropriate checks were done to ensure they were suitable to work with the people living there.

Staff received the training they needed so that they knew how to support people who lived there safely and ensure their well being.

Management audit systems and quality assurance checks were in place to audit the safety and quality of care. People consulted with were complimentary about the care people received.

We met all four of the people living at Natalie House during the time of our visit. People were not able to tell us about their experiences of living in the home, as they all had communication needs linked to their learning disability.