56 Sycamore Grove is a care home for three people with learning disabilities. 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.

This is the first time this service has been given an overall rating of Requires Improvement. At the previous inspection dated November 2015 we rated the key question Safe as Require Improvement. We found that risk assessments were devised over significant periods of time which the registered manager had signed annually as ongoing. Action to improve this key question from Requires Improvement to at least Good is now required.

This inspection took place on the 28 February 2018 and was unannounced.

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. Registering the Right Support CQC policy

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.

Quality Assurance systems were in place, but areas identified as requiring action had not been prioritised or completed. The registered manager had self-assessed how set outcomes were being met. We saw the registered manager had indicated that all standards were met in the self-assessment, dated December 2017. Action plans were devised and included “re-formatting” care plans, having keyworker meetings, assessing staff competency with medicines and developing questionnaires to relatives. The area manager had conducted an assessment of the set outcomes in January 2017 and had recorded “plan to review and re-write care plans”. While we acknowledge the staff and people went through a period of instability, no action was taken in relation to “re-formatting” care

Although people’s records were securely stored, they were not complete or up-to-date. Risks assessments were devised over a significant period of time, which the registered manager signed and dated to indicate they were reviewed annually. At the inspection of November 2015, we said “where risk assessments were in place they had been devised over a significant period of time” and were not updated in that period. While the risks identified may be ongoing, there was little consideration given to changes of legislation and good practice that have occurred in the meantime. This meant no action had been taken to improve the guidance to staff on how to minimise risks.

The staff we spoke to were knowledgeable about people’s individual risks and the actions needed to minimise the risks. Individual risks to people included self-harm risk of malnutrition and mobility impairments. Some risk assessments lacked detail and were inconsistent with information held in care plans. For example, the risk assessment for one person with a mattress monitor was missing.

There were people who expressed their anxiety and frustration using aggression. Staff told us and training records confirmed that staff had attended positive behaviour management training. For one person there were a number of behaviour management strategies which had been devised over ten years and had been reviewed annually as current. Risk assessments were not reviewed although the person had continued to express their anxiety and frustration. Strategies were not reviewed to assess that appropriate action was being taken to minimise the risk of self-harm to the person.

Care plans did not full

Ordinary Life Project Association - 56 Sycamore Grove is registered to provide accommodation and support to three people with a learning disability. The home was last inspected in April 2014 and was found to be meeting all of the standards assessed. At the time of the inspection three people were living at the home.

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.’

People were enabled to make day to day decisions. They were not subject to continuous supervision in the home but needed staff supervision in the community. Deprivations of Liberty Safeguards (DoLS) applications were made to the supervisory body for some people who needed staff supervision in the community. Where there were concerns about people’s ability to make specific decisions Mental Capacity Act (MCA) 2005 assessments were undertaken. MCA assessments lacked detail for people who had fluctuating capacity to make decisions. Decisions for supporting people with some behaviours were taken by the staff without consideration to the principles of the MCA (2005). This meant the MCA 2005 legal framework was not in place to make best interest decisions.

Risk management systems enabled people to take risks safely. Where risks to people’s health and wellbeing were identified, action plans were developed to minimise the level of risk. However, risk assessments had been devised over a significant period of time. They were signed to say they were reviewed but not updated. This meant changes in legislation and best practice were not considered. Also risk assessments were not in place for all risk for example, audio listening devises for people who experience epilepsy seizures.

Safe systems of medicine management were in place. People said the staff administered their medicines. Members of staff signed the medication administration records (MAR) charts to show they had administered medicines as prescribed. People were taking over the counter medicines such as pain relief, vitamins and supplements over long periods of time. Protocols which gave staff guidance on when to administer over the counter remedies were in place. This meant people using homely remedies over long periods of time may have a persistent illness that requires attention from a healthcare professional.

Sufficient numbers of staff were deployed to meet people’s needs. People told us there were sufficient staff on duty for them to have the attention they wanted. They said the staff were caring and their needs were met by staff who knew their likes and preferred routines. People described how staff respected their privacy and dignity.

People said they felt safe living in the home. Members of staff knew the signs of abuse and the actions they needed to take for suspected abuse. Safeguarding adults procedures were in place for staff’s reference.

Recruitment procedures in place ensured that the staff working at the home were suitable to work with vulnerable adults. Records of the checks and processes followed lacked detailed. For example, the quality of the references received and the correct legislation which covered employment of staff working at the home.

People benefitted from staff that were trained and supported to meet the roles and responsibilities. The induction prepared new staff them to undertake their role at the home. They said the induction provided was detailed. Staff received training which enabled them to develop their skills to meet people’s specific needs. One to one meetings with the registered manager to discuss concerns, training needs and performance were regularly held.

The dietary requirements of people living at the home were catered for. People participated in men

A single inspector carried out this inspection. 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 is based on our observations during the inspection, speaking with people who used the service, the staff who supported them and from looking at records. We reviewed three people’s records and other records; we spoke with two people who used the service, three staff including the Registered Manager (RM) and the Human Resource’s (HR) Manager, about the service.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The Registered Manager (RM) who told us that there were four full time and one part time permanent members of staff employed at the home, including herself. The parent organisation, Ordinary Life Project Association (OLPA) had a bank staff group and this was used to supplement the staffing when needed. When there were three people at the home, then there would be ordinarily three staff on duty each day, with one staff member completing a night (sleep) duty. Because there were at that time just the two people, the staff number had been reduced to two. The RM told us that staff numbers fluctuated according to the needs and number of the people living in the home. All staff received induction training and had to complete various other training courses each year. This meant that people were safely supported by sufficient and appropriately trained staff.

Risk assessments were made for things such as riding in the front seat of a car, holding the bedroom room key, using a walking aid, or a bath hoist. Solutions had been identified to some of these issues or, the means to minimise risk had been identified. There were ‘Personal Emergency Evacuation Plans’ for every individual in the home.

Safeguarding procedures were followed and the men living in the home knew who to contact, both internally and externally, if they were concerned about any form of abuse. The staff recruitment files we read had all been appropriately compiled and contained the various checks and references needed for safe recruitment.

People we spoke with told us that they felt safe. The men we spoke with had had limited verbal communication skills but their reaction to questions and conversation was evident by their brief verbal responses, physical nodding or shaking their head and their facial expressions. The house was calm and welcoming. Each person had a key to his room. The care we witnessed was caring and appropriate and staff had been trained in safeguarding adults and behaviour and anger management. The men living in the home had their own key worker and had one to one meetings each month with them. Part of the meeting was a reminder of who they could contact if they felt concerned about anything.

People’s health needs were documented with information on how best to manage those. 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 have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

The service aimed at providing accommodation for people with learning difficulties in an ordinary residential setting. This had been achieved through the siting of the home within a quiet residential suburb of Trowbridge. People living at 56 Sycamore Grove were able to go out and mix with the community, attend coffee morning and go to art classes, for example. This meant that the aims of the organisation which supported the people living in the home were met. The people living there told us they were happy with the activities they had each week.

The care plans were informative, comprehensive and appeared thorough. There had clearly been a contribution from the people for whom the care plan was about. They were available in easy read format so accessible by the people with learning difficulties who lived in the home.

We saw that staff understood the care as detailed in the plans and used the information there in their everyday care of the people living in the home.

Is the service caring?

We found that the home had developed comprehensive and informative care plans, much of which were also available as easy read documents. People had been enabled to give their consent and involvement in the design, development and review of the care plans. The care detailed within these documents we saw was practised and the two residents we spoke with told us that the staff were caring and they were very happy living at 56 Sycamore Grove and. We saw that people’s choice and dignity was respected and we heard this in conversations people had with staff. Staff were quietly spoken but very communicative with the men. People living in the home were supported and encouraged to participate in a range of outside activities and learning opportunities.

Staff were observed to be caring and positive in their interactions with people very communicative with them. Respect for choice was evident in all of the conversations we heard.

Is the service responsive to people’s needs?

People’s preferences were recorded in their care plans and they were able to make choices about what they wanted to do, or eat, on a daily or weekly basis. An example of this was the weekly residents meeting held each Sunday. One of the things discussed was the following week’s menu. There was a photograph album of a large range of dishes to choose from. This would be decided and a shopping list drawn up for the Monday. People would be supported by staff to shop and in some cases to prepare the food for the menu. Some of the men had attended a course at the local college to improve their cooking skills. Baking was particularly popular. If a person did not want to be involved, then that was respected. If someone changed his mind about their meal preference, then alternatives were available.

People living in the home were also offered alternative activities as these presented themselves. Where people had a desire to do something, the RM tried to meet this. For example, a resident told us that he wanted to go on ‘proper’ holiday as opposed to spending time at a relative’s home. The RM told us that she would try to find out what he wanted. She also told us there were various charities they had used to help people with learning disabilities, to holiday and travel. We saw notes within the care plans that some men had visited places abroad.

Is the service well-led?

The home had a stable staff establishment and was managed by a RM who had been in post several years. The RM appeared knowledgeable, informed and up to date with her client group and was aware of evidence based knowledge available. She kept good records and helped develop her staff to become more skilled by ensuring that they had training opportunities available.

There were quality checks by managers and issues which arose from the monthly residents meeting were incorporated into action plans. The RM was instigating better quality checks to incorporate other stakeholders such as GP,s dentist, family members and other people involved in the care of any person living at 56 Sycamore Grove.

The RM was supported by the parent organisation, OLPA and we also talked to the HR manager for them, who delivered the staff files for us to view. This manager was very supportive of the home and was very aware of the responsibilities of a corporate provider.

On the day of our visit we met with the three people who lived at the home. People we spoke with did not tell us whether they were happy living at the home. However, we observed people were relaxed and comfortable in the company of the staff.

We met three staff and the manager during our visit. We noted staff were knowledgeable about people’s needs and how they should be met to ensure their wellbeing. Staff told us they received training, which was appropriate to the needs of the people who used the service.

People were involved in making decisions about what they ate.

We looked around the home and saw it was suitable for the needs of the people who lived there. The communal areas were spacious and accessible for all people. One person invited us to see their bedroom. They told us they were happy with their room.

Staff we spoke with said they were well supported by the manager and the provider. They said they received regular formal supervision with their manager. They added they could also have an informal chat, if they needed support or advice. We saw regular staff meetings had taken place. Staff said their views were listened to.

Systems were in place to regularly monitor the service delivery. Monthly management visits were completed and an action plan put in place. Health and safety checks were in place and environmental risks were assessed to ensure people using the service and staff remained safe.

People told us they were treated respectfully by staff. Each person said that they felt safe and liked living at Sycamore Grove.

We observed staff caring professionally throughout the visit. Their calm attitude produced a relaxed and happy atmosphere.

The care records were an accurate reflection of people's support needs and described how those needs were to be met. Information was written respectfully and clearly recorded to provide good continuity of support at all times.

There were systems in place to ensure people were supported to make informed decisions about their daily lives.

Where people had a concern or complaint, it was dealt with straight away with people being supported throughout the process.

People had their own interests and links in the community, which they were supported to maintain. For example, one person went regularly to a country park and another enjoyed going to a cyber café. People were supported to make choices, such as when and where they wished to eat. At weekends people generally spent a lot of time away from the home, with their families.

We saw that people had the space to have their own things around them. Bedrooms reflected people’s interests. One person looked after a rabbit in the garden. People were supported to keep their rooms as they wished, and to play a part in everyday housekeeping tasks.

Each person had a health action plan. We could see that people had been very involved with staff in putting them together in ways they could understand. One person showed us a new walking aid that had just been delivered for them. This was as a result of the person and staff working together with outside professionals to improve how they got around independently.

People told us they had a meeting on Sunday mornings to decide their menu and shopping needs for the week ahead. We saw that people could get snacks and drinks when they wished. People said they enjoyed their meals.

They were sometimes involved in cooking. When we visited, a person had been supported to bake biscuits in the morning.