This inspection took place on 21 and 29 August 2017. Bisley Drive is a short-break service providing care and support for people with a learning disability, some of whom may have physical disabilities. The service can accommodate up to seven people.

A manager was in place and they had applied to become registered with the Care Quality Commission. 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.

At the last inspection in June 2016 the service was not meeting all of the legal requirements. People were not always protected from the risks of inappropriate care because care records were not always complete to ensure their needs were met and people were at risk of being deprived of their liberty without proper authorisation. At this inspection we found improvements had been made and the service was no longer in breach.

Care plans were individualised and contained comprehensive personalised information about the person and their preferences.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice.

People were supported to make decisions about their care and support and staff obtained their consent before support was delivered. The service was able to assist people to access an advocacy service where people had no family or personal representative.

Staff we spoke with were knowledgeable about the people they supported. They were aware of their preferences and interests, as well as their health and support needs.

The provider ensured the right mix of staff with appropriate knowledge and experience were readily available to make sure people’s needs were met.

Staff had received safeguarding training and were knowledgeable about how to protect people from abuse.

The provider continued to maintain an effective recruitment process. People were involved in the selection and interviewing of potential new staff members.

Training and development was up to date and staff told us they received regular supervisions and appraisals.

Where risks were identified they were assessed and managed to minimise the risk to people who used the service and others.

The provider had a thorough continuity plan in place to ensure people would continue to receive care following an emergency. Checks were in place to maintain the safety of the home.

People were supported to receive their medicines in a safe manner. Medicines records we viewed were complete and up to date.

Feedback was sought from people, relatives and staff in order to monitor and improve standards.

People were provided with a choice of healthy food and drinks to help ensure that their nutritional needs were met.

Relatives and people told us staff were kind and caring. We observed many happy interactions between staff and people living at the service, people were comfortable in the company of staff.

The service planned activities around the wishes of people staying at Bisley Drive. Staff told us they ran the service like a hotel.

The service had an easy to read complaints and compliments procedure was in place. This explained how to make a complaint and what would happen.

Staff told us they felt supported by the manager.

The last inspection of this care home took place on 18 September 2014. The service met the regulations that we inspected at that time.

This inspection took place over 21, 27 and 30 June 2016. We gave the service 24 hours’ notice about the visit.

Bisley Drive is a short-break service providing care and support during a holiday-style stay for people with a learning disability, some of whom may have physical disabilities. The service is registered to provide seven places. There were five people staying there at the time of this inspection. The service does not provide nursing care.

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

For some people there were no capacity assessments or best interest decisions recorded for restrictive practices, for example use of bedrails or wheelchair straps. This meant they were potentially restricted without the proper authority to do so.

Some people’s individual care records did not accurately reflect their needs or were incomplete. This meant that it was not always possible to be clear if a person was supported in the right way.

During this inspection we identified two breaches of regulations. You can see what action we told the provider to take at the back of the full version of the report.

People said they felt safe and comfortable at the service. They said they enjoyed their holidays at Bisley Drive and regularly stayed there. A relative said, “My [family member] has been using the service for years. They like it and we’ve had no problems with it. They’re well looked after.”

People, relatives and staff felt there were always enough staff to help people to have an activity-based holiday. The registered manager said staff were “very accommodating” and flexible to work at short notice if more staff were needed to meet guests’ needs.

Staff were vetted before they started work at the service to make sure they were suitable to work with vulnerable adults. The staff managed people’s medicines in a safe way for them. Staff were clear about how to recognise and report any suspicions of abuse. There were clear systems for staff to be able to raise concerns.

People told us staff were “good” at their jobs and relatives told us staff were competent and skilled. One relative said, “The staff training is good. A lot of them have worked there for years and they’re very experienced – I can’t fault them.”

Staff told us they felt they received sufficient training to carry out their roles. One support worker told us, “I had lots of induction training before I even started. They make every course available to you and then mandatory training is annual.”

People’s views about the service were very positive. One person told us, “I like it very much. I really enjoy it.” Relatives told us, “All the staff are very nice,” and “it’s small and friendly”. One relative commented, “The atmosphere is very good. They keep it well decorated and furnished so it’s a nice place to stay.”

There were friendly relationships between the people who were staying there and the staff members. One person commented, “I really like the staff, they’re all lovely.” Staff felt their colleagues were caring and supportive towards people. One newer staff member told us, “I can honestly say I’ve never met a nicer group of care staff. They’re so patient and understanding.

People said there was a range of activities to choose from during their stay. People said they were asked what they would like to do before they stayed at the service and this was arranged for them. Relatives and staff felt activities could be a bit limited for some people since the service no longer had a vehicle.

People were able to show i

We spoke to three members of staff who spoke positively and without prompt regarding local management, training and working conditions. We observed a guest in the home interacting with staff. The person was treated with dignity, warmth and respect. We also found evidence of this by reviewing procedures such as the provider's statement of purpose, individual easy-to-read one page profiles of guests, activity plans and behaviour profiles. We viewed five private rooms and the communal areas in the home and found a safe, inviting and friendly atmosphere throughout. There was a large, bright and airy communal lounge, a dining room and a garden with a pet rabbit that was available for people to use for activities and relaxation. We reviewed the complaints procedure with the registered manager and found that there were no current complaints. The home had received thirteen unprompted written communications praising their service from people who used the servie and their family members.

People using the service and relatives were complimentary and spoke positively about the care provided at the service and staff. Their comments included; “I love it here”, “The staff are great” and “I like the food”.

People using the service and relatives were complimentary and spoke positively about the care provided at the service and staff. Their comments included; “Super, can’t wait to get here”, “The staff keep us informed” and “I love it”. Other comments included that they were "very happy" with the service provided by the staff.

The inspection team consisted of a lead inspector and an expert by experience who had experience of learning disability services. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five key questions; 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, speaking with the relatives of people at the service, staff supporting them, and from looking at records.

Is the service safe?

The service was safe. During the planning of this visit we received some concerns from a relative about the moving of staff from another of the provider’s locations to 18 Bisley Drive. People were concerned staff may lack accurate knowledge of the people they were caring for and families had not been properly consulted or involved before a decision was made. We were unable to substantiate and confirm these concerns at this visit.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no applications had been made to notify the CQC of issues involving the Deprivation of Liberty safeguards the home manager was aware of the recent Supreme Court decision to clarify what constitutes a deprivation of liberty. She agreed to re-assess all of the people using the services at 18 Bisley Drive and forward on any relevant notifications to the CQC. We saw a copy of the safeguarding adults policy and a guide for staff on how to report safeguarding incidents. Staff had received safeguarding training and understood how to safeguard the people they supported.

Is the service effective?

The service was effective. Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare, however not all of the support plans and risk assessments were signed by the person using the service or their representative and not all were signed and dated by all members of staff. We found that people who used the service were receiving the care and support they needed. The staff we spoke with could describe how they met the assessed needs of the people they were providing with care.

Is the service caring?

The service was caring. People were supported by kind and attentive staff. Relative’s feedback from surveys said “We think the staff are very caring and they have a good understanding of her needs.”

Is the service responsive?

The service was responsive. Records showed that people’s preferences, interests and needs had been taken into account and care and support had been provided in accordance with people’s wishes. People had access to activities that were important to them and were supported to maintain relationships with relatives and make new friends. People knew how to make a complaint if they were unhappy. One person told us “I am very satisfied coming here.”

Is the service well-led?

The service was well-led. The home was being managed by a person who had been in post since March 2014, and was collating all of the necessary documentation to submit her application to the CQC as the registered manager for this service.

The provider undertook regular audits to check the quality of service, including the views of family members and professionals responsible for the care of people. The provider may find it useful to note that some of the shift handover notes had not been fully completed and gaps we noted in some people’s records had not been picked up during the audit process.

The manager held regular team meetings with staff and asked people and their relatives their opinions on how the service was run. Regular checks of the premises took place to ensure it was safe and suitable for the people who lived there.