This inspection was announced and took place on 24 October 2017.

The provider was given 48 hours’ notice that we would be coming to inspect. This is because service is small home for people with learning disabilities who are often out during the day and we wanted to be sure that someone would be available.

4 The Stables is registered to provide care and support for four people who have a learning disability. It is owned by Royal Mencap Society, a national organisation who provide a variety of support services to people who have a learning disability. The house has been adapted to accommodate people who have restricted mobility. It is situated in a residential area of Crosby.

At the time of our inspection there were three people living in the home.

There was a registered manager in post, however they were not available at the service during our inspection. The area manager was available, and there was another manager who made themselves available as well as the deputy 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.

Staff we spoke with were clearly able to explain the course of action that they would take if they felt someone was being harmed or abused, and how they would report it, including whistleblowing to external organisations.

Medicines were well recorded and managed for people who required support. Assessments were completed to support people with their medication needs.

Risk assessments were clear, concise and explained the impact of the risk as well as how the staff should support the person to manage it. Risk assessments were regularly reviewed with the input of the people who used the service and their families.

There were enough suitably trained staff to meet their individual care needs. Staff were only appointed after a thorough recruitment process. Staff were available to support people to go on trips or visits within the local and wider community and attend medical appointments.

The deputy manager and the staff understood the principles of the Mental Capacity Act 2005 and associated legislation and had taken appropriate steps to ensure people exercised choice where possible. Where people did not have capacity, this was documented appropriately and decisions were made in their best interest with the involvement of family members and relevant health care professionals where appropriate. This showed the provider understood and was adhering to the Mental Capacity Act 2005.This is legislation to protect and empower people who may not be able to make their own decisions.

The provider was meeting their requirements as set out in the Deprivation of Liberty Safeguards (DoLS). DoLS is part of the Mental Capacity Act (2005).

Care plans with regards to people’s preferred routines and personal preferences were well documented and plainly written to enable staff to gain a good understanding of the person they were supporting. Care plans contained a high level of person centred information. Person centred means the service was tailored around the needs of the person, and not the organisation.

We discussed complaints. There had been no complaints in the home in the last 12 months.

Quality assurance procedures were robust and identified when actions needed to be implemented to drive improvements. We saw that quality assurance procedures were highly organised and processes had been implemented from another internal source to help support the service to continuously improve. We were shown these procedures by the deputy manager during our inspection.

Feedback had been gathered from people who used the service in the form of questionnaires, telephone conversations with families and when family members visited the ho

This inspection took place on 31 August 2016 and was announced.

4 The Stables is registered to provide care and support for four people who have a learning disability. The house has been adapted to accommodate people who have restricted mobility. It is situated in a residential area of Crosby.

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.

Medicines were not always administered in accordance with best-practice guidelines. There was no clear description or instructions for staff to assist them in establishing if the PRN medicine was required. Additionally, the service did not make use of body charts to indicate where topical medicines (creams and lotions) should be applied.

We have made a recommendation regarding this.

The registered manager implemented an approach to quality monitoring which was appropriate for the size of the service. The quality team also completed annual checks on the service. We saw that this process had been completed. However, none of these checks had identified the issues relating to the administration of medicines noted during the inspection.

The registered manager told us that open communication with families and staff was encouraged at all levels. However, some staff expressed concern about the consistency of management responses and said that they were sometimes reluctant to raise concerns.

Staff were vigilant in monitoring people’s safety and family members spoke positively about the safety of their relatives. Staff clearly understood the different types of abuse and neglect and what signs to look out for. Staff also knew what action to take if they suspected that abuse was taking place.

Risk to the people living at the service was appropriately assessed and recorded in care records. Each risk assessment focused on maximising people’s independence while safely managing any risks and had been recently reviewed.

Staff were safely recruited and deployed in sufficient numbers to meet the needs of the people living in the service. There was a minimum of two members of staff per shift with extra provision depending on activities. However, the registered manager acknowledged that the service regularly relied on staff undertaking overtime and used staff from other services to ensure that adequate staff cover was provided.

Staff were trained in a range of subjects which were relevant to the needs of the people using the service. New staff were required to complete an induction programme which was aligned to the Care Certificate. Staff were supported by the provider through regular supervision and appraisal. We saw from records that this had been delivered as planned. However some staff told us that they did not always feel well supported.

People’s ability to consent to care had been assessed and recorded. DoLS applications had been submitted in accordance with good practice within the previous 12 months.

Staff had been trained to ensure that people received their food and drink in a safe manner. The people living at the service were not always able to demonstrate a preference for a particular meal or drink, but staff knew from experience what people preferred and provided food accordingly.

People’s day to day health needs were met by the services in collaboration with families and healthcare professionals. Staff supported people at healthcare appointments and used information to update support plans.

Throughout the inspection we observed staff interacting with the people living at the service in a manner which was kind, compassionate and caring. We saw that staff spoke regularly with the people living at the service. They explained what they were doing and discussed their need

We carried out an unannounced comprehensive inspection of this service on 7 & 8 May 2015 when three breaches of legal requirements were found. The breaches of regulations were because there was a lack of maintenance and management of risks associated with health and safety; procedures were not in place to obtain valid consent to care and to adhere to the principles of the Mental Capacity Act 2005 and effective systems or processes to assess and monitor the service were not in place.

We asked the provider to take action to address these concerns. After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches.

We undertook a focused inspection on 22 September 2015 to check they now met legal requirements. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover three of the domains we normally inspect; 'Safe', ‘Effective’ and ' Well led'. The domains, 'Caring' and 'Responsive' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Royal Mencap Society - 4 The Stables on our website at www.cqc.org.uk.

We announced this focused inspection to ensure someone was in, as people who live at the care home, and the staff, go out from the home most days.

Royal Mencap Society - 4 The Stables is registered to provide care and support for four people who have a learning disability. It is owned by Royal Mencap Society, a national organisation who provide a variety of support services to people who have a learning disability. The house has been adapted to accommodate people who have restricted mobility and is situated in a residential area of Crosby.

At the time of the inspection the home had a new 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 and associated Regulations about how the service is run.’

At the last inspection on 7 & 8 May 2015 we found a lack of maintenance of the environment and poor management of risks associated with health and safety. At this inspection we found that action had been taken to improve the maintenance and management of risks associated with areas such as, legionella compliance and fire safety. Work was on-going to improve the standard and décor of accommodation and upkeep of the grounds.

At the last inspection we found a lack of staff knowledge around the principles of the Mental Capacity Act (MCA) 2005. In particular this was around decisions being made for people in the home and whether restrictions to people’s freedom might amount to a deprivation of liberty. At this inspection we found improvements had been made and staff were adhering to the principles of the MCA to help protect people who may not be able to make their own decisions, particularly around their health care. The manager agreed to undertake further work around monitoring this process to ensure areas such as, consent and assessing people’s mental capacity was recorded, to fully protect people.

At the last inspection we found systems and processes were not effective to assure the quality of the service. At this inspection we found improvements had been made as internal systems and checks on the service were in place to monitor the quality of the care and standards were in place to help improve practice.

A new registered manager was in post and feedback from staff about the management of the service was positive. The new manager and the changes being made would suggest the provider was actively addressing the concerns we found at the last inspection and on-going improvements found now need time to embed.

Feedback was now sought by the manager from relatives regarding how the service was operating and discussions were being held with relatives around the support needs of their family member.

People who lived at the care home appeared comfortable and relaxed in the presence of the staff.

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People living at the Stables had complex needs and most had lived at the service for a long time. When we visited there were four people living at the home. Most people had limited verbal communication, however the staff working at the service were able to understand people's needs and choices and there was evident warmth and respect between the staff and the people who lived at the home.

At the previous scheduled inspection in January 2013, we found the home to be non compliant in the safe management of medicines. We therefore conducted a follow up inspection at this time, to check up on the improvements the provider (owner) had made regarding how medicines were managed. We also followed up on the action plan, which the provider sent to us after the January 2013 inspection. This told us the actions they had taken to ensure compliance in medicine management.

We did not meet any people who lived at the service, as they were out on a day trip during the time we were there. We met with two staff to discuss what arrangements were in place to support people with their medicines.

At this inspection we found improvements had been made, so that people's medicines were managed safely. This included the safe storage of medicines in people's individual medicine cupboards and accurate records of medicines in the home. People were therefore protected from the risks associated with the unsafe use and management of medicines.

During our visit we met with three people who lived at the home. Due to the different ways that the people communicated we were not able to directly ask them to tell us about the home. We observed good communication and understanding between the members of staff and the people who received care and support from them. Signs, pictures and symbols were used by the staff to support people to ensure effective communication and so people had the information they needed to make decisions and be involved with their care. People were supported to express their views in their own way.

We observed people being supported with their daily life activities. The people we met with appeared relaxed, comfortable and at ease with the staff. There was positive interaction between the staff and people who lived at the home. It was evident staff had a good understanding of what was important to each person, how they provided care and support and also ensured people's independence was promoted. Care documents recorded people's care needs and provided the information staff needed to support them.

People were not protected against the risks associated with medicines because there were not appropriate arrangements in place to safely manage them.

Staff received training to ensure they had the skills and knowledge to work safely.

A complaints policy and procedure was in place should people wish to make a complaint about the home.

This announced inspection of Royal Mencap Society - 4 The Stables took place on 7 & 8 May 2015.

Royal Mencap Society - 4 The Stables is a care home offering a service to four people who have a learning disability. The home is owned by Royal Mencap Society. The home is situated in a residential part of Crosby with close links to public transport links and local community facilities.

The home is a bungalow and has a large lounge with dining space, bathroom, kitchen and a garden to the rear. There is car parking space on the front drive and on the main road.

The service did not have 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 organisation had appointed an experienced internal manager as the new acting manager for the service. The acting manager was aware they needed to apply to the Care Quality Commission (CQC) for the position of registered manager.

People appeared comfortable and relaxed with the staff. A relative told us their family member was safe living at the home.

The staff we spoke with told us they had received safeguarding adults training and were aware of what constituted abuse and how to report an alleged incident.

Our observations showed people were supported by sufficient numbers of staff.

People took part in different social activities, some of which were organised social events in the community. Relatives however raised concerns about the current staffing levels and the impact this had on arranging social activities.

We saw the necessary recruitment checks had been undertaken to ensure staff employed were suitable to work with vulnerable people.

Medicines were administered safely to people. Staff received medicine training and had their medicine practice checked to help ensure they had the skills and knowledge to safely administer medicines.

We found a lack of maintenance of the premises and management of risks associated with health and safety.

Care files showed staff had completed risk assessments to assess and monitor people’s health and safety.

People at the home were supported by the staff and external health and social care professionals to maintain their health and wellbeing.

The acting manager informed us people who lived at the service needed support to make decisions regarding their care. We found staff were not always following the principles of the Mental Capacity Act (2005) for people who lacked capacity to make their own decisions. There was lack of consent around aspects of care and treatment.

People’s nutritional needs were monitored by the staff. People were offered a good choice of meals in accordance with individual need and choice.

Staff told us they were supported through induction and on-going training. We saw formal supervision and appraisals with staff had not taken place recently.

Staff had a good knowledge of people’s care needs and support was provided in accordance with their support plan.

We observed a good rapport between the staff and people who lived at the home. Staff were polite, patient, attentive and caring in their approach; they took time to listen and to respond in a way that the person they engaged with understood.

The home had an acting manager in post. We received positive feedback about the acting manager from relatives and staff. Staff told us the acting manager was approachable and always at the end of the phone.

Staff were aware of the whistle blowing policy and they told us they would use it if required. Staff said there was an ‘open’ culture in the home and they were able to speak with the acting manager if they had a concern.

Feedback from people who lived at the home and relatives appeared to be limited. Relatives told us they would like to attend relative meetings and be more involved with the service.

On inspection we found there were breaches of regulations in respect of some standards. Although there were systems and processes to assess the quality of the service provided we found that these were not effective.

You can see what action we told the provider to take at the back of the full version of this report.