This unannounced inspection took place on 25 January 2017. Warren Farm Road provides care and accommodation for five people who have sensory impairments and learning disabilities. The service was last inspected in November 2015 where we found that the registered provider was breaching regulations in relation to the assessing, monitoring and improving on the quality of the service. Following that inspection the registered provider sent us an action plan detailing action they would take to address the breach. At this inspection we found that improvements had been made and the provider was no longer breaching the regulation.

There is a registered manager at the service who was present throughout 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.

People living at the home were safe. Staff had a good knowledge of signs of abuse and the correct safeguarding procedures to follow. There were sufficient staff available to support people when they needed staff support.

People received their medicines safely. Staff received training and their knowledge and skills were checked to make sure they were safe to support people with their medicines. We saw staff supporting people with their medicines in the way they preferred.

Staff had received sufficient training to ensure they had the knowledge of how to support people. We observed staff using different skills to support people such as using specific communication techniques.

People were supported to make daily choices about their care. Staff understood how to support people under the Mental Capacity Act (2005) and provided care in people’s best interests. Where there were restrictions on people’s care the provider had ensured authorisations were in place to deprive people of their liberty.

People received meals of their choosing. People had their healthcare needs monitored regularly and changes in healthcare needs were responded to appropriately.

Our observations during the inspection showed us that staff knew people well and relatives we spoke with informed us they were happy with the care their relative received. We observed kind and relaxed interactions between people and staff.

People had care plans developed with people who knew them well. Care plans detailed how people would prefer to receive their care. Staff we spoke with could describe how they supported people in a way they preferred. Care was reviewed regularly to monitor whether care was still meeting people’s needs. Where any changes were identified care records were updated to ensure staff had information to support people consistently.

People took part in activities based on their interests. There were new systems being introduced to increase the range of activities on offer which would enable people to have new life experiences.

There were systems in place for concerns or complaints to be made. Relatives felt able to raise any concerns they may have.

Relatives were happy with how the home was managed and staff felt supported in their roles and received opportunities to reflect on their practice. There were systems in place to continuously monitor the quality and safety of the service provided to people living at the home.

At our last inspection In December 2013 we found that improvements were needed in the ordering of medicines, the records accounting for medicines and the records of application of medicinal creams. We found the home's audit systems were not robust enough to ensure that errors were identified and rectified. At this visit we looked at all of the medicine stocks for each of the people who lived in the home and checked the storage and administration records. We spoke with the manager. People who lived in the home had sensory impairments and learning disabilities and were not able to tell us about their medicines.

Appropriate arrangements were in place to ensure that medicines prescribed were available and suitable to the individual person. People living in the home were not taking 'as required medicines' on a routine basis. Medicines were kept safely and disposed of appropriately when not required. Records were maintained of how people were supported with medicines, when these had been administered and any monitoring checks that were needed. Medicines were appropriately stored. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People living in the home were unable to tell us about the care they received. We observed how people were cared for to understand people's experience of care. We also looked at the environment to see if it met people's needs. We looked at records, spoke with three care staff and the registered manager. We also had contact with a social care professional and two relatives. Relatives told us: "I am extremely happy with the care and attention given to my (relative) by the staff at Warren Farm Road" and “The care (my relative) gets is very good."

Care plans were detailed and individual enough to ensure that staff could give people the care and support they needed. Staff used a range of methods to communicate with people throughout our visit with good effect. People were helped to have their nutritional and hydration needs met as described in their eating and drinking guidelines. Systems were in place to ensure that risks to people's safety and well-being had been identified and risks minimised. People were supported to experience a range of activities and to undertake some day to day tasks. People appeared well cared for, having their personal care needs met in an environment that supported them.

Improvements were needed to ensure that all medication was accounted for and that audit systems for medication identified any errors.

Appropriate checks were made before staff were recruited and staff were supported by supervision and relevant training. Relatives told us: "Not even once have I doubted the care provided by the staff" and "I have no concerns about the care given."

We visited this service on 19 June 2012 following concerns being raised with us about the management and the level of knowledge of the care staff. We found that improvements were needed in the supervision and training of bank staff and in the review of injuries to people living in the home. We visited on 15 October 2012 at 296-298 Warren Farm Road to review improvements. We found that there were enough members of care staff to support people living in the home. We looked at the recording of injuries to all of the people living in the home. We found that there was insufficient oversight of these injuries to ensure that opportunities to minimise the frequency and the effects of these were minimised.

At this visit we found that, in addition to action taken at the time of incidents and accidents, that there were regular meetings to discuss any further actions that may need to be taken to reduce the risk for the individual. The provider had ensured that staff had received further training so any emerging risks could be identified and action taken. We found action had been taken when risks had identified. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people that lived in the home.

We visited this service on 19 June 2012 following concerns being raised with us about the management and the level of knowledge of the care staff. We found that improvements were needed in the supervision and training of bank staff and in the review of injuries to people living in the home.

We visited on 15 October 2012 at 296-298 Warren Farm Road to review improvements. We found that some people were being assisted with their personal care and others being supported to eat. There were enough members of care staff to support people living in the home. Care staff displayed good skills in communicating with people who use the service and made use of differing communication tools. Arrangements were being made to ensure that people were ready to enjoy an external day time activity. Care staff knew who was in charge of shift.

We looked at records for two bank staff and found that they had received the training required. Bank staff used at the home were not having regular supervisory meetings; this could mean that their performance was not being adequately monitored.

We looked at the recording of injuries to all of the people living in the home. We found that there was insufficient oversight of these injuries to ensure that opportunities to minimise the frequency and the effects of these were minimised.

People living in this home were unable to tell us about the care and support they receive. We carried out a Short Observational Framework for Inspectors (SOFI) activity in the home's dining area. SOFI involved sitting and observing the interactions between people using the service and the staff providing care.

Through the observation we were able to make assessments about the quality of the interactions and whether people receiving the care were in a positive, negative or neutral mood. This observational activity is used where people are not able to tell us verbally about the care they are receiving.

We also spent time observing care in the lounge area of the home whilst looking at records. We also looked around the home.

We saw that people were spoken with kindly and supported in the way their care plan said. Care workers used different ways of communicating with people such as objects, communication cards and hand over hand signing. People had their personal care needs met and looked cared for.

We spoke with two of the five people's relatives. We spoke with two care workers, the registered manager and area manager for the service. We spoke to two health care professionals. Relatives were happy with the care provided. They said that no concerns about the care their relative received. They said that they were kept informed about the health of their relative.

On 19 June 2012 we had concerns raised with us about care workers' response to requests for information and staffing levels in the home. We visited the same day. We found that improvements were needed to be made in the supervision and record keeping for some staff. Where we found other improvements were needed the registered manager had identified these and had an action plan in place.

A professional responsible for the placements of one of the people living at the home told us "They had no concerns about the service. Good support was being given by individual carers. There were high standards at the home. They try to take X out on a daily basis in the community."

A professional who regularly visits the home told us "I definitely agree that the needs and choices of the individuals are met, the staff are great from what I have experienced and observed."

"The staff always seem to know the needs of the clients and follow my advice."

"I have no cause for concern at all with this home, it has been a pleasure to work with them as they seem to genuinely care about the clients and follow all advice that I give. The manager is respected and always knows what is happening with all of the clients."

A care professional told us " During an audit we spoke to staff, looked at care plans, staff ratio and environment. Found to be good. Parents happy with placement."

Relatives that we spoke to told us:

“People were supported to go and visit them.”

“They were taken on holidays.”

"Their bedroom was lovely."

"Have peace of mind. I know they are on the phone straight away if anything happens, good or bad."

"X is healthy. Gets medical help when she needs it."

"Had information about being able to make complaints. Never had to and can't see it happening."

They also told us that people were supported to go and visit them and that the home was clean.

One person told us that they used to go for family weekends. It was a shame they were not going to happen in the future.

Another person told us how the home had made lots of efforts to keep them involved in making decisions for the people living in the home.

We were told that peoples' cultural needs were being met at the home by providing the right care, food and taken to church.

This report provides details from two separate inspection visits which took place months apart. The first inspection was in April 2015 and the second inspection visit was in November 2015. We were unable to provide a report from the first visit but felt it valuable to provide summaries of both visits together with the judgements from the most recent inspection visit in November 2015. Both visits were unannounced. Prior to the April visit we had last inspected this service in March 2014 when the service had met regulations.

The home provides accommodation, care and support for up to five people with learning disabilities, physical disabilities and sensory impairments. People in this home were unable to tell us verbally about the care that they received so we observed how care was provided to people.

The registered manager had formally left the service in July 2015 but had yet to apply to cancel their registration with us. 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 line manager, (the area manager for the service), was managing the service on both of our visits in April and November 2015. We were told that a person had been identified to take over as a permanent manager and checks were currently being undertaken.

People were kept safe from the risk of harm. Staff knew how to recognise signs of abuse and who to raise concerns with. People had assessments which identified actions staff needed to take to protect people from risks associated with their specific conditions and they administered medicines appropriately.

People were supported by the number of staff identified as necessary in their care plans to keep them safe. However there had been significant number of changes in the staff that provided the care and relatives told us that they were concerned about this and had reported their concerns to the management team. There were robust recruitment and induction processes in place to ensure new members of staff were suitable to support the people who used the service.

Staff we spoke with had the skills and knowledge to ensure people were supported in line with their care needs and good practice. They told us that they had received support and guidance to ensure people received the best care.

Staff sought consent from people before providing any care or undertaking any tasks using the individual person’s preferred method of communication. Applications were made to the appropriate local authority where people did not have the capacity to make decisions about their care and treatment for their authorisation. We had not been informed before the inspection that one of these had been authorised as required.

When necessary, people were supported to eat and drink and access other health care professionals in order to maintain their health. However staff were not consistently showing that systems to ensure food was safe were being adhered to.

On both of our visits staff communicated with people well and people showed by their expressions that they were happy with the care they were receiving. However relatives were concerned about the amount of staff changes there had been. We saw evidence of this in the complaints book we could not find a response from the provider to these complaints.

People’s care plans were changed when their needs changed so staff had up to date instructions to follow. People were involved in a range of leisure activities some individual to them and some in groups. Although there were systems in place for handling complaints – that was not consistently applied, expressions a smaller concerns were not being managed and responded to consistently.

We had received a number of concerns about incidents in the home, the investigation process and ability of staff to raise concerns. Although staff we spoke with told us that there had been improvements in this we have continued to get concerns raised. This indicated to us that the management had not ensured that there was an open effective and safe environment for existing staff and relatives to be heard. Some systems were not identifying short falls in recording or changes in people’s health that needed investigating which meant that the service was not able to learn from or reflect on what was working well and what needed to improve.

The issues noted related to a lack of consistent management oversight and handling of day to day issues. The systems in place to assess, monitor and improve the quality of the service that the provider had in place had not been consistently used. In some instances where action had been taken to address issues the action taken had not been comprehensive and this had resulted in only partial solutions. You can see what action we told the provider to take at the back of the full version fo the report.