The Pastures is a residential care home that is registered for up to 13 people. On the day of our inspection visit it was providing care to 10 people with learning, physical and sensory disabilities.

This care service supported people in line with the values that underpin the Registering the Right Support and other best practice guidelines. These values include choice, promotion of independence and inclusion. People with learning disabilities using the service can live as ordinary a life as any citizen.

Audits and quality checks by the management team did not always result in improvements. Deficiencies identified in care plans by management audits had not been addressed in a timely way. Some staff and visiting professionals spoke of discontent in the staff team and differences in the care provided by different shifts in the service. Staff also spoke of concerns as to how work was allocated to care staff. The registered manager was aware of these concerns but on the day of our inspection visit action plans had not resulted in improvements.

Staff understood their responsibilities to protect people from abuse and discrimination. They knew to report any concerns and ensure action was taken. The registered manager worked with the local authority safeguarding adults’ team to protect people.

Staff were supported in their roles and received an effective level of training. We observed them supporting people in a caring and competent manner. Safe recruitment of staff ensured people were supported by staff of good character.

Staff promoted people's dignity and privacy. Staff provided person-centred support by listening to people and engaging them. People using the service appeared comfortable in the presence of staff.

The premises provided suitable accommodation for people with communal areas and bedrooms which were personalised to people's individual interests.

Support plans were detailed and supported staff to meet people’s assessed care needs. Staff worked with and took advice from health care professionals. People's health care needs were met.

People had a variety of activities which they enjoyed on a regular basis.

Formal supervision meetings were carried out with staff. They told us they were supported and clear about what was expected of them.

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.

More information about the inspection is in the full report.

Rating at last inspection: The home was rated Good at the last inspection (report published in October 2016).

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will continue to monitor the service through the information we receive and inspect in line with CQC guidance.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on the 19 October 2016 and was unannounced.

The Pastures provides care for up to thirteen people, on the day of our visit nine people were living at the home. The Pastures is a nursing home which supports people who have complex health needs. People had a range of learning and physical disabilities. The home was purpose built offering accommodation in the form of three large bungalows.

There was a registered manager in place and a deputy manager who was a qualified nurse. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Throughout this report the registered manager will be referred to as the manager. When we state ‘management team’ this refers to the manager and the deputy manager.

People benefitted from being supported by staff who had been safely recruited and trained. Staff worked in a collaborative way with their colleagues and the management team. Staff felt supported by the management team. There was consistently enough staff to safely meet people’s individual needs.

Staff understood how to protect people from the risk of abuse and knew the procedures for reporting any concerns. Medicines were administered safely and adherence to best practice was applied. People received their medicines safely and in the manner the prescriber intended. The service regularly audited the administration of medicines. Medicines were stored securely.

Staff knew and understood the needs of people living at The Pastures. Staff made real efforts to get to know the people who lived at the home. People received care which was person centred.

The management team observed staff’s care practice and was involved in the daily running of the service. Staff had not received supervisions for some time but the manager was addressing this. Staff received training; however the manager needed to improve their overview of this.

Staff told us they were happy working at The Pastures. Staff were committed and dedicated to the service. They assisted people with compassion and in a professional way. People’s dignity and privacy was maintained and respected. People were treated as individuals. People’s wishes and what was important to them was promoted by staff and the management team.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service was depriving some people of their liberty in order to provide necessary care and to keep them safe. The service had made applications for authorisation to the local authority DoLS team. The service was working within the principles of the MCA. The manager and the staff had a good knowledge of the MCA and DoLS.

People’s care plans contained important, relevant, detailed information to assist staff in meeting people’s individual needs. People’s needs were regularly reviewed.

Staff promoted people’s emotional wellbeing. The service responded proactively to changes in people’s health and social care needs.

The service encouraged people to maintain relationships with people who were important to them. Relatives felt involved and welcomed to the home. There were planned group and individual activities daily, people also went on trips and day experiences. People were encouraged to develop and maintain their interests.

There was a positive, open culture at The Pastures. The service was welcoming and had a friendly atmosphere. There were also systems in place to monitor the quality of the service and the management team were developing these further.

One adult social care inspector undertook the inspection of The Pastures. At the time of the inspection there were eight people using the service.

We were not able to speak with people who used the service because of their complex needs. People's relatives were not available to speak with. We spoke with the deputy manager, one registered nurse and five care staff. The registered manager was not available to speak with us on the day of our inspection. We reviewed three people’s care records. We also reviewed a selection of other records that included the provider’s policies and procedures, staff files, training records and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA), 2005, and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The MCA provides a framework to empower and protect people who may make key decisions about their care and support. The DoLS are used if extra restrictions or restraints are needed which may deprive a person of their liberty. We saw evidence that the provider had acted in accordance with the law in relation to the MCA and DoLS. People who used the service had received appropriate mental capacity assessments and a number of ‘best interest’ decisions were recorded. At the time of this inspection no person living in The Pastures had a DoLS authorisation.

Staff felt that there were generally enough staff on duty to meet the needs of people. However, there was a consensus of opinion that one person should receive 24-hour one to one care due to their complex needs. We highlighted this to the deputy manager. They told us that they agreed with staff and that they were in the process of submitting a proposal for 24-hour one to one care for the person.

People’s medicines were appropriately managed to help ensure that they received them safely. We saw the training records for staff who administered medicines. We observed staff administering medicines and saw that this was done in accordance with the provider’s medication policy.

We reviewed staff files and saw that the appropriate checks had been undertaken before staff commenced employment. These included Disclosure and Baring Service (DBS) checks.

We saw evidence that the provider’s audit schedule was effective. This included regular auditing of the quality of the service, as well as accidents and incidents and environmental risks.

The provider had effective arrangements in place to manage foreseeable emergencies. These included fire and loss of utilities.

Is the service effective?

People’s needs were assessed, and care and treatment was planned and delivered in order to meet their needs. Care plans were person-centred. People had complex needs with limited verbal communication. Staff showed a thorough understanding of people’s communication needs and demonstrated different communication techniques to help people understand what was being said.

People had effective risk assessments in place to help maintain their safety and welfare. A nationally recognised screening tool had been used to help identify people at risk of pressure ulcers.

The provider worked collaboratively with other health and social care professionals. These included physiotherapists, dieticians and psychologists. This helped to ensure all of people’s needs were being met. We saw that the guidance and information provided by specialists was followed by staff. This included the correct positioning of people to help prevent muscle spasms.

During our inspection we observed staff manage two medical emergencies with competence. Care workers sought the assistance from the registered nurse in a timely manner, and the situations were dealt with calmly and in accordance with people’s care plans.

Is the service caring?

We could not speak with people about the care and treatment they received because of their complex needs. We did however observe staff interact positively with people at all times. We saw that people enjoyed the interaction and were seen to be smiling and laughing. People’s care plans explained the meaning behind the different gestures and vocal sounds they made. It was evident that staff knew the meanings exceptionally well. They responded to people’s needs in a compassionate and respectful manner at all times.

The care we observed staff delivering to people was outstanding throughout our inspection. People were included in group activities as well as one to one time. Staff displayed kindness and spoke with people about the different things that they enjoyed. Staff explained about the importance of ensuring people were involved in the community and the ‘community spirit.’ We saw that people were regularly assisted to participate in different activities in the community and that these were designed to meet people’s preferences and interests.

Is the service responsive?

People’s care plans responded to, and reflected their physical and mental health needs as well as their social and emotional needs. The registered nurse and care staff responded to people’s complex needs in a timely and appropriate manner. We saw that people’s individual rooms, the bathrooms and the communal areas were all designed and equipped to assist and support people safely.

Some people could not eat or drink because of the complexity of their needs. They therefore required ‘Enteral Nutrition.’ This meant that their food and drink was given to them through tubes into their stomach. Staff responded to this by ensuring the correct procedure was followed to help avoid any complications. Staff also followed the speech and language therapist’s instruction in relation to people being given a small amount of appropriate ‘taster’ food so that they could still enjoy the taste of different foods.

The care and support people received reflected and responded to their personal interests and hobbies. One person enjoyed trains and technical items. Staff therefore took them to the railway station so that they could observe the trains and experience the environment of the station. Another person enjoyed different bright colours. The staff therefore used a sensory light that projected different colours on to the wall.

The service had not received any complaints. Staff we spoke with could tell us what they would do if a person wished to make a complaint.

Is the service well-led?

All of the staff we spoke with told us that they felt well supported by the management team. The care staff also said that they felt well supported by the registered nurses.

Staff told us that there were staff meetings and that they were encouraged to raise any concerns or issues. They told us that they always felt listened to by the management team. They said that if they suggested something that could improve the quality of the service then this was usually acted on.

Staff told us that they felt there was 'great team’ work within the service. We saw evidence of this during our inspection. Care staff we spoke with understood their roles and responsibilities and knew when they needed to ‘escalate’ an issue or concern to the registered nurse or the management team. We noted that there was an on-call service. This meant that staff could seek the advice of a senior person or manager during any time of the day.

Quality assurance processes were in place. These included regular audits of all aspects of the service. Accidents and incidents were audited on a monthly basis by the provider’s health and safety team. We saw evidence that there was learning from accidents and incidents to help prevent reoccurrences. This included information being shared with staff as appropriate.

We found that there was detailed care planning for each of the four people whose records we reviewed. These included detailed, step by step information for staff on how to meet the person’s needs. All care planning documents had been reviewed regularly to ensure the information contained within them reflected the person’s current needs.

We found that people who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. There was a safeguarding policy and a whistle-blowing policy in place and staff knew where to access them. Staff were able to describe the process they would take if they had a concern, and this matched what was documented in the safeguarding policy.

We found that there were enough staff to meet the needs of those using the service. People were engaged throughout the day in positive interaction or in activities. Most people using the service had care delivered on a one to one basis, but otherwise, there was one carer for two people using the service.

We found that the records kept at The Pastures for people using the service and staff were accurate and fit for purpose. Care records for those using the service reflected their current needs and information in care documents matched that specified in other care documents. There were sufficient records kept for staff, including training, supervision and appraisal records.

People living in this home had complex needs and were not able to communicate verbally. Because we visited in June 2012 and spent some time formally observing how people were supported by staff, we did not repeat this formal observation. However, as at our last visit, we saw that staff responded to people in a caring and respectful manner and we did not see any signs of people being ill at ease in the presence of staff.

We carried out this visit in order to assess whether the provider had done what they needed to do, to comply with standards for care and welfare and record keeping. While we were there we also identified that we needed to record findings in relation to the way the quality of the service was assessed and monitored.

Because people had complex needs and were unable to tell us verbally what they thought about their care, we observed how they were being supported. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people.

These observations showed us that staff treated people with respect. People were supported at a relaxed pace that suited them. Staff showed affection to people and we saw no signs that people were ill at ease or concerned in the presence of the staff.

People living in the home were not able to communicate with us verbally to tell us what they thought about their care. Because of this, we spent some time looking and listening to what was going on in the home, seeing how people responded to staff and talking to staff about people's needs.

We did not plan to look at outcome 21 about records before our visit. However, we found some problems with these so we included this essential standard during our visit.