This unannounced inspection took place on 17 and 24 May 2018.

At the previous inspection in January 2017 we found three breaches of regulations. Risks associated with people’s personal safety or behaviours that may be challenging to others were not always identified; some areas of the service had an institutional appearance; care plans were not always regularly and thoroughly reviewed and documented and systems in place to monitor the quality of care being provided were not always effective. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) safe, effective, responsive and well-led to at least a rating of good. This inspection found improvements had been made and the service was now meeting these regulations. However, we found a new breach regards to medicines management and infection control.

The Tobias Centre is a ‘care home’ which provides accommodation and personal care for up to seven people with learning disabilities and autistic spectrum conditions in one adapted building. 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. At the time of our inspection there were six people living at the service.

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.

There was 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 2008 and associated Regulations about how the service is run.

Medicines management was not robust. On the first day of our inspection we found the medicines keys were not secure; some ‘as required’ medicines protocols were not in place to guide staff and hand written entries on medicines records were not signed and checked to show the information was correct. By the second day of our inspection, the issues were starting to be addressed. This included ensuring staff had the medicine keys on their person.

People were not fully protected from cross contamination. On the first day of our inspection we visited the laundry and found the laundry contained discarded, dirty equipment, including seating and a washing machine not now functional. The room was unclean, and not readily cleanable, posing an increased risk of cross contamination. The one sink was particularly dirty and there was no soap or towels for staff to wash their hands. By the second day of our inspection the issues had been addressed. The laundry room had been thoroughly cleaned, the washing machine removed and the sink was accessible with soap and hand paper towels.

Systems in place to monitor the quality and safety of the service were not always effective. Checks had failed to identify the issues around medicines management and infection control.

The service provided safe care to people. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service. People were supported to maintain a balanced diet. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with

This inspection took place on 30 January and 6 February 2017 both days were unannounced. The service was last inspected on 15 April 2016 when it was rated as ‘Good’.

The Tobias Centre is registered to provide accommodation and personal care for up to seven people with learning disabilities and autistic spectrum conditions. On the day of inspection there were six people living at the service.

The service had a registered manager in place. 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.

Prior to this inspection we received concerns that people may be at risk of being unlawfully restrained and having their liberty restricted. There were also concerns relating to risk assessments regarding the use of seclusion and restraint and that staff at the service did not fully understand the terms ‘seclusion’ and ‘restraint’. A report had been prepared by a specialist team from Devon Partnership NHS Trust that outlined their concerns. The findings of this report are being challenged by the provider and the concerns are currently being looked at through the safeguarding processes of the local authority.

Risks associated with people’s personal safety or behaviours that may be challenging to others were not always identified. People were not protected from the risks of being unlawfully restrained or restricted. This was because the principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards (DoLS) were not always followed. Records did not demonstrate that required reviews took place regularly or involved others outside of the organisation. Systems were therefore not sufficient or open to ensure or demonstrate that restrictions remained appropriate, safe and lawful.

Systems in place to monitor the quality of care being provided were not always effective. The audits that were in place and visits from the provider’s representative had not identified the issues raised by the inspection.

Some aspects of the environment were institutional in appearance and in need of maintenance. The ceiling of one bathroom was mouldy and had a strong smell of damp. The entrance gates were chained together and gave a negative impression of the people living at the service.

Prior to the inspection we spoke with one relative who was not happy with the way their relation was being supported by the service. Following the inspection we spoke with three other relatives. They all told us they were very pleased with the way their relations were supported. Comments from them included “[person’s name] is happy there and I would hate to think anyone would move him,” and “This is the best placement he has ever been in.”

People were supported to participate in activities inside and outside the service. These included swimming, shopping and going to the pub. People were supported to maintain contact with their families. Wherever possible people and their relatives were involved in making decisions about care provided by staff. Relatives and staff were confident any concerns would be dealt with.

People’s needs were met by kind and caring staff. People were not able to tell us about their relationships with staff. However, we saw that people were relaxed and happy in staffs’ presence. We observed positive relationships between staff and the people we met at the service. Staff were seen supporting people in an easy, unrushed and pleasant manner. Staff genuinely cared for people’s happiness and wellbeing. People were treated as individuals. Staff listened to people and supported them to express their needs and wants. People’s abilities varied and staff told us how they encouraged people to be as independent as their abilities allowed.

The Tobias Centre provides accommodation for up to seven people with learning disabilities and autistic spectrum conditions.

This unannounced inspection took place on 15 April 2016. At the time of the inspection there were six people living at the service.

The service was last inspected on 21 January 2014 when it met the requirements that were looked at.

A registered manager was employed at the service. 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.

Kind and caring staff ensured people received care and support that was responsive to their needs. Staff ensured people’s privacy and dignity was respected and all personal care was provided in private. Staff were respectful in their interactions with people. One social care professional contacted us by email and wrote ‘I have felt that the care they give our service user is good and it appears that support workers have a genuine fondness for them and work proactively to give them a good quality of life.

People’s care plans gave staff instructions on how their needs were to be met. Staff knew the people living at the home and their needs and preferences well. People were offered choices in all aspects of their lives. People’s relatives could be involved in making decisions about care provided by staff, if they chose. One person’s relatives told us “[The person] likes it here and that’s the main thing”.

There were enough staff available to meet people’s needs and support people to take part in activities and outings. People were supported to enjoy activities in the community. On the day of our inspection one person was supported by staff to go out with their relative.

People were supported to maintain a healthy balanced diet and had a choice for each meal. Staff knew people’s likes and dislikes. Staff ensured people’s health care needs were addressed. People were supported to attend dental appointments and received visits from healthcare professionals. People's medicines were stored and managed safely and they received their medicines at the times they were prescribed to be given.

People were protected from the risks of abuse. Staff knew how to recognise and report abuse both within the service and to outside agencies. Thorough recruitment procedures ensured the risks of employing unsuitable staff were minimised. People’s human rights were upheld because staff displayed a good understanding of the principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards (DoLS).

Staff received training that helped them meet people’s needs. This included mandatory training such as first aid as well as training more specific to people’s needs such as autism. Staff also received regular supervision to support them in their role. Staff told us the registered manager and deputy manager were very open and approachable.

There were effective quality assurance systems in place to monitor care. Regular audits were undertaken to ensure the quality of care was maintained.

Relatives had recently completed a questionnaire about the quality of care provided by the home. We saw that they had made many positive comments. For example one relative wrote ‘The people who work with my [X] are very caring and look after them very well’. Another had written ‘[X] is very well looked after and the staff are wonderful’.

There were six people living at this service at the time of our visit. We observed care practices, met people, talked to staff and viewed people's records to help us understand how people viewed the support they received at this service. This was because people we met did not communicate verbally and were not able to tell us about their experiences.

There was a friendly atmosphere. We saw that all staff interactions were patient and respectful and that people were relaxed. Staff listened carefully to each person and demonstrated that they respected their opinions. We met five people. One person communicated to us through a staff interpreter. Their body language was relaxed and confident. They told us that they liked living at this service.

The service had policies and procedures in place that kept people safe. Staff were confident about their safeguarding responsibilities and each staff we met told us that the safeguarding training they received was of a good quality.

There were processes in place to monitor the quality of service being provided. We saw that the opinions of people's families were sought through review meetings and surveys.

Each person had a carefully considered living space designed to meet their individual needs. Two people had special areas specifically furnished and decorated to facilitate the best way for them to keep calm. One area, that was not occupied at the time of our inspection, had been furnished to minimise potential damage to the person living their or the fabric of the rooms.

Each person had at least one to one staffing, and some people had two to one support. Most of the people living there had been settled for some time. We were told that they were calmer than they had been.

No one living at the home was able to verbally communicate with us. However they were able to communicate their likes and dislikes to the staff. We spoke with one person and staff interpreted for us. The person told us that they liked living at Tobias.

We saw staff treating people with great respect and care. For example one person spent a lot of time walking around the ground floor of the home. Staff gave them the space while being vigilant for their safety. We saw a staff member waiting outside a bathroom for a considerable time, facilitating a person to have a relaxing bath in privacy while being vigilant to their safety.

We saw that the home employed enough suitably qualified staff to ensure that people's care and support needs were met. Safeguarding and other risks were considered to ensure people's welfare. The home monitored the quality of the services they provided.