This comprehensive inspection took place on 9 November 2018 and was unannounced.

The Well House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can provide accommodation and care for 14 people. This is in one detached building that is adapted for the current use providing a one bedded self-contained annex, a four-bedded self-contained annex and individual bedrooms on three floors in the main house. The home provides support for people living with a range of learning disabilities, and people may live with autism and have sensory needs. Some people live at The Well House on a permanent basis while others use the service on a rotational basis for short stays of one or more nights. There were seven people living at the home permanently at the time of our inspection and two people having a short stay.

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’. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 Well House was designed, built and registered before the Care Quality Commission (CQC) ‘Registering the Right Support’ policy and other best practice guidance was published. 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 other complex needs using the service can live as ordinary a life as any citizen.

At the last inspection on 5 October 2017 the service was rated as ‘Requires Improvement’ overall and there was a breach of regulation. This was because the provider had failed to display their performance rating on either their website or in the service from the previous inspection in September 2016. Provider’s must ensure that their ratings are displayed conspicuously and legibly at each location delivering a regulated activity. At this inspection the provider had displayed their performance rating and the breach of regulations had been met.

At this inspection improvements had been made in some areas and the overall rating of the service was Good overall. This report discusses our findings in relation to this. However, we found further areas of improvement that were needed.

Quality assurance systems were in place and being embedded to monitor the running and overall quality of the service and to identify any shortfalls and improvements necessary. Improvements had been made since the last inspection in relation to recording and equipment required to support infection control and medicines procedures. Records demonstrated that regular internal audits and checks were being completed. The provider had also identified in response to changes in data protection legislation that their systems needed to be reviewed and was in the process of completing this activity to ensure people’s rights were maintained. Despite these improvements, the care planning quality assurance systems required further embedding to ensure that the service kept pace with the positive work they had completed in relation to enabling people to make decisions and working in line with the Mental Capacity Act.

The provider’s electronic information systems also needed further embedding to ensure they could demonstrate their quality assurance and compliance in a timely and robust manner.

People and their relatives told us they felt safe and that staff cared for them. People

We inspected the Well House on the 5 October 2017 and the inspection was unannounced. The Well House provides accommodation for up to 14 people with a learning disability and complex care needs. Some people live at The Well House on a permanent basis while others use the service on a rotational basis for short stays of one or more nights. The age range of people living at the service varied between 20 – 60 years old. People require support with personal care, mobility, health, behavioural and communication needs. Accommodation is provided on two floors in the main house and in the garden of the service was a one bedded annex and a four bedded annex. Each annex was purpose built with kitchens and wet rooms.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 undertaken on the 6, 8 and 22 September 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to people being unlawfully deprived of their liberty. The management and storage of medicines was not safe. Robust risk assessments in relation to bathing had not been maintained, accurate records had not been maintained and the provider’s quality assurance framework was not fit for purpose. Recommendations were also made in relation to staffing levels, cleanliness, implementing the principles of the Mental Capacity Act into the care planning process and submitting statutory notifications. The provider sent us an action plan stating they would have addressed all of these concerns by October 2016. At this inspection we found the provider had followed their plan and they were now meeting the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Part of the requirements of the provider’s registration is to ensure that when their service is inspected by CQC, that they display their performance rating, to provide members of the public with an awareness of the rating of the service. The provider had not displayed the rating of the previous inspection on their website. Failure to display a rating is a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Steps had been taken to drive improvement and the provider was now meeting the legal requirements. Quality assurance checks were now in place and the provider was routinely submitting statutory notifications. However, further work was required to strengthen the provider's internal quality assurance framework. We have identified this as an area of practice that needs improvement.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLs) which applies to care homes. Where required, DoLS applications had been made and steps had been taken to embed the principles of the Mental Capacity Act 2005 (MCA) into the care planning process. However, further work was required to strengthen this. We have identified this as an area of practice that needs improvement.

Systems were in place for staff to support people with the management of their diabetes. Risk assessments and guidance were in place. However, the disposal of insulin needles required addressing. We have identified this as an area of practice that needs improvement.

All risks to people's safety had been assessed and were managed in line with individual risk assessments. Risks associated with bathing had been addressed and robust risk assessments were in place. Systems were in place to ensure water temperatures did not exceed recommended temperatures.

People were supported to take their medicines safely. People were supported to maintain good health and had access to healthcare servic

We inspected The Well House on the 6th and 8th September. Following the inspection we received some information of concern and as a result we returned for a third day of inspection on 22 September 2016. The Well House provides accommodation for up to 14 people with a learning disability and complex needs. Some people live at The Well House on a permanent basis while others use the service on a rotational basis for short stays of one or more nights. The age range of people living at the home varied between 20 – 70 years old. People require support with personal care, mobility, health, behavioural and communication needs. Accommodation is provided on two floors in the main house and in the garden of the service was a one bedded annex and a four bedded annex. Each annex was purpose built with kitchens and wet rooms.

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.

People, relatives and staff spoke highly of the service. One relative told us, “The Well House is wonderful. I can’t sing their praises enough.” Another relative told us, “I’m very happy with the care my loved one receives.” Whilst the feedback from people was positive, we found areas of practice that were not consistently safe, effective or well-led.

Management of medicines was not always safe. People received their medicines correctly, on time and as they wished to have them. However, best practice guidelines regarding storage and documentation of medicines were not being followed. We also found that the date of opening was not recorded on two open liquid medications which meant that people were at risk of receiving expired medicine which can be less effective.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLs) which applies to care homes. One application to restrict people's freedom had been submitted to the appropriate DoLS office. However, there was a risk that people’s rights under Article 5 of the Human Rights Act 1998 were contravened as robust systems were not in place to identify if other people were unlawfully deprived of their liberty. Where an application had been made, staff were not aware that this person was subject to a DoLS authorisation and what it meant for the individual.

The principles of the Mental Capacity Act (MCA) were not consistently embedded into practice. Further work was required to clearly demonstrate whether people had consented to their care plan, staff holding their personal allowance, photograph being taken or sharing of information. We have made a recommendation for improvement.

People felt staffing levels were sufficient. One person told us, “There’s always someone to talk to.” During the course of the inspection, we received intelligence of concern which raised concerns about insufficient staffing levels. Although people felt staffing levels were sufficient, the provider was unable to demonstrate how staffing levels were based on the individual needs of people. We have asked the provider to make improvements in this area.

Robust systems to monitor the safety and quality of the service were not in place. Governance systems to identify shortfalls were ineffective and complete, detailed and contemporaneous records were not consistently in place. Where risks were identified to people’s safety, documentation failed to evidence how those risks were mitigated. The provider's quality assurance system did not identify service shortfalls we found during the inspection, to ensure service improvements were made.

The provider did not routinely submit statutory notifications to the Care Quality Commission, as required. Under the Health and Social Care Act 2008, p

As people using the service had complex needs, we used a number of methods to help us understand people's views and experiences. We spoke to one person living at the home, looked at feedback forms, spoke to staff and looked at a range of documents.

We saw that communal areas and people's rooms were clean and comfortable and promoted people's privacy and dignity. People and carer's views and comments were taken into account through feedback. We found that people were encouraged to make decisions and saw that people were treated with dignity and respect.

People had their individual needs assessed and we saw evidence that the service provided care which was planned in a way that ensured people's welfare. The provider had put the appropriate measures and equipment in place to maintain the care and safety of people in the building.

Staff members demonstrated a good awareness of safeguarding, were able to discuss their actions in the event of a safeguarding concern and give examples of what may constitute abuse.

The provider had a formal recruitment and selection process in place with evidence of checks being undertaken for new employees. Staff completed a thorough induction process followed by on-going training and development.

The provider had effective systems in place to monitor the quality of service provision through feedback and audits. The provider effectively dealt with risks and complaints.

We used a number of different methods to help us understand the experiences of people using the service, as they had complex needs which meant they were not always able to tell us their experiences. We spoke with five people living in The Well House, we looked at a range of documents, spoke with care staff and the manager.

People told us they were very happy and felt that staff were their friends. Three people invited us to look at their rooms and said that they had everything they wanted. One person said they would like to book additional weeks for respite, and another person told us the food was very good and they had enjoyed their dinner. We found evidence that people were encouraged to make choices and observed people being treated with respect and dignity.

We examined three care plans. We found that people who used the service, and their relatives were involved in making decisions about the care provided. We spoke with three of the care workers and they demonstrated an understanding of people’s needs, and discussed how they enabled people to make choices and be independent.

We looked at staff training and supervision records. Staff told us they received the training and supervision they needed to help them provide the care and support people needed and wanted.

There were a number of systems in place to review the quality of service being provided at The Well House, including regular meetings with people using the service.