This inspection took place on 7,10 and 11 January 2019 and was announced. The inspection was announced to ensure people who used the service would be present.

Tynedale is a 'care home'. 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. Tynedale is registered to provide residential care and support for up to four adults with a learning disability or autistic spectrum disorder. At the time of our inspection four people were living at the home.

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.

The registered manager had deregistered on 18 December 2018 and had taken up the post of deputy manager. A registered manager from another of the provider’s services had taken on the role of interim manager on the 4 January 2019. The regional director had started their application to become the registered manager of the service. 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 comprehensive inspection in January 2018 we rated the service as ‘Requires Improvement’ overall. We identified two breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. We found the service did not have systems in place to monitor the level of cleanliness and areas of the home were visibly dirty. The provider did not actively encourage feedback about the quality of care and support provided and quality assurance checks were not regularly completed.

Following the inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve in the areas identified. The provider sent us a plan showing what actions would be taken to address the issues.

During this inspection we noted improvements had been made to the environment and the premises were clean and tidy. The service advised us that a survey was to be sent to families to gather feedback in summer 2018. We found this had not happened. The deputy manager advised a survey was sent on the day we gave notice of our inspection. The regional director told us the provider had considered various methods to capture people’s and relative’s views but had not concluded what method they wished to use.

We found that quality assurance systems remained ineffective. Whilst audits had been introduced to address the issue of the cleanliness of the premises, other quality assurance systems had not identified the issues we found during the inspection relating to Deprivation of Liberty Safeguards (DoLS) applications, medicines audits, people’s finance records and training records.

The management team at the service did not have clear oversight of training which meant training had lapsed in a number of areas. Staff told us they had regular supervisions and an annual appraisal.

The service did not have effective systems in place for people’s DoLS. One person’s application was made the day after it had ended which meant the person was restricted unlawfully. The status of other people’s ongoing DoLS applications were not recorded.

Medicines were safely received, stored, administered and destroyed, for example, where people refused to take them or they were no longer required. Although medicines audits did identify issues, the service was unable to confirm what action it took and no associated do

This inspection took place on 15 and 18 January 2018 and was unannounced. Which meant the provider and staff did not know we would be visiting.

Tynedale is a 'care home'. 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. Tynedale is registered to provide residential care and support for up to four adults with a learning disability or autistic spectrum disorder. At the time of our inspection four people were living at the home.

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.

A registered manager was 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.

The registered manager was absent and we were supported by the deputy manager and the Positive Behaviour Support (PBS) practitioner.

During this inspection we found the service had breached two regulations. The service did not have systems in place to monitor the level of cleanliness. We noted areas of the home were visibly dirty. The provider did not actively encourage feedback about the quality of care and support provided.

Identified risks to people were assessed and managed. Sufficient staff were available to ensure people’s needs were met. Medicines were managed safely. The provider had systems in place to analyse information from a range of sources to identify and recognise lessons learnt.

Training was up to date and was constantly reviewed. An action plan was in place to monitor and deliver regular supervisions and appraisals. The service had a robust recruitment process in place. Safety checks of equipment and premises were routinely carried out. The provider had systems in place to ensure people were protected from abuse and harm. Staff had completed safeguarding training.

People were supported to maintain a balanced diet. The service worked in partnership with external health care professionals ensuring people received joined up care. The provider had an action plan in place to improve people’s environments. People were supported to maintain good health and had access to healthcare professionals.

People were able to make day to day decisions about where and how they spent their time. People were supported to maintain relationship important to them and to take part in their preferred interests and hobbies. Care plans were individualised and contained personalised information about the person and their preferences.

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.

Relatives told us they were not always involved in reviews of their family member’s care and support. Staff were knowledgeable about the people they supported. They were aware of their preferences, interests and family structure.

Relatives and staff were complementary about the deputy manager. We observed staff were supportive of each other. The deputy manager was passionate about implementing new ideas to improve people’s lives. Whilst the service had quality assurance processes to monitor the quality and safety of the service provided it was not consistently completed.

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

The inspection took place on 19 November 2015 and was unannounced. A second day of inspection took place on 20 November 2015 and was announced. We previously inspected Tynedale on 8 April 2014 and found the service was meeting the requirements of the regulations we inspected.

Tynedale is registered to provide residential care and support for up to four adults with a learning disability or autistic spectrum disorder. At the time of our inspection there were four people living in the home of whom one was in hospital.

At the time of our inspection there was 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.

Relatives told us people were safe. One relative said their relation was “safe, happy and always clean”.

Staff had a good understanding of safeguarding. All safeguarding concerns were recorded, investigated and outcomes fed back. Incidents and accidents were also recorded and investigated along with actions taken and lessons learnt. The registered manager analysed incidents and accidents to identify any trends that may require further action to be taken to prevent reoccurrences.

Electronic systems were in place for the recording, investigating and monitoring of safeguarding concerns, complaints, accidents and incidents. Electronic logs and records were kept for all and included details of investigations, outcomes and action taken. Lessons were learnt from safeguarding concerns, complaints, accidents and incidents and appropriate feedback was given to the relevant people.

Risk assessments were in place for people where risks had been identified. There were also risk assessments regarding the premises and environment.

There were up to date checks and risk assessments in place in relation to fire, electrics, gas safety and legionella. Personal emergency evacuation procedures (PEEPs) were in place for people who used the service.

Medicines were managed effectively with safe storage and appropriate administration, reflective of the individual needs of people.

Staffing levels were not always consistent and therefore did not always meet people’s needs. The registered manager organised rotas around the levels of staff required to meet the individual needs of the people receiving the service. However, additional staffing was not always in place to cover leave for the cook and domestic.

Staff understood the needs of people within the service. Staff described how they provided support to people and how they met their needs.

Staff were supported to fulfil their caring role. One staff member told us they “feel supported by the manager”. Staff received regular supervision and annual appraisals which were up to date.

Every person within the service had a communication tool within their care files which contained information of their individual communication needs. Clear detailed instructions of how staff should communicate with each person and how people could communicate were included. For example, that they wanted something. Communication strategies used within the service included picture exchange communication systems (PECS), photos, objects and gestures.

People’s care records contained best interest decisions which corresponded to the information contained in deprivation of liberty safeguard (DoLS) authorisations and care plans put in place, for example, restraint. DoLS authorisations were in place for every person receiving the service and were also stored within care files alongside mental capacity assessments and best interest decisions.

We observed people and staff during mealtimes. People were enjoying their meals, some independently and others with support from staff. There were choices available for people

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of our inspection. Her name appears because she was still a registered manager on our register at the time. During our inspection we were assisted by the new manager who has applied for registration on our register.

People who were using the service had complex needs which meant they were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences.

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

Below is a summary of what we found –

Is the service caring?

A relative told us, “They treat my (relative) really well. I come every day at different times and everything is always the same.” Another told us, their relative was cared for “lovingly.”

Staff were provided with the training and support they needed to ensure people received caring and consistent support. Other health and social care professionals who were familiar with the service were confident the service was caring for people well. One told us, “The staff are passionate. The staff are very skilled; they’re a very good stable staff team”. A relative told us, “Generally my (relative) is always with a trained member of staff. The girls here are really good. They have a soothing manner.”

The provider carried out checks to ensure people were treated well. Relatives were asked for their feedback and felt listened to by the service.

Care was individualised and centred on each person. Their care and support was provided by staff who knew and understood their needs and preferences and responded promptly and consistently to these. Staff communicated effectively with people using the service, no matter how complex their needs.

Is the service responsive?

We found that people were treated with dignity and respect. We observed that staff provided personalised care and they respected people’s choices and wishes.

People had complex needs, but staff clearly understood their individual communication styles and provided consistent care. Staff supported and encouraged people to use the most effective methods to communicate their wishes. For instance, one person used the Picture Exchange Communication System (PECS) and another used flash cards. A health professional who visited the service told us, “Staff reinforce the use of flash cards with (the person) which reduces (the person’s) anxieties.”

People and their families were encouraged to be involved in decisions about their care and treatment. A relative told us, “My relative is really happy there.” Relatives participated in regular reviews of their relative’s care and felt that the service responded to any concerns or issues. One relative commented, “They keep us informed. We feel free to speak with them. We always have done. If we have had concerns, they’ve always done something (about it).” A social worker who knew the service well told us, “Any issues we’ve raised were dealt with very quickly.”

Is the service safe?

We found that people who were using the service were protected from abuse as the provider had procedures in place for the staff to follow if they suspected anyone was at risk of abuse. Staff were confident about the action they should take if they believed anyone was at risk of abuse.

Relatives told us they were confident their relatives were safe. One said, “My relative is probably as safe as you could get.”

We saw that risks to people’s safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe. A relative told us, “They introduced a new harness as (my relative) was taking his seat belt off. He enjoys it as he feels secure.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one.

Staff had been trained in non-abusive psychological and physical Interventions and rarely needed to use restraint, as people were cared for in consistent, appropriate ways, which helped ensure they were safe.

The evidence we found showed 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.

The provider had implemented sound audit processes, to ensure the service was safe and to identify ways to improve.

Is the service effective?

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We found that people who used the service were receiving the care and support they needed. The staff we spoke with could describe how they met the assessed needs of the people they were providing with care. Relatives and health and social care professionals told us people received good, effective care.

Relatives acting on behalf of people using the service were given appropriate information and support regarding their relative’s care and treatment and understood the care and treatment choices available to them.

Support for staff was provided through effective training, supervision and appraisal. Staff told us they were able to provide the personalised support people needed, because they had been trained to develop the specialist skills required. A member of staff told us, “The training is very worthwhile. It’s done once and year and repeated which keeps it fresh in your mind. It’s interactive; we’re given problems and have to come up with answers which is good.”

Is the service well led?

Communication and care of people was tailored to their individual needs. Effective systems were in place to communicate with people with complex needs. Relatives of people using the service felt they were regularly involved and were consulted about the service, which helps to drive improvement.

Quality assurance systems were effective and included working with staff and other stakeholders. There was a culture of openness. A relative of a one person who used the service told us, “I’ve seen the Operations Manager here and know her well. I would discuss any concerns with her.”

The service had recently experienced a change of manager. The new manager showed clear leadership and had already begun to effect positive changes. She had applied for registration with CQC promptly and was awaiting the outcome of her application.

Staff were confident that if they were to raise any safeguarding concerns, these would be taken seriously by management.

The provider had ensured staff received appropriate training and support, which meant staff were motivated and professional in the way they carried out their work.

Some of the people using the service had complex needs which meant they were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences.

The service planned and delivered care and support so that people’s needs were met. Staff supported people in an engaging way and regular activities were arranged. One relative told us “On the whole, I’m very happy.”

The home was suitably designed and adequately maintained and systems were in place to manage risks to the health, safety and welfare of people using the service. One relative told us “I am happy with the living accommodation.”

The service had an effective recruitment and selection procedure in place and carried out relevant checks when recruiting staff.

The manager had systems in place to regularly check the quality of the care, people were consulted about the care received and an effective complaints procedure was in place. One relative told us “They usually keep us pretty well informed.”

The Care Quality Commission, have undertaken two compliance reviews at Tynedale. The inspection for the first review was carried out on 18 January 2012, and we found improvements were needed. The inspection for the second review was carried out on 23 April 2012 and this report describes our findings.

Due to the physical and mental health needs of the people living in the home it was not possible to acquire peoples views.

However we spoke to a number of people during the inspection and we observed the way staff provided the care to the people living in Tynedale and how they supported them in their day to day activities.

We spoke with the relatives of three of the people who lived at Tynedale. Overall, they thought their relatives received care and support that met their needs.

We spoke with a mother about the care of her son. She knew her son’s placement was his home and would not be moving anywhere else, which she was very happy with. She had a lot of input into him moving into his home. She visited as often as she and her son wanted and he came to visit her and his dad. Her son was very happy about going back to his home at Tynedale, which indicated to her that he liked where he was living. She explained that everyone would know if he wasn’t happy as his behaviour would indicate displeasure. She felt that her son’s needs and safety were met at Tynedale. She also said the staff were good and took him out for various activities.

This mother told us that her son’s person centred plan needed reviewing as he seemed to be doing less than was detailed in his person centred plan and that he needed to be motivated to try things.

None of the families we spoke with had any concerns about the safety of their relatives.

We were unable to communicate effectively with people living at the home.