We undertook an unannounced inspection of Walsingham, 1 Ashley Close on the 16 June 2016.

The service provides accommodation and personal care for up to six people with a learning disability. On the day of our inspection, there were six people using the service.

The home had 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.

In our previous inspection carried out on 1 August 2014, we found that the provider had not met a required standard and was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. During this inspection we found that the provider was now meeting the required standards.

There were systems in place to ensure that staff had undertaken risk assessments which were regularly reviewed to minimise potential harm to people using the service.

There were appropriate numbers of staff employed to meet people’s needs and provide a safe and effective service. Staff we spoke with were aware of people’s needs, and provided people with person centred care. Staff were well supported to deliver a good service and felt supported by their management team.

The provider had a robust recruitment process in place which ensured that staff were qualified and suitable to work in the home. This also included agency workers. Staff had undertaken appropriate training and had received regular supervision and an annual appraisal, which enabled them to meet people’s needs. Medicines were administered safely by staff who had received training.

Staff cared for people in a friendly and caring manner and knew how to communicate effectively with people. Staff spent time with people and engaged in meaningful activities that were good for people’s mental and physical wellbeing.

People were supported to make decisions for themselves and encouraged to be as independent as possible. Where people were not able to make decisions for themselves, best interest decisions were made on their behalf which involved advocates and other professionals. People’s choices were respected and we saw evidence that people, relatives and/or other professionals were involved in planning the support people required. People were supported to eat and drink well and to access healthcare services when required.

The provider had a system in place to ensure that complaints were recorded and responded to in a timely manner as well as an effective system to monitor the quality of the service they provided.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

The inspection was unannounced.  When we inspected the service on 24 January 2014 we found that the service satisfied the legal requirements in the areas that we looked at.

Walsingham, 1 Ashley Close provides accommodation and personal care for six people who have a learning disability. The registered manager has been in place since November 2012. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

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. We found that the service had complied with the requirements of MCA and DoLS.

People were not cared for in a clean, hygienic environment which was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Relatives of people who lived at the home and healthcare professionals who had contact with the home said that people who lived there were safe. People who lived at the home 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 an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who lived at the home. There were enough qualified, skilled and experienced staff to meet people’s needs.

People were cared for by staff who were supported to deliver care safely and to an appropriate standard. Staff members had regular supervision meetings with the manager and an annual appraisal meeting at which development goals were set.

Staff members communicated with people effectively and used different ways of enhancing that communication, including touch, body language and facial expressions.  Staff members received training in MAKATON, a recognised communication tool for some people who have a learning disability.

People were encouraged to eat a healthy diet.  People were also supported to maintain their health. Contact with the GP and other healthcare professionals, such as the dietician and occupational therapist, was made on people’s behalf when needed. 

Before people moved into the home a full assessment of their needs had been completed. This was to ensure that the provider could meet their assessed needs. Care records included information about what was important to the person, how to support them well and their likes and dislikes.

Care records were personalised and detailed. People and their relatives had been encouraged to contribute to the development and review of their care and support plans. The care records showed that assessments of people’s capacity to make decisions about their care and welfare had been completed. Regular reviews of aspects of people’s health and well-being had been completed in accordance with their care plans.

Staff members were caring and respectful toward people who lived at the home and protected their dignity and privacy.

The manager was responsive to changes in people’s physical abilities and worked with others, such as the deputy manager of a day care centre, to maintain people’s independence.

People were supported in promoting their independence and community involvement.  Each person had a daily planner that detailed the activities in which they were scheduled to participate.

The service had asked relatives for their opinions on the care and services provided at the home and relatives were given the opportunity to comment on any aspect of the home.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

The registered manager had been in place since November 2012 and operated an ‘open door’ policy for staff. They were supported by a regional operations manager and worked closely with the local learning disabilities team to ensure that people who lived at the home received the correct support.

The manager held monthly staff meetings at which staff members were able to discuss any matters about the running of the home or concerns about the people who lived there.

The provider had a system to regularly assess and monitor the quality of service that people received. The manager had completed a number of quality ‘spot check’ audits both during the day time and at night. However, these audits had failed to identify the areas in which cleanliness and infection control standards had not been maintained.

The people who lived at No 1 Ashley Close, had no verbal communication skills. Therefore, they were unable to tell us about what it was like living there. We observed staff care for people and saw that this was done with gentleness and kindness.

We saw evidence that people’s needs and wishes were recognised and met. We saw that choice had been offered and the staff waited until the person indicated their choice.

The home had a core of well-established staff who knew and understood the people’s needs and wishes. We saw that communication between the staff and the people was effective. Care plans and risk assessments had been kept up to date and reflected the person’s needs and wishes.