About the service: Warrington Community Living, 53 Twiss Green Lane is a home that is registered to accommodate up to four adults with learning disabilities, physical disabilities and/or mental health needs. The home is a four-bedroom bungalow in a residential area of Warrington. At the time of our inspection the service was supporting four people.

People’s experience of using this service:

The outcomes for people using the service reflected the principles and values of Registering the Right Support in the following ways; promotion of choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

Since the previous inspection a new registered manager has been in post who has worked hard with staff to make improvements to the service. The management team and staff promoted a culture that was person-centred and inclusive. Staff were motivated to deliver care and support that was based on people’s needs and choices. People were treated with kindness, compassion and respect and staff interacted well with people. Staff knew people well and how best to support them in the least restrictive way possible.

The atmosphere within the home was calm, friendly and joyful; people felt relaxed during the inspection process and happily invited us into their home. People were keen to tell us how happy they were and how much they enjoyed living in the home. People were proud to tell us and show us the things they had done since living in the home and spoke positively about the caring approach of the staff team. Strong familiar relationships had been built between staff and people and it was clear that a genuine mutual friendship had been developed.

People told us they felt safe living in the home and family members were confident their loved ones were safe and well looked after. Risks people faced were assessed and those identified were safely managed. Medicines were managed safely by trained staff; appropriate assessments were in place for those who managed their own medicines. Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. The environment was safe and people had access to appropriate equipment where needed.

Enough suitably qualified and skilled staff were deployed to meet people’s needs. Since the previous inspection the registered manager had worked hard to recruit new staff and ensure required training was up-to-date. Staff told us they received a good level of support from the management team and felt able to approach them at any time.

People’s needs and choices had been assessed and planned for and care plans identified intended outcomes for people and how they were to be met in a way they preferred. Family members told us they felt their loved ones received the right care and support from well-trained staff. People were encouraged and supported to eat and drink well and were supported to access healthcare when needed. Staff worked hard to advocate for people to ensure they received the health care they were entitled to. Staff continuously offered people choice and control and where able to, consented to their care and treatment. Where people lacked capacity to make their own decisions they were made in their best interests in line with the Mental Capacity Act.

People, staff and family members all described the management team as approachable and supportive. The passion, knowledge and experience held by the management team created a relaxed environment for everyone; it was clear that people were put first and staff worked around what they wanted and how they wanted to spend their day. The management team showed a desire to improve on the service and were always looking at ways to do this. Effective systems were in place to check the quality and safety of the service.

Rating at last inspection: Requires Improvement (report published March 2018)

Why we inspect

Warrington Community Living, 53 Twiss Green Lane 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 is registered to accommodate up to four adults with learning disabilities, physical disabilities or mental health needs. The home is a four bedroom bungalow in a residential area of Warrington.

At the last inspection the service was rated good. At this inspection we found that some improvements to the service were needed and this rating had not been maintained. This was because at this inspection we found breaches of regulation 12 (safe care and treatment), regulation 18 (staff support and training) and regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report. This meant that the domains of safe, effective and well-led were rated requires improvement.

During our inspection we reviewed how people’s needs and risks were assessed and managed. We found that although some of the risks associated with people’s care were assessed and staff provided with sufficient guidance on how to manage these risks, others risks were not. This meant there was a risk that inappropriate and unsafe care would be provided.

The provider’s risk assessment relating to the identification and management of Legionella bacteria in the home’s water supply was overdue and the actions identified as necessary to mitigate risks had not been undertaken. This placed people at risk of contracting a Legionella type infection. Legionella bacteria naturally occur in soil or water environments and can cause a pneumonia type infection. It can only survive at certain temperatures. Under the Health and Safety Act 1974, a provider has a legal responsibility to ensure that the risk of legionella is assessed and managed.

Some aspects of the way medication was managed at the home required improvement. One person’s medication was not stored securely and their ability administer to their own medication had not been assessed. Stock levels were correct for all but one of the medications and staff had received training in how to administer people’s medicines. The competency of staff to administer medication however had not been assessed since 2016. This meant there was no robust evidence that staff continued to be competent in the administration of medication

Staff training was not up to date for some staff members and the majority of staff members had not had a supervision meeting with their line manager for 12 months. There was also no evidence that staff members had received an annual appraisal of their skills and abilities since the last inspection. This meant that staff had not received appropriate managerial support to do their job role effectively.

The provider’s complaints procedure required improvement as it was not in a format that met the legal requirements of the Accessible Information Standard that came into force in 2016. The provider’s complaints procedure was not in easy read format. It was written in small print and there were no pictures, photographs or symbols used in the procedure to make it easy for the people who lived at the home to understand.

The governance systems in place to monitor and manage the quality and safety of the service had not been maintained during a period in which there was no registered manager in the service. We were told the registered manager of the service left in approximately May to June 2017 and from the records we looked at, the quality assurance checks in place had not been continued from this time. This meant the risks to people’s health, safety and welfare had not been properly managed. At the time of this visit, an acting manager had just recently

This inspection was unannounced and took place on the 17 December 2015.

The service was previously inspected in April 2014. One breach of legal requirements relating to records was identified. We undertook a follow-up inspection in July 2014 and found that improvements had been made to address the breach.

53,Twiss Green Lane Residential Care Home provides both accommodation and personal care for up to four adults with learning and physical disabilities. It is located in Culcheth, a suburb of Warrington in Cheshire. The service is provided by Warrington Community Living, a registered charity. At the time of our inspection the service was accommodating three people.

The home is a domestic style four-bedroom bungalow in a residential area of Warrington and blends in with neighbouring properties. The building has been adapted to accommodate the needs of people with a physical disability and has a small laundry area, accessible wet room, spacious lounge, conservatory and kitchen.

At the time of the inspection there was a registered manager at 53, Twiss Green Lane Residential Care Home. 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.

The registered manager was present during the day of our inspection and engaged positively in the inspection process, together with staff on duty.

The provider had established a programme of induction and on-going training to ensure people using the service were supported by competent staff. Additional systems of support such as supervision, appraisals and team meetings were also in place.

People using the service were observed to be comfortable and relaxed in their home environment and in the presence of staff. Staff used their knowledge of the people they supported effectively so their conversations and interactions reflected their understanding of people using the service, their diverse and complex needs and preferences. For example, we observed staff using facial expressions, gestures, eye contact, posture, and tone of voice effectively to respond sensitively to the needs of people with non-verbal communication.

People using the service had access to a range of individualised and group activities and a choice of wholesome and nutritious meals. Records showed that people also had access to GPs and other health care professionals (subject to individual need) and medicines were managed safely.

The needs of people using the service and the management of risks had been appropriately planned for. Likewise, systems to monitor key aspects of the service, obtain feedback on the standard of care provided and to respond to safeguarding concerns and complaints had been established.

We undertook an inspection of Twiss Green Lane residential care home on 1st April 2014. During the inspection we spoke with the registered manager, four staff, two relatives and five health care professionals. Likewise, we also spoke with three of the people who used the service and encouraged each individual to communicate using their preferred method of communication.

We considered all the evidence we had 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. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Policies and procedures had been developed by the registered provider (Warrington Community Living) to provide guidance for staff on how to safeguard the care and welfare of the people using the service. This included guidance on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).

We were informed that two people using the service had been assessed as lacking capacity to make decisions although no applications had needed to be submitted to deprive a person of their liberty. Training records highlighted that the majority of staff had completed Mental Capacity Act training however only three staff had completed Deprivation of Liberty Safeguards training. This has been brought to the attention of the provider so that action can be taken to increase staff knowledge and understanding.

The provider had developed guidance on recruitment and selection to provide information to staff on the procedures for recruiting new employees. We looked at a sample of recruitment records for three staff which had been stored electronically. Examination of records and discussion with staff confirmed staff had undergone a comprehensive recruitment process prior to commencing work with the provider.

Is the service effective?

Feedback received from people using the service was generally positive and confirmed people were happy with the standard of care provided. Comments included: “I love living here. I’m much happier since coming here.” Likewise, in relation to meals, one person reported: “The food is great” and another confirmed the food was nice and tasty by replying “yes” to the question.

Two relatives spoken with were also complimentary of the standard of care provided. Comments received included: “The care has been excellent. They are very caring and understanding”; “The meals are lovely” and “They do all they can.”

We also sought the views of five health care professionals who visited the property during our visit. All feedback received was positive with the exception of one concern. It had been identified that a resident who had recently returned from hospital had an unexplained knee injury. This had been quickly noticed by the staff on the same day and reported promptly and correctly as a safeguarding issue.

Is the service caring?

On the day of our visit the general atmosphere in the home was calm and relaxed. The people living at the property were observed to be comfortable and relaxed in their home environment and were able to follow their own plans and preferred routines. Staff were attentive to the diverse needs of the people living in the property and were noted to communicate and engage with the people they supported in a respectful, dignified and caring manner.

Is the service responsive?

The registered provider (Warrington Community Living) had developed a corporate complaints procedure. Likewise, an easy read ‘service user complaints procedure’ and a ‘complaints and comments' booklet had been produced to provide people using the service and / or their representatives with information on how to provide feedback on the service provided.

No complaints or allegations were received from people using the service or their representatives during our visit and records highlighted that there had been no complaints in the last twelve months.

The representative of one person spoken with lacked awareness of how to raise a concern. This has been brought to the attention of the provider so that action can be taken to raise awareness.

Is the service well- led?

The provider has worked well with the Care Quality Commission and kept us updated on any significant events via statutory notifications. The service also worked well with other agencies and services to make sure people received their care in an integrated and responsive way. For example, during our inspection, five health care professionals visited the property to ensure the holistic needs of the people using the service were met.

The service continued to utilise a comprehensive internal quality assurance system. Overall this was well managed however gaps in the management of records were identified and in need of action. We have issued a compliance action to the provider to ensure people are adequately protected from the risks of unsafe or inappropriate care and treatment.

We used a number of different methods to help us understand the experiences of people using the service because the people living in the home had complex support needs which meant they were not able to share with us their experiences.

We attempted to make contact with the relatives of two of the people using the service to obtain feedback on the standard of care provided. We managed to speak with one relative who was complimentary of the service. Comments received included: “My sister is always happy and smiling”; I can’t complain about the service” and “In my opinion the care provided is good.”

The people living at 53, Twiss Green Lane were observed to be relaxed in their home environment and in the company of the staff team. Staff were seen to carry out their duties in an attentive, respectful and caring manner during the visit.

We used a number of different methods to help us understand the experiences of people using the service because the people living in the home had complex support needs which meant they were not able and / or chose not to share with us their experiences.

We spoke with three relatives to also check care was appropriately delivered. Relatives spoken with were complimentary of the service. For example, comments included: “My sister is well cared for and the staff appear to understand her needs” and “I’m really happy with the care provided to my sister. She appears very happy and I am kept up-to-date on her wellbeing.”

The people living at 53, Twiss Green Lane were observed to be relaxed in their home environment and in the company of the staff team. Staff were seen to carry out their duties in an attentive, respectful and caring manner during the visit.

One person told us they were happy living at 53,Twiss Green Lane and that staff knew her needs.

Due to the complex support needs of some of the people living at 53, Twiss Green Lane, we received limited feedback as follows.

A service user spoken with confirmed that the people living at 53, Twiss Green Lane were treated with respect and dignity and were able to exercise choice and control over their lives and to follow their preferred routines. This was also noted by members of the Local Involvement Network (LINk), during their last visit to the home.

Furthermore, one of the people using the service informed us that she was happy living at 53 Twiss Green Lane and was of the opinion that staff understood how to care for her. The person also told us that they felt safe living at 53 Twiss Green Lane and if they had concerns they would raise them with staff or other professionals. We were also told that the people living in the home get the support they need with their health and personal care needs however a service user reported that she had not had a holiday abroad and wanted to go with staff.

The people using the service were observed to be relaxed and comfortable in their home environment. One service user told us “I’m very happy living at the home and don’t want to ever move.” The person also confirmed everyone was well cared for and told us “I like the staff team they are helpful.”

A visiting health care professional confirmed that she was made to feel welcome when visiting the people who live at 53, Twiss Green Lane and reported that she was given time to talk in private with service users. The visitor also reported “I have no problems with this home. I feel this is one of the best that I go into.”