Charles House

We found the following examples of good practice.

There were systems in place to facilitate visitors attending the home in line with new government guidance.

Care plans considered people’s individual risk to COVID-19 and how to support them to self isolate. Where people lacked capacity, plans were made in people’s best interests and involved the person, their loved ones and relevant professionals.

Suitable indoor activities had been considered for people during lockdown restrictions. The home was in the process of developing a sensory room for people to enjoy.

Staff wore Personal Protective Equipment (PPE) in line with guidance and had received training in using PPE correctly.

Signage was visible in the entrance and around the home to prompt good infection control practices.

Cleaning schedules were enhanced to include high touch areas and two hourly sanitisation of the home.

Charles House is a residential care home providing personal care for five people aged 65 and over at the time of the inspection. The service is registered to support up to 10 people.

People using the service lived in a large house, split over three floors, with shared kitchen and bathroom facilities.

Services for people with learning disabilities and/or autism

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service and what we found

The provider’s systems to monitor the quality and safety of the service had not always been effective at identifying where the registered provider needed to make some improvements. For example, there was some inconsistency with the recording of audits of medicines.

People were safe using the service. Staff knew how to protect people from harm and reduce the risk of accidents and incidents. At the time of our site visit, we found there were enough suitably recruited staff on duty to meet people’s needs and to keep people safe. People were supported by staff who knew their needs well. Staff supported people with their medicines and this was done safely. Staff understood how to prevent and control the spread of infection.

People had been assessed before being accepted to the service to ensure the provider could meet their needs. Assessments addressed people's physical and health needs, their cultural and language needs, and what was important to them. Staff received training which helped them to deliver personalised care. Our observations showed people looked happy and a choice of food was available and where appropriate, people received additional support with their dietary needs. The provider worked with external health and social care professionals and people were supported to access these services when they needed them to ensure their health was maintained.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting 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.

Staff were knowledgeable about people’s care and support needs. People and relatives told us how caring the staff were. Staff enjoyed their work and got on well with the people they supported. Staff encouraged people’s independence, protected their privacy and treated them with dignity.

Most of the people using the service at the time of the inspection could not tell us about their experiences. Whilst on site, we saw positive interactions between people and staff and people looked comfortable with the way they were being supported. Relatives we spoke with gave us positive feedback on the service and the way the staff supported their family members to remain safe. Staff provided responsive care to people in line with their preferences and choices. Where people communicated non-verbally staff knew how to engage with them.

People were supported by staff who knew their preferences. Complaints made since the last inspection had been investigated and relatives knew who to contact if they had any concerns. Relatives and staff were happy with the way the service was being led and there was a culture amongst the staff team in providing person-centred care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 11 December 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Charles House is a care home registered to accommodate up to 10 people who have a learning disability. The home is not purpose built or modified. At the time of our inspection five people were living at the 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 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 registered manager in post at the time of the inspection. 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 home environment had undergone some repairs and improvements. However, there were areas of the home that required further improvement. There was also some improvement required to ensure people received equal opportunities to engage in individual and personalised interests in an environment that was suitable for people living with learning disabilities. Systems and processes in place to monitor the safety and quality of the service required further improvement.

People were protected from the risk of abuse and avoidable harm because staff knew what action to take and the provider had safeguarding systems and processes in place to keep people safe. People were supported by sufficient numbers of staff who were kind and respectful and had the knowledge they required to care for people safely.

People were also protected against risks associated with their health and care needs because risk assessments and associated care plans were in place and had been reviewed within the last 12 months. People received support from staff to take their prescribed medicines. Systems and processes were in place to ensure medicines were managed safely and only staff who had undergone training were permitted to administer medicines.

People and their relatives were involved as much as practicably possible alongside healthcare professionals, to ensure that any decisions made in respect of their care and support needs, were done so within their best interests and in accordance with the Mental Capacity Act 2005.

Where people were assessed to lack the capacity to consent to the support they received, the provider followed key processes to ensure the care being provided was in the least restrictive way possible. Applications had been made to safeguard people against the unlawful deprivation of their liberty, where necessary. People’s privacy, dignity and independence were respected.

People were supported to maintain a healthy diet with choices of different foods available and all their health needs were met with the support from staff and healthcare professionals. Staff knew people very well. The provider ensured that some information was available in different formats to meet the needs of people. There was a complaints process in place although there had been no complaints since the last inspection. People and relatives were complimentary about the management and staff.

During this, most recent inspection, we found the provider had made the necessary improvements to meet the breaches of Regulations 10, 12 and 13 identified at the last inspection. However, there had not been enough improvements to evidence how people were involved in the planning of their care and the activities offered to people were not always personalised to meet each person's identified needs and preferences. The provider’s systems in place to assess and monitor the quality of the service provided to people were not always used effectively and required further improvement.

Full information about CQC's regulatory response to issues and concerns found during inspections are added to this report after any representations and appeals have been concluded.

Charles House is a care home and is registered to accommodate up to 10 people who have a learning disability. At the time of our inspection six people were living at the 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.

There was a registered manager in post at the time of the inspection. 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.

Systems and processes in place to monitor the safety and quality of the service included the involvement of some people and relatives. The provider ensured that some information was available in different formats to meet the needs of people. There was a complaints process in place although there had been no complaints for more than 12 months. People and relatives were complimentary about the management and staff, although some staff felt the management team could be more supportive.

People were supported to maintain a healthy diet and all health needs were met with the support from staff. It was evident that people had developed positive relationships with staff. Staff knew people’s likes, dislikes and preferences well. However, improvements were required to ensure that care and activities were more personalised and took into account people’s abilities, hobbies and interests.

The home required considerable improvement with a number of repairs required to ensure people lived in a safe and homely environment.

We found that people were protected from the risk of abuse and avoidable harm because safeguarding systems and processes were in place. People were supported by sufficient numbers of staff who had the knowledge they required to care for people safely. However, there was improvement to be made with the continuing review of staff members’ suitability to support people.

People were supported by staff members that were caring, kind and respectful. However, we found there were missed opportunities to engage with people.

People were also protected against any risks associated with their health and care needs because risk assessments and associated care plans were developed and reviewed. This ensured that people received the support they required to remain safe. Some people and their relatives were involved in this process alongside any key professionals, to ensure that any decisions made in respect of their care and support needs, were done so within their best interests and in accordance with the Mental Capacity Act 2005. Where people were assessed to lack the capacity to consent to the support they received, the provider had followed key processes to ensure that care was provided in the least restrictive ways possible. Applications had been made to safeguard people against the unlawful deprivation of their liberty, where necessary. People’s privacy, dignity and independence were respected.

People received support from staff to take their prescribed medicines. Systems and processes were in place to ensure medicines were managed safely and only senior members of staff who had undergone specific training and supervision were permitted to administer medicines within the home.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive, comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

There was a registered manager in place at the time of our inspection. 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 did not always receive the support they required to maintain their safety and well- being. Some incidents of harm had occurred including people being touched inappropriately. These incidents had not been identified as potential sexual abuse and subsequently they had not been reported to the relevant agencies. The people involved had not received the support they required to keep them safe and to stop further incidents occurring. There were enough staff to support people with their personal care and day to day life, however the delegation of staff wasn’t adequate to ensure that people were kept safe. The registered provider had undertaken robust recruitment checks to ensure that new staff were suitable to work with people.

Risks relating to people’s healthcare needs and lifestyle had not all been assessed, and the action needed to manage and reduce the risk had not always been identified or planned. Staff we spoke with gave inconsistent accounts of how they supported people and the support was not always consistent with good practice guidelines. Action had not been taken to review the incidents that had occurred to ensure that people’s support plans were adjusted and action taken to reduce the likelihood of the incident happening again. In the area of risk management the registered provider and registered manager had not done all possible to ensure the likelihood of the risk reoccurring was as low as possible.

People required the support of staff to manage their medicines. Staff responsible for administering medicines had been trained and assessed and we found that people received their medicine when they needed it.

People were supported to see a wide range of health professionals, however some of the specific health needs people lived with had not been care planned, and not all specialist appointments had been attended. Staff we spoke with knew people well, and were able to identify changes in people’s wellbeing. People were provided with a wide range of meals and drinks that they enjoyed and that would ensure they maintained good hydration and nutrition.

People were supported to have some choice and control of their lives. We observed some examples of good practice, and some occasions where the opportunity to involve the person more had been missed. When restrictions on people’s liberty were necessary the registered manager had ensured the correct applications had been made to protect each person’s legal rights.

In our discussions staff demonstrated that they cared about the people they supported and many of the interactions we observed supported this. However some of the care we observed was focussed on the tasks to be completed and not the person. The care provided did not always protect and promote the person’s dignity. Staff had failed to protect people and taken action to uphold their human and legal rights. The staff we met knew people well, and were able to tell us about people including their needs, preferences and things and people who were important to them.

A range of activities and opportunities were provided for four of the six people each day. This meant these people were supported into the local community on a regular basis. The activities offered and undertaken were not specifically tailored or planned to meet each person’s needs and preferences. Two people with more complex care and support needs had far fewer opportunities and the registered manager and registered provider failed to demonstrate that they had the skills to provide a more specialist service for people with this additional level of needs. People had been supported to maintain links with people that were important to them.

There was little evidence of people being involved in the planning of their care; however relatives and staff that knew people well had been. The knowledge of the person’s wishes and lifestyle was used to plan care that they felt was in the person’s best interest and best fitted their known preferences and wishes.

The home was not consistently well run. During our inspection we identified numerous and serious issues including potential abuse of a safeguarding nature. The incidents recorded had not been identified as safeguarding issues by the registered manager or provider. They had not taken the action required to protect people, to escalate the concerns, or to ensure the relevant professionals were involved. The inspection identified six breaches of the legal regulations that providers are required to comply with. This meant people were receiving a service that was not safe, did not meet their needs or comply with the requirements of the law.

It was apparent that the registered manager had made improvements to the environment since they had started work at the home in September 2016. People and relatives we spoke with gave us positive feedback about the manager. The staff we spoke with shared mixed feedback about the manager. We shared these concerns with the registered provider for further consideration. The inspection identified that there was no clear plan on how to progress and improve. The checks on the safety and quality of the service had not been effective. The checks had not ensured that the service remained good, or that the service was meeting people’s needs and all of the fundamental standards.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Is the service safe?

We saw that the provider had safeguarding policies and procedures in place and some staff had received training to protect people who used the service from the risk of abuse. However, appropriate safeguarding referrals were not always made in a timely manner. We found that people were not always cared for in a clean and hygienic environment because regular cleaning and maintenance tasks had not been completed and infection control arrangements were not always in place to minimise the risk of infection.

Risk assessments were in place for people but there was no evidence that they were regularly reviewed. Care provided to people did not always reflect the agreed support that people needed to manage any risk. Records relating to incidents were not always comprehensive and there was a lack of recording to show that incidents had been reviewed to identify if changes could be made to protect the health and safety of people using the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to keeping people safe.

Is the service effective?

The provider had some systems in place to monitor the quality of the service. However, regular audits were not in place. Some issues affecting health and welfare were identified but not acted upon. Risk assessments did not manage risk effectively and incidents were not managed appropriately.

Relatives told us that the care provided was good. One relative told us, 'Nothing is too much trouble.' We saw evidence that care plans were used to ensure that care was individual planned to meet people's needs.

Staff had received appropriate induction and on-going training. They had been supported to ensure they had the skills and competencies to care for people effectively.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to managing and responding to risk.

Is the service caring?

People who used the service told us that staff were kind and supported them with activities they enjoyed. Relatives we spoke with said, 'The staff are wonderful and always make you feel so welcome.'

We saw that people who used the service were treated individually and that staff were considerate towards them. Most staff had worked at Charles House for a long time and told us they enjoyed caring for the people who lived there.

Is the service responsive?

Care records detailed the individual needs and interests of each person who used the service. Each person had a keyworker so that any changes that were required could be responded to. However, although risk assessments and care records were in place, changes in care were not always responded to when incidents occurred or risks were highlighted.

We saw that other health and social care professionals were involved regularly so that changes in health or circumstances could be addressed. However, some changes such as responding to elements of risk or putting in safety measures in place where risks were identified were not carried through.

Is the service well-led?

We saw that people using the service and staff were asked for their feedback about the service and that action was taken as a result of the feedback received. We spoke with relatives who were complimentary about the management of the service and felt that staff were helpful. Staff we spoke with said that they felt supported, and that they enjoyed working at the service.

There was evidence that staff training was provided and including specialist training for the needs of the people who used the service such as diabetes and autism. We saw that staff were supported with supervision and team meetings and enabled to gain further vocational qualifications.

Systems in place to assess and monitor the quality of the service provided and to manage risks were not all effective. We saw that the provider had carried out some audits, but recommendations arising from the audits were not always identified, or acted upon. Accidents and incidents had not been audited effectively to identify any risks relating to health and safety of people using the service. Some documentation such as policies and risk assessments were not dated and no checks had been undertaken to provide assurance that all staff had seen and understood the current policies. We saw no evidence that audits were conducted in respect of record keeping and no audits to show that documentation was checked to ensure that agreed plans were being followed up to ensure people received the care and support they needed.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality monitoring and quality assurance.

At the time of our inspection nine people lived at Charles House. During our inspection we briefly met all of the people that lived there and spoke with three of them before they went out for the day to for example day centre or to visit town. We spoke with staff on duty and the registered manager.

One staff member told us, 'If staff have a good relationship with a person, it helps build up trust and people are less anxious when supported with care.' We saw that care was offered to people by staff that they knew which made them less anxious and able to give consent to their day to day care and support needs.

We saw that the registered manager was aware of their legal duties to have a 'best interests' multi-disciplinary meeting where people may not be able to give consent to medical treatment.

We found that not all staff members had completed or received updates in the training that they needed for their job role.

We found that records were not always well organised and some records were not kept as required.

We observed that people were at ease in the company of staff. One person told us, 'I like the staff and they help me.'

We saw that people's needs had been assessed by a range of health care professionals and their healthcare needs had been monitored and met.

Systems were in place to ensure that people were safeguarded from harm and the risk of abuse.

We found that checks had been completed on staff to make sure that they were suitable for their job roles. Staff told us that they felt they had the skills and knowledge to know how to safely support people who lived there to meet their needs.

One person told us that they were asked for their views about the home and these were listened to. We saw that audits were completed and action was taken to make improvements where needed.

sampled the provider's records.

When we inspected the home in August 2012 we found that monitoring systems did not protect the people living there against the risks of unsafe care and treatment. At this inspection we looked at the improvements that had been made in relation to this. We saw that audits had been completed and action taken as a result of these to make improvements to the environment of the home, for example, carpets had been replaced.

Records sampled showed that the manager had identified where there were gaps and ensured the required records were in place. This helped to ensure that the people living there were protected against the risks of being supported by unsuitable staff.

We saw that the views of the people living there, their representatives and staff about the service provided had been sought. The manager told us that they planned to look at the views expressed and make improvements where needed.