Whitstone House

Whitstone House is a residential care home providing personal and nursing care to up to 10 people with a learning disability, and autistic people, with mental and/or physical healthcare support needs. At the time of our inspection there were 8 people using the service. The service provider is Autism Anglia, and the building is owned by a housing association.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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

Right Support:

We identified continued breaches of regulation as part of this inspection. This meant the provider did not assure us that people’s safety could be upheld, as not all risks associated with people’s care and their environment had been assessed and rectified. For example, risks from poor infection control, risks from falls from height and risks from broken or poorly maintained equipment placed people at increased risks of avoidable harm.

People were mostly 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 did not always document this practice.

We were still not confident that people were appropriately supported to make more complex decisions in regards to their health care needs in line with the principles of The Mental Capacity Act 2015.

Best interest decisions did not clearly demonstrate how and why decisions had been made.

Relatives spoken with were not confident that people who staff supported were receiving good outcomes of care. They told us communication could be poor and staff did not always inform them how people spent their day. Relatives said they were advised of anything of an urgent nature but would like to know how people were supported with their needs. They described activities as mundane and not in line with people’s needs and experiences of what they used to enjoy.

We identified a positive culture in the service with people going out often, but less so at the weekend due to staffing fluctuations. Continuity of care and support was important to both people and their relatives, and we still had concerns about staff vacancy rates and the regular use of agency staff which potentially limited people’s opportunities.

Staff were supported in their role by the registered manager, through a recognised national induction and were assessed to ensure they had the right competencies and skills. Some staff training had lapsed, and role specific training had not been fully rolled out which meant potential gaps in staff’s knowledge, some who were new to their roles.

People’s care plans had improved and the ones we looked at were up to date. We reminded the provider to ensure records were cross referenced and to make sure all staff were aware of the records they must adhere to when providing people with care and support. We also recommended that care plans and risk assessments were updated by staff following an incident to ensure risks and actions were clearly documented.

We found medicines were administered to people in line with their needs and monitored to ensure they were necessary and correctly given in line with prescriber’s instruction. We have made 3 recommendations about medicines management in the service. They are around ensuring people understand why they are taking medicines and what the side effects are. Monitoring medicines and where possible reducing them and thinking about a more person-centred approach to medicine administration.

Right Care: Some progress had been made since the last inspection and a new organisational structure and management team meant further improvements had been identified and planned. Relatives were aware of some of the changes but were not aware of how their feedback was acted upon or how they could influence the service. People using the service were encouraged to make choices by staff supporting them, but information should be readily available to them to help them understand more complex aspects of their support such as medicine administration.

At the last inspection we noted notifications were not being submitted in a correct, timely way to CQC in line with the provider’s regulatory responsibilities to provide safe care and support. We were confident the provider now understood their regulatory responsibilities and were submitting notifications in a timely way.

Right Culture:

The provider had learnt lessons and was developing the service to consider people’s immediate needs and how their needs might change in the future. Staff had not received training in end-of-life care. The provider advised us forward planning documents were going to be put in place.

Effective auditing was still not in place and risks identified as part of our inspection had not been identified by the provider. Whilst we were assured that people were going out and received good outcomes of care, we were less assured by the progressiveness of the service and how they ensured people were living their best lives with measurable outcomes of care.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 29 November 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of 4 regulations. The provider had not ensured the premises were safe and fit for purpose. We had concerns about how staff sought consent from people for more complex decisions and the governance and oversight was improving but had failed to identify some of the areas we did as part of our inspection.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed and remains requires improvement.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Whitestone House on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Whitstone House is a residential home providing personal care and accommodation to up to 10 people with a learning disability, and autistic people, with mental and/or physical healthcare support needs. At the time of the inspection, there were eight people living at the service. The service is part owned and managed by Autism Anglia and part owned by a housing association. People lived in spacious accommodation but essential alterations to the building and equipment were necessary to help ensure the service promoted people’s safety and dignity.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

Breaches of regulation identified in the main body of the report meant people were not receiving the right support, right care and right culture. Risks associated with the environment and people's care was poorly developed placing people at risk of avoidable harm.

People when supported by core staff experienced good outcomes of care. However, a turnover of staff and high use of agency staff meant people were not always supported by staff who were familiar with their needs. Fluctuations in staffing levels reduced people’s chance to get out and enjoy spending time doing things they liked to do.

Staffs skills and competencies were enhanced through training and observation, but we found some training was out of date and limited observation of practice were carried to ensure all staff were working effectively.

People’s care records were not up to date in line with their changing and unmet need and some staff’s training in de-escalation techniques had expired. We were not confident all staff would know how to support people in line with their needs and preferences or be able to consistently support people and help them reduce their anxieties.

An open-door policy meant staff did not feel afraid to seek support if required and they told us they were well supported.

Medicines were administered in line with people’s needs and carefully monitored to ensure they were necessary and correctly given in line with prescriber’s instruction.

Right Care

There was limited input from the provider to ensure people received good outcomes of care and all parts of the regulated activity were delivered well and safely. There was a lack of oversight and learning from incidents to ensure lessons were learnt and the service developed its staff in line with best practice.

Notifications were not being submitted in a correct, timely way to CQC in line with the provider’s regulatory responsibilities to provide safe care and support.

People were supported to make day to day decisions, but we were not assured that the principles of The Mental Capacity Act 2015 were followed for more complex decisions which people could not make for themselves. We noted gaps in people’s records and could not be assured people also had timely access to a range of different health care professionals.

Right Culture

The provider did not regularly take into account how people viewed their care. The quality monitoring processes were not robust in identifying concerns about the service. Staff were willing to learn but there were not adequate steps being taken to develop staff from within and supervise their work practices over a twenty-four-hour period.

Effective auditing had not taken place to ensure the standard of accommodation remained appropriate for people’s needs and people were supported to have their best lives and opportunity to develop their skills and independence. Without this we could not be assured of the culture of the service as people were not placed at the centre of the care provided.

The manager was not yet registered. Their lack of experience in a management role was evident through some of the judgements made. But they had experience of working in different roles and had gained some knowledge and insight. They were developing their team from within and enhancing their skills. They were open to our feedback and committed to improving the service and had a clear focus on people’s needs. The staff team respected the manager and felt they were a good leader.

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

Rating at last inspection and update

The last rating for this service was good (19 June 2019). At this inspection we found the rating was requires improvement, with inadequate for well-led.

Why we inspected

This inspection was carried out because of concerns identified about another of the providers locations.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service is requires improvement, with inadequate for well-led. We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Whitstone House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to people’s safety, the condition and maintenance of the care premises, people’s consent to care and support, governance and oversight of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service: The service provided spacious, generous accommodation which was unrestricted, and people could move around freely and access the garden and out buildings. The property was partly owned by Autism Anglia and partly by a housing association. We had some concerns about the safety and cleanliness of the building because audits were not sufficiently robust and had not identified potential hazards to people’s safety. We were however confident about the response of the provider to immediately address our concerns to ensure people were as safe as possible.

The management and oversight of the service had improved upon the appointment of a new registered manager who had started to identify and improve the service with the support of their manager. There had been no registered manager in post for a while after the previous manager left. Some of the governance processes had not been sufficient to identify gaps in the service provision. The service had been using high numbers of agency staff to help ensure they met their contractual arrangements for one to one staffing levels for some people. Since the new manager came into post agency usage had been significantly reduced and staff recruitment robust. This meant people had greater continuity of support by staff they had established a rapport with and were familiar with their needs.

Staff were being well supported with training being brought up to date and in line with their job roles and job description. Records supported a robust staff recruitment process and staff support and development.

Record keeping in general required improvement particularly regarding people’s care plans which were large documents and did not clearly and specifically show what people wanted to achieve and how the service supported them to do it.

People using the service had opportunities to go out and pursue a range of different activities appropriate to their needs. The staffing levels at the service made it possible to provide individualised support and people were supervised to help reduce any risks they might otherwise encounter.

People were supported to maintain good health and the service was proactive in monitoring and helping to manage people’s health care needs.

Staff were clear about how to support people who might lack mental capacity or unable to make decisions about their care, health and welfare. There was clear documentation in place where people could not consent particularly around access to health care.

People were supported to take the medicines they had been prescribed and there was clear guidance in place to ensure staff understood the benefits and side effects of medicines.

Rating at last inspection: Good: Report published 26 September 2016

Why we inspected: This was a planned inspection to check that the service remained Good.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

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

Whitstone House is registered to provide accommodation with personal care for adults with learning disabilities or autistic spectrum disorder. The home can accommodate up to ten people. The home has a communal lounge, conservatory and dining room. People each have their own bedroom and bathroom. At the time of our visit eight people were living at the home.

The provider has another home, Walnut House, which is also situated on the same site as Whitstone House and is managed by the same manager. The two homes have some staff who work across both homes and some of the provider’s records also relate to both locations. The two homes share communal gardens, swimming pool and garden rooms.

The homes registered manager had recently left, and the newly appointed manager was in the process of registering to become the 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.' 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.

Staff told us they worked as part of a team, and that the manager and deputy manager were supportive, encouraging and led by example. There was a strong caring culture in the care and support team.

Staff received the training they needed to deliver a high standard of care. Specialist professionals employed by the provider, such as a speech and language therapist, worked closely with and supported staff to deliver high quality care. People received individualised care in relation to their needs.

There were effective systems in place to manage risks, safeguarding and medicines, and this helped to keep people safe. Where people displayed behaviour that some people may view as challenging there was training and guidance given to staff. This helped them to manage situations in a consistent and positive way, and protected people's dignity and rights. The manager and staff ensured that people’s consent was obtained where they had the capacity to do so before providing support. There was a process in place to ensure that where people did not have the capacity to make decisions themselves, then this was done in their best interests on their behalf. People were able to contribute to the planning of their care.

People received care and support that was responsive to their needs. Care plans provided detailed information about people so staff knew exactly how they wished to be supported. People were at the forefront of the service provision and encouraged to develop and maintain their independence. People participated in a wide and varied range of activities. Regular outings were organised and people were encouraged to pursue their interests and hobbies.

The staff recruited had the right values and skills to work with people who lived at the home. Staffing levels remained at the levels required to make sure every person's needs were met and helped to keep people safe. The manager planned staffing resources flexibly and responsively so that people were able to enjoy a varied but well-structured day.

Systems were in place which continuously assessed and monitored the quality of the service provided at the home, including obtaining feedback from people and their relatives. Systems for recording and managing complaints, safeguarding concerns, incidents and accidents were managed well. The management took steps to learn from such events and put measures in place. This meant that lessons were learnt and similar incidents were less likely to happen again.

We spoke with three people who used the service, one person's relative, the assistant manager and three support workers. The registered manager was not available to speak with us. We reviewed the care records for three people. We also reviewed a selection of other records. These included staffing rotas, minutes from meetings and audit results.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

The Care Quality Commission 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. The MCA provides a framework to empower and protect people who may make key decisions about their care and support. The DoLS are used if extra restrictions or restraints are needed which may deprive a person of their liberty.

At the time of our inspection no person was subject to a DoLS authorisation. The assistant manager told us that they and the registered manager were currently applying for DoLS authorisations for all of the people who used the service. This was in relation to preventing people from leaving the service unaccompanied. The assistant manager told us that they had assessed people as lacking mental capacity and that the safeguard would help to protect people's safety and welfare.

We saw evidence that there were enough suitably skilled, qualified and experienced staff on duty at all times. This included staff to provide one to one and two to one care for people.

There was a safeguarding policy and procedure in place and this was in date. All of the staff, including the bank and agency staff used, had received training in relation to safeguarding vulnerable adults. The provider undertook the necessary checks to ensure that employees were of good character before employing them.

We saw evidence that the provider's audit schedule was effective. This included regular auditing of the quality of the service, as well as accidents and incidents and environmental risks.

Is the service effective?

The care and support that people received met their needs. All of the staff demonstrated a good understanding of the needs of people living with autism. We saw evidence that staff had received specialist training in relation to their roles and responsibilities.

Plans of care and risk assessments were regularly updated in order to reflect any changes in people's needs. We saw evidence that staff helped people to achieve their goals and aspirations. Effective communication techniques were used and all information was presented in an easy read format to help people understand what had been written.

The provider had effective working arrangements with other health and social care professionals. This included psychologists and speech and language therapists. This helped to ensure that people's care needs were being met.

Is the service caring?

All of the people told us that they were happy with the care and support that they received. One person said, 'I am happy. I have been playing table tennis and the staff are nice.' Another person said, 'I have been to the day centre and enjoyed myself. My key worker is good.'

We spoke with a relative of one person and they said, 'The staff are very good with my (relative). They look after their priorities and needs. I cannot think of a better place for my (relative) to be in. They are so happy here. The service is wonderful and all of my (relative's) needs are met.'

People received person-centred care. This meant that their care was individualised to their specific needs. It was evident that staff thoroughly understood the needs of the people that they were caring for, and treated people with compassion and respect. We observed staff interacting with people in a positive way. Different communication techniques were used to help ensure that the person understood what the staff member was saying. At all times, staff were courteous and caring towards the people they supported.

Is the service responsive?

The environment at Whitstone House was arranged to help meet the needs of the people who used the service. This included different areas where people could choose to spend their time. We noted that there were secure gardens, a swimming pool and numerous communal areas. One of the communal areas had been adapted for a person who wished to spend time alone.

It was evident that the care and support people received met their individual needs. People's care plans included all aspects of the person's daily living and there were support plans in place for staff to follow to help ensure that they responded to people's needs in an effective way. People's likes, dislikes and preferences were taken into consideration on all accounts. We noted that the activities people undertook reflected their hobbies and interests.

Each person who used the service had stated what their goals were. We found that their care and support was structured in a way that facilitated people to achieve their goals. The staff promoted people's independence whilst ensuring that their safety and welfare was maintained.

The provider had a complaints policy and procedure and we saw evidence that they took account of complaints and comments to improve the service.

Is the service well-led?

All of the staff we spoke with spoke positively about the management team at Whitstone House. Staff told us that they felt well supported and were able to access specialist training. Each person told us that they were encouraged to raise any concerns or comments that they had. They told us that the management team always listened to what they had to say and responded to their comments appropriately.

Staff told us that the staff meetings held by the manager were meaningful and productive. All of the staff we spoke with felt valued and part of the team.

We noted that there was a positive culture within the service. The staff told us that the management team regularly worked alongside them while they carried out their duties in order to support them.

The service had effective quality assurance systems in place to assess and monitor the quality of the service that people received. This included monthly audits of all aspects of the service as well as regular meetings with the people who used the service. Included in these were appropriate action plans to address any shortfalls in the quality of the service provision.

The individual care records reviewed demonstrated that people's care and therapeutic needs were recorded in detail and that they were being met in line with their assessed need. This meant that people experienced care, treatment and support that met their needs and protected their rights.

We saw that people were enjoying their lunch and could choose what they would like to eat and drink. This and the other evidence assessed demonstrated to us that people were protected from the risks of inadequate nutrition and dehydration.

Staff reported that they felt well supported by senior managers and by the provider and that there were good opportunities for training and career development. This showed us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The service was being audited monthly by the regional service manager with the assistance of the registered manager. We noted that any actions arising had been addressed. This demonstrated to us that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

The purpose of this inspection, carried out on 21 November 2012, was to ensure that improvements had been made. We found that they had.

We found that the manager of the home had put in place processes which would ensure people were able to consent to their care and treatment and that should a person's mental capacity need to be assessed in relation to a specific decision, records were in place to show how specific decisions had been reached.

We also saw records which demonstrated significant improvements in the way in which safeguarding referrals are recorded and monitored by the service.