Nak Centre

The service was not able to demonstrate how they were meeting some of underpinning principles of "Right Support, Right Care, Right Culture.

The Nak Centre is a residential care home providing personal care for up to 6 people with learning and /or physical disabilities and autistic people. At the time of our inspection there were 6 people using the service. The Nak Centre is a detached building located in its own gardens near the city of Truro.

The registered provider, has the joint role of registered manager, and will be referred to in this report as registered provider.

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

Right Support

The registered provider did not have effective safeguarding systems in place. The registered provider , did not demonstrate a clear understanding of their responsibilities to report safeguarding concerns. Staff had limited understanding of what to do to help ensure people were protected from the risk of harm or abuse.

People were not always supported by enough staff on duty which placed restrictions on their everyday lives.

Staff supported people to have some choice and control in their everyday lives. Their ability to do this had been impacted by staffing shortages in the service which meant people were not always able to access the community or take part in activities that they enjoyed.

Risk assessments varied in their quality; some identified a person's risk but did not state what should happen to reduce the risk, and therefore didn’t mitigate risk.

Infection control procedures and measures were in place to protect people from infection control risks associated with COVID-19.

People lived in a safe and well-maintained environment.

Staff supported people with their medicines and worked with health professionals to achieve good health outcomes.

People were supported to have some 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.

Right Care

The service did not have enough appropriately skilled staff to meet people's needs.

People using the service told us they felt they were cared for, comments included “They are looking after me” and “It is nice here.”

We observed many kind and caring interactions between staff and people.

Right culture

The service was a long-standing family run business, and the size of the staff team was small. Five people had lived with the registered provider since they were young children, therefore they had built a familiar routine with people that they appeared to be comfortable with and it felt more akin to a family unit. This allowed the potential of a closed culture to form. The registered provider had not kept up to date with good working practices and was not part of any manager forums or other similar groups. This meant the service was isolated and there was a risk of a closed culture developing.

The service had fixed routines that were not flexible, for example drink and meal times routines. This was due to how the service had been organised, and perpetuated by the lack of staff available within the service. This meant people lacked opportunity to choose what they wanted to do and when.

Staffing levels had impacted on the registered providers availability to ensure that managerial tasks were completed. Feedback from staff, and the review of records and care documentation evidenced there was poor oversight of the service which was affecting aspects of the operations of the service. Audits to oversee the service were not up to date and therefore were ineffective in identifying areas for improvement.

The service had not sought the views and opinions of people using the service, staff and professionals. Staff team meetings and staff supervisions had not been held which meant that opportunities for staff and managers to discuss any issues or proposed changes within the service had been missed.

The registered provider had not been open and transparent with people and relatives and commissioners in respect of the recent concerns at the service. The lack of opportunity for stakeholders to provide feedback or raise concerns increased the risk of a closed culture developing.

The registered provider was inconsistent in how they worked with professionals. For example, they were welcoming of support but had not attended a meeting that had been arranged.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Last rating and update

At the last inspection the service was rated as good (published 20 July 2022).

Why we inspected

The inspection was prompted in part due to concerns received about people's safety, staffing and leadership. A person using the service was placed at significant harm. The information CQC received about the incident indicated concerns about the leadership of the service, the safety of people using the service and that staffing was not sufficient to meet people’s needs. This inspection examined those risks. As a result, we carried out a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

We have found evidence that the registered provider needs to make improvements. Please see the safe, and well led sections of this full report.

Enforcement and recommendations

We found breaches relating to safeguarding, staffing and the governance of the service. Please see the action we have told the registered 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

The Nak Centre is a residential care home providing personal care to up to six people with learning and /or physical disabilities. At the time of our inspection there were six people using the service. The Nak Centre is a detached building located in its own gardens near the city of Truro.

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.

Based on our review of safe, responsive and well-led, the service was able to demonstrate how they were meeting some of the underpinning principles of “Right Support, Right Care, Right Culture for the people they currently support.

Right support:

Model of care and setting maximises people's choice, control and independence. The home was spacious and adapted to meeting people's changing needs.

People were supported to make their own decisions. This included choosing menus, going shopping and accessing the community. People were able to access timely support from health and social care professionals.

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.

People were supported by enough staff on duty. People received their medicines in a safe way. People were protected from abuse and neglect.

Right care:

People were treated as individuals, their communication styles were respected, and staff understood what worked well for them. Care plans informed staff of any specific ways to best communicate with people.

People were treated in a dignified manner and staff were aware of people's support needs. Staff were observed talking to people in dignified and respectful way. Staff delivered personal care when people needed it and gained consent prior to providing any support.

Right culture:

Five people had lived with the registered provider/manager since they were young children, therefore they had built a familiar routine with people that they appeared to be comfortable with. People appeared comfortable and it felt more akin to a family unit. The registered provider/manager told us that each person was treated as individuals and their personal preferences and choices were respected by the staff team. A professional told us “The care is old fashioned but for the people here it is right for them. [Registered managers name] has known these people for so long, she knows everything about them, as does her staff they get good care.”

Staff were caring and worked positively with people living at the home.

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

We had received a concern that some staff were not always wearing a face mask. It was apparent that there had been confusion in how the guidance had been understood. The registered provider/manager immediately changed practice so that masks were always worn and relayed this to staff immediately. We were somewhat assured that the provider was using PPE effectively and safely.

We have made a recommendation about this in the safe section of this report.

Cleaning and infection control procedures had been updated in line with COVID-19 guidance to help protect people, visitors and staff from the risk of infection. Government guidance about COVID-19 testing for people, staff and visitors was being followed.

People told us, and we observed that they were happy with the care and support they received. Health and social care professionals were complimentary about how people were cared for.

There were staff vacancies at the time of this inspection. Regular agency staff were being used to cover these absences whilst a recruitment campaign was on going. Duty rotas confirmed that there was a mix of permanent and agency staff on duty so that people were supported by some members of staff that were familiar to them on each shift.

All necessary recruitments checks had been completed. New staff completed an induction.

People were supported to access healthcare services, core staff recognised changes in people's health, and sought professional advice appropriately.

The registered provider/manager maintained oversight of complaints, accidents and incidents and safeguarding concerns. They engaged well with health and social care professionals. Systems to assess and monitor the quality and safety of the care provided were in place. They were effective in assessing quality and identifying and driving improvement. The service had clear and effective governance systems in place.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Last rating and update

At the last inspection the service was rated as good (published 2 October 2018).

Why we inspected

We received concerns in relation to how people were supported to move around the service safely, medicines stored incorrectly and the use of PPE. We undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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 following this inspection. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, responsive and Well led sections of this full report.

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

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.

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Nak Centre 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. The provider is also 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.

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 Nak Centre is a detached home which provides accommodation for up to six people. At the time of the inspection six people were living at The Nak Centre. People had lived at the service for several years and staff knew the people they supported well. The registered manager took an active role in the running of the service. They were supported by a core staff team who had worked at the service for some time.

People had limited verbal communication skills so we spent time observing their interactions with staff. The atmosphere at the Nak Centre was calm and friendly. Interactions between staff and people were kind, respectful and supportive. Relatives were positive about the care their family members received. Staff described to us how they worked to support people to make day to day choices and build on their independent living skills.

The premises were well maintained, pleasant and spacious. People's bedrooms had been decorated and furnished in line with their personal preferences. Risks associated with the environment had been identified and action taken to minimise them.

Staff said they were proud to work at The Nak Center and told us “This is our extended family.” People were protected from abuse and harm because staff understood their safeguarding responsibilities and were able to assess and mitigate any individual risk to a person’s safety.

The service had suitable arrangements for the storage and disposal of medicines. Medicines were administered by staff who had been trained and assessed as competent to manage them safely.

People received care and support that was responsive to their needs because staff were aware of the needs of people who lived at the Nak Center. Staff were prompt at recognising if a person’s health needs had changed and sought appropriate medical advice promptly.

Staff had received appropriate training so that they could communicate with people in a meaningful way, for example use of pictures/photographs to support effective communication. The care plan identified the person’s communication needs and this was shared with other agencies when necessary.

Care plans were well organised and contained personalised information about the individual person’s needs and wishes. Care planning was reviewed regularly and whenever people’s needs changed. People’s care plans gave direction and guidance for staff to follow to help ensure people received their care and support in the way they wanted. Risks in relation to people’s care and support were assessed and planned for to minimise the risk of harm.

Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. Where people needed assistance with eating and drinking staff provided support appropriate to meet each individual person’s assessed needs.

People were supported to maintain good health, have access to healthcare services and receive on-going healthcare support. The staff had developed positive working relationships with health and social care professionals.

Care records showed that people took part in a range of activities both in the service and in the community. For example, carriage riding, and the opportunity to go on holidays supported by staff.

Staff were recruited in a safe way. There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes.

Staff were supported by a system of induction training, one-to-one supervision and appraisals. The induction and on-going training of staff ensured they were effective in their role. Staff knew how to ensure each person was supported as an individual in a way that did not discriminate against them.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). They demonstrated their understanding of these principles in the way they cared for people. Staff believed that everyone at the service had the right to make their own decisions and respected them. The registered manager knew the process to follow if a person’s level of capacity changed so that the service would act in accordance with legal requirements.

There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example.

People, relatives and health and social care professionals were asked for their views on the service regularly. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.

We carried out this focused inspection to check the provider was now meeting the legal requirements. The inspection took place on 7 June 2017 and was unannounced. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for the Nak Centre on our website at www.cqc.org.uk.

The Nak Centre provides care and accommodation for up to six people who have a learning disability. At the time of the inspection five people were living at the service. 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.

Care plans were up to date, accurate and gave a comprehensive picture of people's needs and preferences. There was a system in place to help ensure they were regularly reviewed and any changes in people's needs were clearly highlighted. Daily logs were completed regularly and the information was detailed and descriptive. Where necessary, people's health was monitored to help ensure any changes would be quickly recognised. We found the service was now meeting the requirements of the legislation.

People had access to a range of activities which were meaningful and appropriate to their needs. Activities took place both within the service and in the local community. People were supported to be involved in daily tasks such as laundry and other household chores according to their abilities.

The Nak Centre provides care and accommodation for up to six people who have a learning disability. At the time of the inspection five people were living at the service. 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.

People had lived at the Nak Centre for several years and staff knew the people they supported well. The registered manager took an active role in the running of the service. They were supported by a core staff team who had worked at the service for some time. Staff told us they had worked with other agencies to improve the way they supported people. They were confident this had been a positive development for people who they said had been “empowered” by the changes.

People had limited verbal communication skills so we spent time observing people and their interactions with staff. The atmosphere at the Nak Centre was calm and friendly. Interactions between staff and people were kind and supportive. Staff described to us how they worked to support people to make day to day choices and build on their independent living skills.

The premises were well maintained, pleasant and spacious. People’s bedrooms had been decorated and furnished in line with their personal preferences. Risks associated with the environment had been identified and action taken to minimise them.

Care plans had not been updated for some time and some information was out of date or contradictory. We identified a breach of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

There were sufficient numbers of suitably qualified staff to keep people safe. Recruitment practices helped ensure staff were fit and appropriate to work in the care sector. Staff received an induction when they first started work which included training in areas identified as necessary for the service. This included training in safeguarding and staff knew how to recognise and report abuse. They were confident the registered manager would take any concerns they had seriously.

People took part in a range of activities such as riding, attending local day centres and regular trips out to cafes and restaurants. In addition external health care workers often visited the service to facilitate sessions such as drumming, creative art and aromatherapy massages. People were supported to be involved in daily tasks for example, laundry and preparing meals, according to their abilities.

This inspection was completed to check compliance with the warning notice issued by the Care Quality Commission on the 9th January 2014. We issued the warning notice due to concerns about the lack of effective quality assurance systems in place at the Nak Centre.

At this inspection we found the Nak Centre had made some improvements to the way in which the quality of the service was monitored and audited.

We found staff had received training to enable them to support people to a good standard. Supervision was occurring although this was not always documented.

We found records were not always maintained to a high enough standard to ensure people who used the service and staff were protected from risk. We will check again within six months to ensure improvements have continued.

Most people living at the home had very limited, or did not have any, verbal communication skills. We spent two hours in the lounge observing care practice whilst we were inspecting records.

From our observation of care practice, and from the feedback we have received from external professionals, we have judged there has been significant improvement in care practice within the home. We observed, and have been told by external professionals, that people who used the service were treated with respect and dignity. External professionals and our observations have concluded that, at the time of our inspection, there was more involvement of people who used the service both within the home and in the community than we previously saw. There was limited improvement in the management of the financial benefits and monies of people who used the service, although we still had significant concerns regarding how the personal monies system operated.

The home was well maintained and furnished. The home was situated in a rural setting and had pleasant gardens. The home was clean and odour free. Health and safety standards needed improvement to comply with the regulations.

Staffing levels were adequate. Staff training and supervision arrangements were not satisfactory.

The quality assurance system was not satisfactory. Despite significant involvement from the multi-disciplinary team, the registered provider had not developed any systems of audit or improvement planning.

At this inspection we still had significant concerns about how the registered provider looked after people's finances. For example in most cases the totals of money held, did not tally with records kept. We were also concerned about the arrangements in place regarding the management of government social security financial benefits.

We have reported our concerns to Cornwall Council, who, at the time of the inspection, were co-ordinating a systemic safeguarding review regarding the service. As a consequence of our findings, we decided to extend the deadline of the warning notice for it to be complied with by 29th November 2013. After this date, we will check again to ascertain it has been complied with.

The inspection resulted in significant concerns relating to the management of monies belonging to people who used the service. In summary financial records made it difficult to account for monies people should have received. It was difficult or impossible to account for how people's monies were spent. There were significant discrepancies between the balances in financial records and cash held.

During the inspection we were satisfied people were adequately cared for and treated in a respectful manner although we had some concerns whether there were enough activities available for people. The registered provider was currently in the process of rewriting care plans. We were concerned about the management of people's finances and have discussed these concerns with the local authority.

When we inspected the home it was well maintained, was clean and odour free. Health and safety standards were adequate, although some improvements were required.

Staffing levels were adequate although we were concerned whether they were sufficient to give satisfactory flexibility if people's needs changed and /or people wanted to go out in the evening. Most staff personnel files contained satisfactory information to confirm appropriate staff recruitment checks had been completed. Training records contained limited information and improvement was required in this area. There was no quality assurance system in place.

The home accommodated six people with a learning disability, some who were autistic. Most people did not have verbal communication skills, although we spoke with one person who said they were happy with the care and support they received.

The inspection was carried out over two days in order to observe care in the evening and during the day time. On both occasions we used our 'Short Observational tool For Inspection' (SOFI) tool to observe care. The care we observed was generally to a satisfactory standard. We concluded the four people we case tracked had satisfactory activities. Each person had a care plan, but these did not effectively describe people's care needs.

We inspected the home on a Saturday. Most people did not have verbal communication skills. Two people had some verbal communication skills and said they were happy, and that the food and the staff were nice.

We used our 'Short Observational tool For Inspection' (SOFI) tool to observe care. During a period of one hour and ten minutes we recorded every five minutes the interactions between staff and people who used the service, the activities people were engaged in, and noted people's moods. We had significant concerns about how staff worked with people.

We concluded care plans and records did not describe people's care needs, and records kept by staff caused us significant concern regarding care provided.

We checked the service's medication system. This operated well and suitable records were kept.

When we inspected the home it was well maintained and furnished. The home had pleasant gardens, in a rural setting. The home was clean and odour free. We had concerns about health and safety standards.

Staffing levels were satisfactory. We had significant concerns regarding the conduct of the staff. We subsequently used safeguarding procedures to report our concerns to the local authority. We were not able to check staff recruitment and training records as these were not available for inspection.