Harbour

About the service

Harbour is a residential care home that provides personal care and support for up to six people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were six people living at the service.

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

Right Support: The model of care and setting maximises people’s choice, control, and Independence. People had fulfilling days and staff supported people by focussing on their strengths and encouraging people to be independent. People were supported to receive specialist health and social care support locally in line with their assessed needs. The service was homely, clean and people's bedrooms were personalised.

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. However, we have recommended the provider reviews documentation in relation to restrictive practise.

Right Care: Staff respected the people they supported and provided care that was caring and compassionate. People were encouraged to take positive risks to enhance their wellbeing and support plans reflected their individual needs and preferences.

Right Culture: The ethos, values and attitudes of staff helped to ensure people using the service were enabled to lead confident, inclusive, and empowered lives. Staff understood their role in making sure that people were always put first, and their care and support was tailored to their individual needs and preferences. The management team had created an open and transparent culture, where constructive feedback was encouraged.

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 on 31 March 2020) and there were multiple 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 not enough improvement has been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 07 and 13 February 2020, breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment, Need for consent and good governance.

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

Enforcement and Recommendations

We have identified breaches in relation to good governance and have made recommendations in relation to homely remedies and Deprivation of Liberty Safeguards (DoLS). Please see the action we have told the provider to take at the end of this report.

Follow up

This is the third consecutive time this service has been rated 'Requires Improvement.' 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.

Harbour is a residential care home that provides personal care and support for up to six people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were four people living at the service.

Harbour was a large home, bigger than most domestic style properties. This is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs, intercom, cameras, industrial bins or anything else outside to indicate it was a care home. Staff were also discouraged from wearing anything that suggested they were care staff when coming and going with people.

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

People received individualised care and support from staff who knew them well. People told us they felt safe and liked living at Harbour. One person said, "I do feel safe living here now, it’s a much nicer place to live.”

We found the service had made a number of significant improvements in all areas over the twelve-month period since the last inspection, however some improvements were still required.

Quality assurance and governance systems were in place to assess, monitor, and improve the quality and safety of the services provided. However, we found the systems in place were process driven and were not undertaken robustly, and as such had not identified the issues we found at this inspection. This meant they were ineffective and did not always drive the necessary improvement.

Harbour had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published, we found it followed some of these values and principles. 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.

Whilst we did not find people were being disadvantaged, people were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

People were not always protected from the risk of avoidable harm. We found where some risks had been identified, it was unclear what action had been taken to mitigate those risks and keep people safe. For example, in relation to the management of homely remedies and the environment.

Other risks were well managed. For example, were risks had been identified in relation to people’s complex care and/or health needs, records demonstrated action had been taken to minimise these.

People, staff and relatives felt there were enough staff on duty to support people and keep them safe. However, we were unable to tell from the rota if there were sufficient staff on duty with the right skills to meet people's needs. We have recommended the provider reviews staffing levels.

People were protected by safe recruitment processes. Systems were in place to ensure staff were recruited safely and were suitable to be supporting people who might potentially be vulnerable by their circumstances.

People's privacy and dignity was respected, and their independence promoted. People had access to healthcare professionals when required and were supported to maintain a balanced healthy diet.

People’s medicines were stored safely and staff had received training in the safe administration of medicines and were having their competency regularly assessed.

People using the service receive planned and co-ordinated person-centred support that was focused on them having opportunities to gain new skills and become more independent.

People, relatives, staff and healthcare professionals had confidence in the registered manager and told us the service was well managed. One health care professionals said, “The registered manager and staff have worked extremely well together to improve the service and change the culture, this has positively impacted on all the people living there.”

People were encouraged to share their views through regular reviews and relatives felt comfortable raising complaints and were confident these would be acted on.

The service was clean, and staff had access to personal protective equipment (PPE).

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 on 19 February 2019) and there were multiple 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 not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the safe care and treatment, need for consent and good governance. We have also made recommendations in relation to staffing levels and record keeping. Please see the action we have told the provider to take at the end of this report.

Follow up:

This is the second consecutive time this service has been rated 'Requires Improvement.' 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. In addition, we will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Harbour 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. Harbour is registered to provide personal care and support for up to six people who have a learning disability or autistic spectrum disorder. The home does not provide nursing care. At the time of the inspection there were six people living at the home.

The home did not have a registered manager in post at the time of the inspection. An interim manager had recently been appointed by the provider to oversee the running of the home. However, they were not present during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered provider, 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 home is run.

The home had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published, we found it followed some of these values and principles. These values relate to people with learning disabilities living at the home being able to live an ordinary life.

Prior to our inspection an incident had occurred which raised concerns about the conduct of one staff member and the culture within the home. During this inspection we looked at the actions taken to minimise the risks of similar incidents taking place. We found the provider had not taken sufficient steps to ensure other people living at the home were protected from similar risks. There was insufficient management oversight to ensure people received the care and support they needed, in a respectful and dignified way that promoted their wellbeing and protected them from harm. Where staff displayed poor practice, this was not always known or challenged by senior staff which impacted on the culture of the home. This had led to one person not having the opportunity to access advocacy, advice and support when they had need it.

We looked at the home’s quality assurance and governance systems to ensure procedures were in place to assess, monitor, and improve the quality and safety of the services provided. Although some systems were working, others had not been effective, as they had not identified the concerns we found during this inspection. This meant the systems in place to manage risk could not be relied upon.

People were not always protected from the risk of avoidable harm. We found risks such as those associated with people's complex care needs, medicines and the environment had not always been assessed or managed safely. Where risks had been identified, guidance had not been provided to staff to mitigate these risks. Although systems were in place to identify and record accidents and incidents, we found staff were not consistently recording accidents and incidents or taking sufficient action to prevent future reoccurrence.

People’s needs were assessed prior to coming to live at the home. This formed the basis of a support plan, which was further developed after the person moved in and staff had gotten to know the person better. We found people were at risk of receiving care that did not meet their needs as support plans were not being regularly reviewed.

There was a staff training programme in place and staff confirmed they received regular training in a variety of topics. These included safeguarding, health and safety, fire awareness and medication. However, we found some improvements were needed to ensure that staff had the necessary skills and knowledge to meet people’s needs.

We have made a recommendation in relation to training.

People mostly told us they were happy living at the home and liked the staff that supported them and a relative told us they did not have any concerns about people’s safety. People were encouraged to share their views and people told us they were aware of how to make a complaint. Although they were not confident their concerns would be taken seriously.

We have made a recommendation in relation to the management of complaints.

Systems had failed to ensure that people's personal and confidential information was being held securely or confidential information was not being discussed openly.

The registered provider had not always notified the Care Quality Commission of significant events, which had occurred in line with their legal responsibilities.

The management and staff structure provided clear lines of accountability and staff knew who they needed to go to if they required help or support. Throughout the inspection, we found the provider’s locality manager to be open, honest and transparent. Whilst they had not been aware of all the concerns we identified they were aware of the need to improve.

People were protected by safe recruitment processes. Systems were in place to ensure staff were recruited safely, and were suitable to be supporting people who might potentially be vulnerable.

People's healthcare needs were monitored by staff and people said they had access to

healthcare professionals according to their individual needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice.

People were encouraged and supported to maintain links with the community to help ensure they were not socially isolated. People’s support plans contained information about people’s hobbies and interests.

The home was clean, staff had access to personal protective equipment (PPE) and there was an on-going programme to redecorate and make other upgrades to the premises when needed.

We found breaches 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 the report.

The Harbour is a large Victorian house set within its own gardens in a residential area on the outskirts of Torquay. The service is registered to provide care and accommodation for up to six people with learning disabilities and autism.

On the day of inspection, there were two people living at the service permanently and two people receiving short term support.

The home had a 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.

People told us that they felt safe and there were systems in place to help ensure people were protected from all forms of abuse. Staff had received training in how to recognise signs of harm or abuse as well as in whistleblowing, and knew where to get further information if they needed it.

The provider had developed a number of easy read documents and posters which were displayed within the home which told people how they could seek advice or raise a concern.

The registered manager ensured that there were sufficient numbers of staff on duty to keep people safe and meet their identified needs. We reviewed the staffing rota for the month prior to our inspection and found that the registered manager determined staffing levels according to people’s needs and adjusted the rota accordingly. Recruitment procedures were robust and records demonstrated that the registered manager carried out robust checks to help ensure staff employed were suitable to work with vulnerable people. This included checking people’s identity, obtaining references and carrying out DBS checks (police checks).

Staff training records demonstrated that staff had undertaken a comprehensive induction and received regular training. This included training in medication, first aid, autism, mental health, communication, Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS), breakaway techniques, de-escalation techniques; person centred planning and safeguarding of vulnerable adults. Staff received regular supervisions and annual appraisals. Supervision gave staff the opportunity to sit down with their manager and discuss all aspects of their role as well as the opportunity to discuss their professional development.

People were supported by staff who had a good understanding of their needs and were skilled in delivering individualised care and support. Support workers spoke about people knowledgeably and demonstrated during our conversations a clear understanding of people’s needs and preferences.

Harbour provided services to people with multiple complex needs. There were safe systems in place to assess and manage risk within the service. Risks to people’s safety, health and wellbeing were individually assessed and regularly reviewed. People’s support plans included detailed risk assessments with clear guidance for staff on the action they should take to protect people from identified risks. Where appropriate, prompt referrals had been made to health care professionals to ensure the service continued to meet people’s needs safely. Keyworkers reviewed people’s support plans monthly, and recorded the person’s comments, which included details of progress, challenges and any changes in their support needs.

People received their prescribed medicines on time and in a safe way. There was a system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely when they were no longer required. The service used a monitored dosage system (MDS), provided by a local pharmacy on a monthly cycle. When medicines arrived at the service the medication administration record (MAR) showed that medicines had been counted into stock and staff signed to say the right numbers had been received.

Medicines, which required additional secure storage, were locked away in accordance with legislation. The Harbour used two systems to record this type of medicines, one system was accurate, however the system they were legally required to complete was not. This meant the home was not recording medicines in a way that met their legal responsibilities.

People’s support plans contained records of referrals to a range of health care professionals including GPs, opticians, dentists and chiropodist, the outcomes of these appointments and any changes were documented in people’s support plans.

The registered manager and staff we spoke with had received training and demonstrated a clear understanding of The Mental Capacity Act 2005 (MCA). People were fully involved in all aspects of their care and had full access to their records. People’s support plans clearly demonstrated that their consent and views were sought in relation to any decisions being made about them. Where decisions had been made in people’s best interest, documentation showed that staff had consulted family, and health care professionals when making these decisions, which meant that the home was working in line with the principles of the act.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedure for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). The registered manager had made the appropriate referrals for the two people living at the home to the local authority, which had been granted. Although the registered manager had failed to notify the care quality commission of these authorisations as they should do, they sent the required statutory notifications as soon as they realised they needed to.

The registered manager had a clear vision for the service, which they told was to provide positive individualised person centred care, by supporting people to make their own decisions and choices about their lives. Staff demonstrated they understood the principles of individualised person centred care through talking to us about how they met people’s care and support needs. We saw that staff treated people with respect and offered people choice.

People who used the service were supported and encouraged to share their views through regular house meetings and by completing annual surveys and their responses were recorded. Due to peoples limited communication abilities we saw that people had been supported to express their views by family members, keyworkers and independent advocates. People were actively involved in setting the agenda and were supported to discuss topics, which were important to them. Staff meetings were held regularly, staff were able to share ideas and express any concerns. The registered manager used these meeting to empower the staff team to discuss and learn from incidents, highlight examples of best practice and challenge poor practice were it had been identified.

There were effective quality assurance systems in place to monitor the standard of care and ensure that people received care that was safe and met their identified need. The registered manager carried out health and safety quality audits on a monthly basis and submitted weekly reports to the registered provider that were used to identify any areas of concern and plan on-going improvements.

We have made a recommendation about the management of some medicines.

We found that people's consent had been obtained for care and treatment provided to them by the service. Records showed that people had regular opportunities to be involved in and discuss how they wished to have their care provided. Where people did not have the capacity to make significant decisions their rights had been protected.

People's health and social care needs had been assessed and care was planned and delivered in line with their individual care plan. People had access to community and specialist health services.

People had been protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. However, the system was not being followed by all support staff.

People were cared for by suitably qualified, skilled and experienced staff.

People who live at the home were aware of how to make it known to support staff if they were unhappy.

We found that people's privacy was protected. Information was provided to people in suitable formats. Records showed that people had regular opportunities to be involved in and discuss their care.

People made choices about everyday living, such as what to eat, what to wear and which activities they took part in. Where people did not have the capacity to make significant decisions their rights were protected.

People's needs were assessed and care was planned and delivered in line with their individual care plan. People had access to community and specialist health services. Records showed and people told us that they had made progress at Harbour such as learning new skills. One person told us they would be moving on to live in a flat.

There were effective recruitment procedures and sufficient trained staff were employed to meet people's needs.

People told us they felt safe. The provider had effective systems to prevent, identify or respond to abuse.

The provider had effective quality assurance systems in place which took into account people's views.