Boulevard House

About the service

Boulevard House is a residential care home providing accommodation and personal care to up to 15 people. The service provides support to people with a learning disability. The accommodation comprises of a bungalow with 3 bedrooms and a main house with 12 bedrooms. At the time of our inspection there were 11 people using the service.

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

Right Support

Risks were not always assessed or managed to ensure staff had the appropriate guidance to keep people safe. The use of restrictive interventions had not been risk assessed so we could not be assured people would be kept safe if restrictive practice was used. Restrictive interventions are interventions that restrict or limit what people can do or where they can go; they can also be used to subdue or control distressed reactions. Restrictive intervention includes physical restraint which is any direct physical contact where the intention is to prevent, restrict, or subdue movement of the body, or part of the body of another person.

Positive behaviour support plans did not give enough information to staff on whether restrictive interventions could be used when people were distressed. Staff told us they had training in prevention and management of violence and aggression but did not need to use it.

Improvements had been made to how incidents were recorded and responded to. Further action was required to ensure documentation and management oversight was consistently completed to ensure it was clear what strategies or interventions had been used when people were distressed.

We could not be assured body maps were effectively used to document and illustrate visible signs of harm and physical injuries. Body maps that had been created, were seen to not be reviewed to track progress and ensure the appropriate treatment was being given.

Further improvements were needed to ensure medicines were managed and administered safely. There had been a reduction in the use of prescribed 'as required' (PRN) medicines, used when people were distressed.

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, Deprivation of Liberty Safeguards and the key requirements of the Mental Capacity Act 2005 were not fully understood by the management team.

Right Care

There were sufficient staff to meet people's needs. Most staff had the right skills and competency to meet people’s care and support needs. Staff knew people well and the staff rota provided consistency for people who required this.

People received opportunities to lead active and fulfilling lives, social inclusion and independence was promoted as much as possible.

People had choice and access to sufficient food and drink.

Right Culture

The provider's governance arrangements did not provide assurance the service was well-led. Systems and processes to oversee the safety and quality of the service were effective and had not identified the shortfalls we found during our inspection. Although improvements had been made since the last inspection, these were ongoing and regulatory requirements continued not to be met.

Staff knew and understood people well. There was a clear commitment to minimising the use of restrictive interventions and supporting people to have choice and control over their lives.

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 inadequate (published 11 February 2023).

We issued the provider with a warning notice asking them to make improvements in relation to person-centred care, consent, safe care and treatment, safeguarding, good governance and staffing. The provider completed an action plan after the last inspection to show what they would do and by when to improve in relation to requirements. At this inspection we found the provider remained in breach of regulations.

This service has been in Special Measures since 10 February 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted by a review of the information we held about this service and to follow up from the previous inspection. 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 have found evidence that the provider needs to make improvements.

Please see the safe, effective 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.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding and good governance at this inspection.

We have imposed conditions on the provider's registration to drive improvement in the areas of concern highlighted above.

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.

Boulevard House is a residential care home providing accommodation and personal care to up to 15 people. The service provides support to people with a learning disability. The accommodation comprises of a bungalow with 3 bedrooms and a main house with 12 bedrooms. At the time of our inspection there were 12 people using the service.

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

People were not 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; the policies and systems in the service did not support this practice.

Physical intervention was used by staff who had not received the necessary training by a certified training provider.

Incident forms did not contain enough information to explain what had happened and what physical interventions staff had used on people. It was not clear if physical interventions were safe or justified.

One person’s wardrobes were locked without consent. The provider had not completed a mental capacity assessment or carried out a best interest meeting to evidence locking the wardrobe was in the person’s best interests.

There were no protocols for ‘as required’ (PRN) medicines which were used to manage distress. When PRN medicines were given to people, records were not thorough or detailed. There was no evidence of post incident analysis or review of PRN medicines when they had been used to support people in distress.

Right Care

People were not supported in a way that promoted their dignity and human rights. There were significant concerns on how people were supported when they were distressed.

Lessons were not learnt, and improvements were not made when things went wrong. Staff did not learn from incidents to ensure people had better experiences and positive outcomes.

Risks were not identified or assessed which put people at risk of harm.

Right Culture

We identified a closed culture in the service. A closed culture is a poor culture that increases the risk of harm. Language used in care plans showed a controlling culture. A care plan referred to ‘house rules.’

The provider had not taken effective action to identify and address the poor culture in the service. Governance systems in the service were ineffective as they failed to ensure regulatory requirements were met.

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 good (published 22 January 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

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 changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. 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 Boulevard House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to consent, safe care and treatment, safeguarding people from abuse and improper treatment, good governance and staffing at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

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.

Boulevard House is a residential care home providing support for up to 15 people who experience learning disabilities. The accommodation consists of a bungalow where three people can live and a main house where 12 people can live. At the time of the inspection 10 people were living at Boulevard House.

The service is larger than current best practice guidance. However, the service had been developed and designed before Registering the Right Support and other best practice guidance was produced. The size of the home 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 outside to indicate it was a care home.

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

People who lived at the home received planned and co-ordinated person-centred support that was appropriate and inclusive for them.

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. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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.

Systems were in place to protect people from the risk of abuse. Risks to people’s health, safety and welfare had been identified and management plans were in place to minimise those risks. Medicines were managed safely and in line with good practice guidance. There were enough, safely recruited staff to ensure people had all of their needs met.

People’s needs were assessed, planned for and kept under regular review. Staff were well trained and supported to enable them to provide good quality care. Staff supported people to maintain a healthy diet and access healthcare service in a timely manner.

People were treated with kindness and respect by staff who understood the importance of maintaining people’s privacy and dignity. Staff encouraged people to develop their independence and maintain relationships with those who were important to them.

There was an open and inclusive culture within the home. Systems to monitor the quality of services and drive improvements were in place.

Rating at last inspection

The last rating for this service was good (published 14 June 2017).

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.

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

At the last inspection, the service was rated good.

At this inspection on 11 and 17 May 2017, which was unannounced we found the service remained good.

People were protected from abuse and avoidable harm because staff were aware of individuals' needs and what was a potential risk for them. Sufficient numbers of staff were employed to ensure people’s needs were met. People’s medicines were managed so they received them safely and they were stored in a place which only certain suitably trained staff had access to.

Staff had the knowledge and skills to carry out their roles and responsibilities, which was based on best practice to ensure people received effective care. Consent to care and treatment was always sought and where people could not consent themselves a suitable advocate was found. People were supported to eat and drink and maintain a balanced diet and were encouraged to help with the preparation of meals. They had access to healthcare services and received on-going healthcare support by staff at the home and other local health and social care agencies.

Positive and caring relationships were developed with people using the service and staff ensured people had access to other family members and friends when they wished. People were supported to express their views by individual discussions with members of staff and in group house meetings. Each person was actively involved in making decisions about their care, treatment and support. Staff ensured people’s privacy and dignity was respected and promoted.

People received personalised care that was responsive to their needs. Staff ensured they routinely listened and learnt from people’s experiences, concerns and complaints. People were actively involved in putting together a care plan of their needs and where this was difficult for them staff involved their family members or other advocates.

The registered persons and registered manager always promoted a person-centred, open and inclusive culture. This ensured people would be empowered to take part in as much as of the running of the home as they wished. The registered manager and registered persons ensured they regularly met with people who used the service, family members, other advocates and visitors to the home to obtain their views of the quality of the services being provided. Any actions from quality assurance audits were passed on to staff to ensure they learnt from events and incidents.

The registered manager and registered persons continued to look for ways of improving the services it offered and how to ensure the views of people were incorporated into the running of the home. The home was currently meeting all relevant fundamental standards.

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 service supported this practice.

Further information is in the detailed findings below.

We considered all the evidence we had gathered under the outcomes we inspected.

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

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

Is the service safe?

There were some systems in place to protect people who lived at the home from abuse and avoidable harm. For example risk assessments were carried out to ensure vulnerable people were protected from harm and abuse when they were out in the community. Assessments were carried out to assess the ability of people to cross roads safely.

The registered manager undertook a monthly health and safety and environmental audit. We looked at the range of issues audited such as cleanliness, outstanding maintenance and fire alarm testing. This demonstrated the service was being proactive to isolate problems before they could become a risk to people.

However we found that procedures and practice for the administration of medicines was inadequate and placed people at risk. Our observations led the manager to make a safeguarding referral and a notification to the Care Quality Commission.

Is the service effective?

We looked at three people's care plans and found they included clear instructions to enable staff to carry out effective care. All aspects of people's personal and health care needs had been assessed and were reviewed on a monthly basis. This meant staff had up-to-date guidance on how to support each individual.

It was clear from what we saw and from speaking with staff that they understood people's care and support needs and they knew them well.

Is the service caring?

Care plans had been regularly reviewed to ensure there was up-to-date information on the person's needs and how these were to be met. Staff we spoke with demonstrated they were aware of the needs of the people they supported and their individual personalities and preferences.

People were very comfortable, well dressed and clean which demonstrated staff took time to assist people with their personal care needs.

The atmosphere throughout the home was relaxed and we saw staff took time to talk to people.

Is the service responsive?

Peoples' care, treatment and support at the home achieved good outcomes and promoted a good quality of life for the people that lived there. People told us they were happy with the care provided at the home and their care and support needs were being met.

From our observations and from speaking with staff and people who lived at the home we found staff knew people well and were aware of peoples care and support needs. We also found staff had received appropriate training to meet peoples' needs.

We saw evidence of the service accessing health care professionals to ensure people with unmet needs were cared for appropriately.

Is the service well-led?

We found the service had some effective quality assurance systems in place and any identified actions had led to improvements in the service that people received. We found some inadequacies in the auditing of medicines which the provider is urgently addressing.

People who used the service and staff were asked for their views about care and treatment. We saw evidence that these had been acted upon. We looked at the way the home gathered information about the service they provided. Records of audits and meetings confirmed that a programme was in place. We found the service was well-led.

The people we spoke with told us their care was personalised to their needs. They knew staff kept records on them and had seen those records and discussed the content. One person said, "My key worker goes over my care plan with me each month."

People who used the service told us they felt safe at the home and liked living there. If they were concerned they told us they would approach a staff member. One person said, "I love it here."

Details were in the care plans and on display about the types of activities people were involved in. People who used the service told us there were always enough staff on duty to ensure their needs were attended to and they could take part in a variety of social activities. One person said, "I enjoy dancing and staff can always come with me."

The people who used the service told us they were involved in meetings with staff who asked them how they liked living in the home and what they wanted to do. One person said, "We have talks about holidays." People knew meetings were recorded.