What life is like for people using this service:

• People were supported by staff who were kind and affectionate and knew people’s needs well. Every person was calm during our inspection, some people told us they were happy, other people made sounds or facial expressions that indicated they were happy.

• People lived in a service that was homely, with freshly cooked food and a range of drinks on offer. People’s rooms were comfortable and reflected people’s character. The communal areas needed some redecoration and there were plans for wider refurbishment.

• Care staff felt supported and were receiving supervision. They were also supported through the provision of relevant training so they could effectively meet people’s needs.

• The service was linked in with health professionals who had regard for the service. Professionals we spoke with said their advice around meeting people’s health needs was followed.

• Where people did not have capacity to make decisions, they 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.

• Care records and risk assessments were not always up to date with recent information and had conflicting information about people’s care needs and how to manage risks. Care staff knew people well enough to support them with distressed or self-injurious behaviours but the records did not reflect this.

• The provider had recently recruited a new manager as the longstanding registered manager was leaving. People were sad to see them go and some support had been provided around the changes taking place in the service for people.

• There were enough staff to meet people’s basic needs but people could have accessed the facilities in the local community more. We saw some people going out but not everyone had the same opportunities as others because of transport difficulties.

• Staff knew what potential abuse might look like and how to report it. Medicines were managed safely. Building checks were completed regularly.

• We found one breach in relation to legal requirements in good governance. More information is available in the detailed findings below.

Rating at last inspection: Requires Improvement, the last report was published on 18 July 2018.

About the service: 1-4 Windsor drive (referred to in this report as the service) is a residential care home in a rural setting that was providing accommodation and personal care to 11 people with support needs around physical and learning disabilities and people with autism at the time of the inspection.

Why we inspected: This was a planned, scheduled inspection based on the previous rating.

Enforcement: The provider is required to send us an action plan addressing the concerns we found at this inspection regarding the breach of regulation we found, within the timeframe we specify.

Follow up: We will meet with the provider after an action plan has been sent to us to discuss the improvements they are going to make.

This comprehensive inspection took place on 12 and 13 March 2018 and the first day was unannounced. We last inspected this service in December 2016 where it was rated ‘Requires Improvement’ overall and ‘Requires Improvement’ in the Safe, Caring, Responsive and Well-led key questions. Following this previous inspection in December 2016 we identified four breaches of regulation, corresponding to regulation 9, person-centred care, regulation 10, dignity and respect, regulation 17, good governance and regulation 18, staffing.

Following our inspection in December 2016 we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Caring, Responsive and Well-led to at least a ‘good’. We found that although action had been taken this was not sufficient to improve the ratings at the service or to meet the requirements set by the breaches of regulation.

1-4 Windsor Drive 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. 1-4 Windsor Drive is registered to accommodate up to 12 people with learning disabilities and complex needs across four separate bungalows, each of which has separate adapted facilities. At the time of this inspection in March 2018 there were eight people living at the service, spread across all four bungalows.

The service was not 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. We found these were not shared by the service.

The service 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.’

During our previous inspection in December 2016 we identified four breaches of regulation, relating to people not receiving care which always met their needs, people’s lack of opportunities to spend time outside the service, staff failing to demonstrate respect towards some people, insufficient staffing numbers to meet people’s needs and ineffective systems in place to monitor and improve the service. During this inspection we found three of these areas still required improvements and three regulations were still in breach. We also identified two further breaches of regulation and new concerns.

People who lived in 1-4 Windsor Drive were not always safe. Although we saw a number of good examples of risks to people being identified, reported and well managed, we also identified instances where risks had not been adequately assessed or mitigated. For example, staff did not have any information relating to the acceptable blood sugar levels for one person living with diabetes. Although staff were regularly checking the person’s levels they did not know what these should be, how they presented should their levels be too low or too high or what they should do in these instances. We also found risks relating to one person’s meals containing items identified as being high risk for them by a specialist speech and language therapist. This placed this person at risk of choking.

All the people living in the service required help to take their medicines. Prior to our inspection a medicine error had taken place and the registered manager had assured us they had reviewed systems for medicine management in order to ensure risks of reoccurrence were minimised. We found, however, when reviewing people’s medicines, that the systems in place to record and review medicines did not make it possible for the staff or registered manager to ensure p

1-4 Windsor Drive is made up of four bungalows. They are registered together to provide personal care and support for up to 12 people with a learning disability. Each bungalow provides accommodation for three people. At the time of the inspection the service was supporting 11 people.

The inspection took place on 19 and 21 December 2016 and was unannounced. The service was previously inspected in June 2014 and was found to meet the regulations inspected at that time.

The service had 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.

Prior to the inspection we had received information about the welfare of one person supported by the service. Concerns were raised with us that this person’s complex care needs were not being met. We reviewed this person’s care. We saw the service was working with staff from the local authority to ensure this person was safe. However, we did find that improvements were required in the number of staff available to respond promptly and consistently people’s support needs.

Staffing levels did not promote opportunity or choice for people to engage with staff or participate in activities outside of the home. In addition, while some people’s care and support needs were clearly identified in their care plans and risks to their health and safety were being well managed, this was not the case for everyone. Systems in place to assess quality and risk had not been effective in identifying these issues.

The registered manager and staff told us they felt there were insufficient staff available to meet people’s care needs. Staff were identified to work in each of the bungalows but at times there was insufficient staff in the bungalows to support people with their personal care, such as going to the toilet. Staff told us they asked staff from one of the other bungalows to help them at these times. Staff told us that they were anxious there was not always enough staff available to support people in the way they wished to be supported. Relatives told us they felt there was not enough opportunity for people to go out of the service as there was not enough staff on duty. Following the inspection, the registered manager confirmed that staffing levels had been increased.

Not all care plans provided staff with accurate guidance about people’s current care needs and how risks to their health and safety should be managed. Two of the three care plans we looked at provided staff with clear guidance about people’s care and their preferences. However, the third care plan did not accurately reflect the person’s care needs. Staff were not guided about how to support the person with their personal hygiene, how to encourage the person to become involved in activities or how to support them at times of anxiety and distress. Information held in the care plans stated whether people had the capacity to consent to the support identified in these plans. However, there were no records of formal capacity assessments having been undertaken for those who staff thought lacked capacity.

During our observations we saw kind and friendly interactions between staff and some people. However, we observed staff favouring those people who were able to communicate with them and those with limited communication abilities received less attention from staff. While staff were not being outwardly unkind to people, they ignored people who, due to their disabilities, were not able to seek staff company and interaction.

Relatives and advocates told us they found the staff caring and kind. Staff were described as “excellent” and “absolutely amazing”. Staff talked of people fondly when they told us about people’s support needs. One

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

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

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

Is the service safe?

People's needs were assessed with care and treatment planned and delivered in line with their individual plans to ensure people's safety and welfare. For example we saw that there were detailed mental health assessments in place which detailed the person's condition, symptoms and behaviours. These were reviewed and shared with Social Services with any concerns regarding changes in mental health. This meant the service was able to make sure that they met people's needs.

Risk assessments had been developed around areas of risk and those showed evidence of review and update. A scoring system was used to make an assessment and a plan completed which gave staff clear guidance on how to manage the risk. These were then cross-referenced to care plans outlining how risk could be managed so that the level of risk was reduced.

Records showed that care plans and risk assessments were reviewed monthly and updated as necessary in recognition of the changing needs of the people they described. This ensured that people received good quality support that was responsive to each person's changing needs.

One family member told us "I have every confidence in the quality of care received, we have an excellent relationship with the home and all other health professionals involved." They added "If I did have any concerns I could approach any of them and be assured my concerns would be dealt with professionally."

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people's human rights. The manager said they had not needed to submit a Deprivation of Liberty Safeguards application to-date. However, the manager was aware when an application should be made and knew where to go if an application was required.

Is the service effective?

People were encouraged to remain independent. Care plans identified what people were able to do for themselves, rather than only focusing on what a person could not do. For example, such as picking out their own clothes. One relative told us "The staff go above and beyond what's expected of them. They really know what's important". They added that staff treated them like an "old friend".

Relatives told us "Communication from the home is very good, they keep me informed." They added "It's important for us to feel involved and we are always kept up to date with any changes."

Is the service caring?

Relatives told us that they had visited the service before their family member had come to stay. One person told us "Social Services suggested I visited and I really had thought there wasn't anywhere good enough." They added "We are now very happy and feel content with the decision we made. They are settled and very well cared for."

One relative said "I just can't praise the home enough. The staff are absolutely excellent, every one one of them".

Due to people's conditions we were not able to discuss their experience in detail. A relative told us "All staff are very good here, they are polite and would do anything for you"'. They added "Staff really know the people that live here and know their personalities"

Staff were seen to explain to people about what they were doing when providing care. For example when helping a person to stand, the staff member explained why they needed to help them, how they were going to do it and if it was alright for them to do it.

One relative told us "Staff are very sensitive to people's needs, they are all wonderful." They added "Staff go above what is expected and do those little extra things that show just how much they care."

An external therapist visiting the home said they were "very impressed" with the standard of care. They added that staff "told people exactly what was going to happen" and were "gentle".

Is the service responsive?

There was evidence that advocacy was used for some people. We spoke with an advocate who had represented some of the residents for a number of years. They told us "I have seen enormous improvements with some people since moving here, you can tell people are happy."

Close links were evident with other professions such as GP, hospital and dentist. It was evident that the home regularly sought the support of relevant professional advice. This showed that staff were given information to enable them to provide care that met people's specific needs.

People's care was planned and delivered in a way that protected people from unlawful discrimination. Reasonable adjustments had been made to meet individual needs. For example the home was adapted to meet disability access needs and specialist equipment was available.

One staff member said "It's really important to build a relationship with people, you become able to learn and understand their own style of communication." They added "I have learnt to recognise certain noises or behaviour as their way of telling me just what they want."

One staff member told us "I had felt the need to learn more about autism to support people's needs." By approaching the manager and discussing further training a course was agreed and attended within a few months. The staff member felt confident with the new skills and went on to share experience with other staff.

Is the service well led?

The Registered Manager demonstrated a good awareness of the needs of the people that lived in the home and looked at good practice guidance in order to improve care provided.

Staff told us that they felt supported to carry out their role. They felt that the manager was approachable, professional and supportive. We saw evidence of staff meetings hosted by the manager. This showed that staff were provided with support in a number of different ways, through supervision, staff meetings and by the manager having an open door policy.

Staff reported that they had regular supervision meetings with the manager. Staff members said they "Felt free to discuss anything and any suggestions on improvements were always considered."

The manager told us they operated an 'open door' policy and were frequently within the home and worked alongside staff when required.

One staff member told us "The training is always good, it makes you think about the things you do". Another said "The manager is very approachable if I need to discuss anything and I could use my supervision time if needed". This demonstrated that people could be confident that the manager would identify and respond to any safeguarding matters promptly and correctly.

On the day of our inspection 12 people were living in the home. We spoke with two people, two relatives, two visiting health professionals, one advocate and four staff.

People who lived in the home had limited verbal communication and therefore were not able to tell us about their experiences. We spent time observing interactions between people and the care workers who were supporting them. We observed interaction between staff and people living in the home that was respectful, positive and encouraging. Relatives, health professionals and an advocate were positive about the care and support provided. Comments included “the staff are brilliant and we’re always welcomed” and “people always look smart, well cared for and happy.

We found that care workers were receiving appropriate training and professional development so they could carry out their job role effectively. Care workers knew how to report concerns to ensure people were protected from the risk of harm.

Records were accurate, kept up-to-date and stored securely.