This inspection took place on 30 August and 19 September 2018. The first day of the inspection was unannounced.

Acrefield House 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 care home is a large Victorian style building over three floors in a residential location. The home provides care and support to people who have a learning disability, autism or a brain injury. The home is registered to provide care and accommodation for up to 12 people. At the time of our inspection nine people were living at the home.

The home is required to have a registered manager. Since our previous inspection there was a new manager in place. The new manager was in the process of applying to become registered with the Care Quality Commission (CQC). 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 November 2017 we had found breaches of regulation 10 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for the service was ‘requires improvement’. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; ‘Is the service safe?’ ‘Is the service effective? ‘Is the service caring? and ‘Is the service well-led?’ To at least a rating of good.

At this inspection we found that there had not been sustained improvements to the quality of the service provided for people and the majority of the actions we were told the provider would take had not been completed. Although the service was no longer in breach of Regulation 10, there was a breach of Regulation 9 and there was a continued breach of Regulation 17 for the third inspection in a row. This is because the provider had not ensured that people’s care and support always met their needs and reflected their preferences; and the provider had not taken adequate steps to assess and improve the quality of the service provided for people. Therefore, arrangements made by the provider for leadership of the service have not been adequate.

This service was not provided in line with the values that underpin the Registering the Right Support and other best practice guidance. The values underpinning Registering the Right Support include choice, promotion of independence and inclusion; to help enable people with learning disabilities and autism using the service to live as ordinary a life as any citizen.

Whilst people were cared for and kept safe; we saw little evidence that showed choice, promotion of independence and meaningful inclusion were integral to people’s support. Many aspects of people’s support appeared to be aimless, it did not regularly promote people having enriching and everyday life experiences.

We have had some concerns with the quality of the service provided for people since our last inspection. One staff member raised concerns about bullying within the home; their concern was then followed by other staff members raising concerns. Also, we learnt from the local authority that historically staff at the home were not following the correct procedures in recording and reporting allegations that people at the home had made. When the manager became aware of these concerns they responded, took appropriate action and were open about these concerns. However, this is the third inspection where we have concerns about the culture and leadership within the home. We are meeting with the provider to address these concerns and we will inspect the home within six m

This inspection took place on 16 and 17 November 2017. The first day of the inspection was unannounced.

Acrefield House 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 care home is a large Victorian style building over three floors in a residential location. The home is registered to provide care and accommodation for up to 12 people. At the time of our inspection nine people were living at the home.

The home requires and 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.

The previous inspection was in February 2017. During the previous inspection the service breached regulations 11, 12, 13, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had also found breaches of Regulation 18 of Care Quality

Commission (Registration) regulations 2009. Failure to notify the Commission of notifiable incidents.

At this inspection we found that improvements had been made. This meant the service was no longer rated inadequate and could be removed from 'special measures' by the CQC. The service was no longer in breach of Regulations 11, 12, 13, 16 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. And Regulation 18 of Care Quality

Commission (Registration) regulations 2009.

At this inspection we found that there were breaches of Regulation 10 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This is because the language and approach of staff both verbally and in written care plans did not always treat people as equals with dignity and respect. We saw that relationships between people and staff at the home were friendly and that staff cared about people; however the predominant approach towards people was paternalistic. We recommended that there needs to be a greater focus on dignity and respect in the language and approaches used when supporting people.

We looked at the record of incidents that had happened at the home since our previous inspection. We saw that the number of incidents had reduced. The response to incidents from the registered manager and the provider had improved. Incident records showed that the manager and staff had taken time to explore the possible reasons that may have prompted a change in the person’s behaviour. Records of physical interventions did not always give a clear picture of what happened or had led to updates to people’s risk assessments or care plans. Also the rationale for decisions made in supporting a person were not clearly recorded to show that they followed the best interest decision making process as outlined in the Mental Capacity Act.

You can see what action we told the provider to take at the back of the full version of the report.

During this inspection it was clear that the registered manager and staff had worked hard to make improvements to the service provided to people. During this inspection we saw that there had been improvements in the culture and atmosphere at the home. People’s family members, staff and health and social care professionals spoke positively about the registered manager and his style of communication. One person’s family member told us, “When [registered manager] came in it stepped up a level and communication improved. They have always been available for us when we need them.” We did see that new thoughts and ideas of different and more person centred ways of supporting people had been written on the plans and there was a culture starting to develo

This inspection took place on 13, 16 February and 6 March. All three visits were unannounced.

Acrefield House is a large Victorian style detached building in a residential area of Prenton, Wirral. The building is over three floors, with well-kept front and rear gardens. The home is registered to provide care and accommodation for up to 12 people. At the time of our visit 10 people were staying at the home.

Accommodation is in 12 bedrooms over three floors, the upper floors are accessible by a staircase. There is a ground floor extension at the rear of the building providing accessible bedrooms. All of the bedrooms are single occupancy. There are suitable toilets, and bathing facilities on each floor.

The home required and 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 inspection we found breaches of regulation 11, 12, 13, 16, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found breaches of Regulation 18 of Care Quality Commission (Registration) regulations 2009. Failure to notify the Commission of notifiable incidents.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

During our inspection we found that there had been failings by the registered manager to alert the CQC of notifiable events and to alert the local authority of incidents and allegations that are reasonably considered to be safeguarding alerts. There was also a failure of the registered manager to investigate specific safeguarding allegations. As a result of the inspection safeguarding alerts were made to the local authority by the CQC for five people living at the home.

People at the home had not been kept safe. Risk assessments had not been effective in reducing risks. At times physical restraint had not been used in a safe way. Altercations between people living at the home caused people to be upset and not feel safe.

Incidents had been recorded, but this information had not been used to reduce the likelihood of any reoccurrence. There was little evidence to suggest staff and people living at the home were de-

This inspection took place on 21 December 2015 and was unannounced. The home was last inspected in May 2014.

Acrefield House is registered to provide care and support for up to 12 adults. At the time of our inspection, there were 10 people resident in the home. The home is run by Mental Health Care (Wirral) Limited and specialises in providing accommodation and personal care to people with mental health problems and/or acquired brain injuries. It is located in the Prenton area of Wirral and is a large, older type building which is within walking distance of local shops and transport links.

The home required a registered manager. There was a registered manager in post who had been in post for two years. 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.

In addition to twelve bedrooms, there was a large communal lounge, a dining room, a conservatory and a large kitchen as well as staff room, several offices and the medication room. To the rear of the property was a single story extension which we were told it was hoped to be enlarged to provide more independent living accommodation.

We saw that staff had been recruited appropriately and numbers of staff in the home were suitable to people's needs, throughout each day and night. There were appropriate employment policies in place such as grievance and disciplinary procedures and a whistleblowing policy.

Staff had been trained appropriately and there was an induction period for new staff which included basic training and knowledge. They demonstrated their skill and knowledge when we observed the interaction with the people they were supporting. Staff were able to tell us about abuse and how to prevent or report it.

Staff demonstrated that they knew about mental capacity and deprivation of liberty safeguards and used this knowledge with empathy and professionalism.

All the staff showed a caring approach and they involved and included people in everyday decisions.

The support for each person was person centred and tailored to their needs. We saw that relationships were good between the staff and the management and that people looked as if they were happy with their support. Other professionals who supported people and the relatives we spoke with told us that they felt that the service was good, caring and well-led.

We gathered evidence to help us answer our five questions: Is the service safe? Is the service effective? Is the service caring? Is the serivce responsive? Is the service well-led?

Below is a summary of what we found

Is the service safe?

We saw there was several deprivation of liberty conditions in place which were in people's best interests and ensured their safety. We saw there was several deprivation of liberty conditions in place which were in people’s best interests and ensured their safety. Deprivation of Liberty Safeguards’ (or DOLS) were introduced to protect individuals from the unlawful deprivation of their liberty as a part of the Mental Health Act 2005. We saw the provider maintained all the correct paperwork for every person who required a deprivation of liberty as well as a capacity assessment.

We saw that the provider was responsible for most people’s finances at the home. We saw the provider regularly reviewed financial risk assessments and capacity assessments for these people. We saw all cash was stored securely.

We saw the provider had policies and procedures in place for emergency situations. The staff we spoke to knew where to locate these. We looked at the accident and incidents book. We saw evidence in records staff were able to respond appropriately in emergency situations.

Is the service effective?

We looked at four care plans, all of which had a range of risk assessments, for example, mobility, nutrition and behaviour. We saw care plans were person centred and reviewed regularly. We saw staff had completed care plans that related to people’s long term illnesses and when asked we found staff were very knowledgeable about these conditions. We saw staff completed assessments in order to understand the person’s family involvement, social history, likes and dislikes. The one relative we spoke with told us staff at the home always respected the person’s wishes and gave them choices in all aspects of their care. We saw people’s needs were taken into account when care plans were developed.

Is the service caring?

We observed staff communicating in a sensitive and supportive manner to those who were confused and anxious. We saw staff were skilled at detecting changes in behaviour and were able to quickly reassure people diverting their attention to more positive thoughts and activities.

Is the service responsive?

We saw evidence that people who lived at the home, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We saw the provider conducted monthly reviews with people who used the service. This looked at whether the people were pleased with their care and the activities they were involved in at the home. From the reviews, we saw people told staff they were happy at the home. We saw people had made suggestions about different foods they wanted to see on the menu and different activities. We saw people’s suggestions and preferences were acted upon and implemented into their care. This meant the provider was responsive to people’s needs.

Is the service well-led?

We asked people who lived at the home and staff about the manager and their ability to deal with concerns. They all felt the manager dealt with any issues very promptly and everyone we spoke with gave positive comments about their management style and personality.

We saw the provider conducted annual audits in order to review the quality of the service. This included the audit of care plans, medication sheets and maintenance records. We saw from the action plan some maintenance logs needed completing and all medication was recorded correctly. This was disseminated to staff.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke to the relatives of two people, who told us their relatives were getting the support and care they needed. Some comments made were:

"This is their home and they are very happy here. I visit every week and I feel part of the family here.”

“I attend my relative’s reviews with them and I feel fully involved in their care.”

We looked at three care records. The support plans showed how the needs of the people who used the service were to be met, including any risks to their well-being. Records also showed that when necessary the service had made deprivation of liberty safeguarding referrals.

Records and discussions with relatives of people who used the service and members of the staff team showed that the service co-operated with other service providers.

Relatives spoken with described the staff as caring and said they always appeared competent in their work. Training records and discussions with members of the staff team showed the staff team were supported to undertake relevant training to support them in their roles.

The provider had systems in place to monitor the quality and safety of the service provided at Acrefield House.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experience. We sought information from other stakeholders in the service to gain their views. We also viewed records that showed external agencies had been involved in people’s care and support.

We spent time with people who used the service and observed care workers supporting them in a caring and supportive manner.

We looked at three care records these included support plans, risk assessments, daily records and information about visits to or by health and social care professionals. The support plans showed how the needs of the people who used the service were to be met, including any risks to their well-being.

We spoke with two care workers who told us they had received training in safeguarding and described how they would ensure the welfare of vulnerable people was protected through the whistle blowing and safeguarding procedures.

We looked at two staff files and found there were effective recruitment and selection processes in place.

Displayed on the notice board in the hallway there were two copies of the complaint procedure. One in a written format and another that used pictorial prompts to support understanding of the procedure. There was also information displayed about local advocacy services, CQC and Wirral department of adult social service.

Due to the complex needs and different communication methods of the people using the service the verbal information given to us was limited.

We spent time with people who use the service. We observed care workers and managers listening and involving them in decision making and considering options and choices offered to them. We spent time with individuals who showed us their communication fobs and directed us to the notice board that had both written and pictorial information about meals and activities planned for the day. It also had photographs of members of the staff team on duty that day.

We observed people using the service being supported in a respectful affectionate manner with members of the staff team spending time with them and enjoying their company.

We contacted Wirral Department of Adult Social Services (DASS) contracts team who told us they had no concerns about how the service supports the people living at Acrefield House.

We contacted Wirral Local Involvement Networks (Links) who had no information to share with us.

At the time of the visit the registered manager was absent from the service and the clinical leads operations manager for the organisation had taken on the role as acting manager.

Due to the complex needs and different communication methods of the people using the service the verbal information given to us was limited. Some of the people spoken with told us they liked living at the home.