This inspection took place on 7 August 2017 and was unannounced. Dimensions 5-6 Duchess Close, is a care home which provides care and support for up to six people with learning disabilities and complex needs. At the time of this inspection there were five people using the service.

There was a registered manager in place. The registered manager was present throughout the inspection. 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.

Risk assessments stated what people’s personal risks were. There was insufficient guidance provided for staff on how to mitigate these known risks. However, staff that we spoke with demonstrated an understanding of people’s personal risks.

We have made a recommendation around the recording and guidance for staff of risks that people faced.

We observed kind and caring interactions between staff and people. People’s responses to staff showed that people felt safe and supported. Relatives were positive about people’s safety within the home.

Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report it to if people were at risk of harm.

Medicines were managed safely and administered on time. There were records of medicines audits and staff had completed training on medicine administration.

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.

Staff had regular supervision and annual appraisals that helped identify training needs and improve the quality of care.

People were supported to eat healthily. There was a varied menu and snacks and drinks were available if people required.

There was a complaints procedure and relatives knew how to make a complaint.

Staff knew how to report accidents and incidents. These were followed up and learning from them was used to improve the quality of care for people.

Care plans were person centred and reflected individuals’ preferences. Relatives were involved in planning people’s care.

People had individual weekly activities timetables that reflected things that they enjoyed. People were supported in the community with appropriate staffing levels.

Audits were completed by both the home and the organisation to check the quality of care. This included health and safety, medicines and overall care provision.

Staff had regular team meetings where they were able to share ideas and raise any concerns.

We carried out an unannounced comprehensive inspection of this service on 9 December 2015. Breaches of legal requirements were found, in respect of the safe care of people’s medicines and providing sufficient numbers of staff at all times. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that the provider had followed their plan and to confirm that they now met legal requirements. 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 Dimensions 5-6 Duchess Close on our website at www.cqc.org.uk.

The service provides care and accommodation for up to six people. Its stated specialisms are for learning disabilities or autistic spectrum disorder. There were five people using the service at the time of our inspection.

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.

We found that the provider had followed their plan to address our previous concerns, and so they were now meeting legal requirements of ensuring appropriate care of people using the service. This was because action had been taken to improve the safety of managing people’s medicines. In particular, all staff had had their medicines competency retested, there were regular stock checks of people’s medicines, and managers audited medicines weekly. This all helped to ensure that any errors were identified.

There were now enough staff working with people. A small group of agency staff were being used where needed, to ensure that there was always at least two staff working with people in the service.

There were procedures in place to protect people from the risk of abuse and from health and safety risks.

However, whilst we found that fire doors were now kept closed when not in use, devices installed to safely hold these open and enable people to still move freely around the premises were not working. Some people therefore relied on staff support to move between rooms, which meant that these doors were not entirely suitable for purpose.

We also found that the laundry area, one dining room and the two lounges were not kept sufficiently clean. This was particularly evident on carpets which had a number of ingrained stains. This provided an infection control risk to people using the service.

There was overall one breach of regulations. You can see what action we have told the provider to take at the back of the full version of this report.

This was an unannounced inspection that took place on 9 December 2015. At the last inspection of 3 July 2014, we found that the service met the regulations we inspected against. At this comprehensive inspection the service was in breach of regulations.

The service provides care and accommodation for up to six people. Its stated specialisms are for learning disabilities or autistic spectrum disorder. There were five people using the service at the time of our inspection.

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.

We found two breaches of regulations at this inspection. One breach was primarily because medicines were not properly and safely managed. Despite a practice of two staff signing for when people were supported with medicines, medicines records had occasional administration gaps. There were other anomalies with people’s medicines records. We had to bring the written instructions for one medicine to the registered manager’s attention, as there was a risk that the medicine would not have been administered as prescribed, which could have compromised the person’s health and welfare.

A few premises and equipment matters were also a factor in this safety breach. Fire-prevention doors were propped open and some of the first aid kit stock was out of date. The premises were, however, kept clean and in reasonable overall condition.

The other breach was because there were occasions when there were not enough staff working to meet people’s needs and promote people’s health and welfare. There was only one staff member working to help people get up when we arrived at the inspection, which resulted in one person not having time to finish their breakfast before pre-arranged transport for them arrived. The same staffing situation occurred the previous day. There were also two occasions across the previous three weeks when only two of three scheduled staff were working during a weekday evening.

People and their relatives told us a good service was generally provided and people enjoyed living there. There was praise of the established and committed staff team, which helped positive relationships to develop with people using the service. People chose the activities they wished to do, and staff supported people well.

During our visit there was a warm, calm and inclusive atmosphere that enabled people to make their own choices and decisions. Staff we spoke with were knowledgeable about the needs and preferences of people they supported. They provided care and support in a professional and friendly way that was focussed on the individual. They were trained and skilled in many areas relevant to meeting people’s needs. Staff said they had access to good training and support.

People were supported to eat and drink enough and maintain a balanced diet. Staff knew people’s dietary preferences and support needs. The service supported people to maintain good health, including through access to GPs and other community based health professionals.

Records were kept up to date and covered all aspects of the care and support people received. Support plans were detailed, regularly reviewed, and guided staff on how to meet people’s individual needs and respect their preferences.

The service worked in line with the principles of the Mental Capacity Act 2005, including Deprivation of Liberty Safeguards (DoLS).

We found the service’s registered manager to be approachable and responsive. He encouraged feedback, recognised service shortfalls, and helped to ensure the service promoted a positive and inclusive culture.

There were overall two breaches of the Health and Social Care Act 2008 (Regulated Activities) Re

We considered our inspection findings to answer questions we always ask; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

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

Is the service safe?

At the time of our inspection, five people were living at the home. We spent time with all of them and observed staff supporting them safely in line with their risk assessments. Staff had undertaken a wide range of health and safety training, medication administration and safeguarding training and understood their role in safeguarding the people they supported. Prescribed medicines were administered appropriately, witnessed by two staff members to ensure that there were no errors.

Accidents and incidents were recorded appropriately, and the home environment was safe, clean and in good condition. Staff received appropriate training and supervision to ensure that they worked with people safely in line with best practice.

Is the service effective?

People told us that their care and support needs were met effectively and they were happy with the home environment. They were encouraged to develop their daily living skills within the home. Comments included “I do all my own cooking,” and “I watered the garden yesterday.” Their health and social care needs were assessed with them, and they were involved in producing their care plans. Care plans and person centred plans were reviewed regularly to ensure that staff met people’s needs consistently.

Staff received appropriate support and supervision to enable them to deliver care and support to people to an appropriate standard.

Is the service caring?

People told us “The people here are nice,” and “The staff are nice.” They confirmed that staff were caring and responsive to their needs and treated them with respect. This was also confirmed by our observations of staff interacting with people living at the home. We observed staff showing patience and empathy when supporting people. People’s preferences, interests, aspirations and diverse needs had been recorded to ensure that care and support were provided in accordance with their wishes.

Is the service responsive?

Staff identified people’s preferences and supported them to follow weekly and daily schedules of their choice. On the day of our visit one person told us “I’m going to photography,” and “I go out all the time.” Other people went out to a day centre, to a horse riding class and out for a drive. We saw that staff had identified people’s social, cultural and religious needs and preferences and attempted to meet these.

There was evidence of suitable arrangements in place for obtaining, and acting in accordance with people’s consent in relation to the care provided to them.

Is the service well-led?

People living at the home spoke positively about the home’s management. They told us “I like living here,” “I’m happy with my room,” and “I like the staff and the manager.” Staff were also positive about the support provided by the management.

Staff were clear about their roles and responsibilities and showed a good understanding of the needs of individual people they supported. We reviewed the results of several surveys of stakeholders in the home, and compliance audits that took place since the previous inspection. These indicated that the service was proactive at finding areas for improvement and addressing these.

As a result of a follow up inspection on 3 May 2013, a warning notice was issued as the provider had failed to ensure that people were protected against the risks associated with unsafe or unsuitable premises. We asked the provider to take action by 19 July 2013.

When we inspected on 8 August 2013 we saw that the provider had taken steps to provide care in an environment that was suitably designed and adequately maintained. In communal areas, carpets had been steam cleaned and walls freshly painted. Bedrooms were well furnished and some had recently been painted. One of the two communal bathrooms had been retiled and freshly painted.

We also saw that people who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We spoke with a person using the service who told us that they felt safe at the home. We saw that the provider had displayed an “easy read” safeguarding leaflet; advising people using the service how they could report a safeguarding concern.

We spoke with one person using the service. They told us that they got on well with other people using the service. They said that there was “lots to do” and told us that they had recently gone on a sea side trip. Other people who used the service could not communicate verbally. However, care plans referred to weekly activities including reflexology and going to the library.

When we inspected on 23 November 2012, we were concerned that care assessments were not in place. We asked the provider to take action. During our 3 May inspection, we saw that detailed care assessments had recently been carried out.

In November, we saw that the ceiling and carpeting in some areas had not been adequately maintained. We asked the provider to take action. When we visited on 3 May, we saw that some concerns had been addressed but also saw that a kitchen drawer was broken and bedroom lights not working. We are considering what further action to take.

In November, we were concerned that we did not see examples of improvements that had taken place as a result of user feedback. During our 3 May inspection, the provider was unable to provide evidence that this had been addressed. After the inspection, we were told that one service user had participated in a survey. We were also later sent a copy of a service improvement plan produced after our November inspection. The provider may wish to note that this did not include actions to obtain service user views.

We used a number of different methods to help us understand the experiences of people using the service because they had complex needs, which meant they were not able to tell us their experiences.

We observed that people were supported to make choices about food and activities. Staff demonstrated that they understood aspects of safeguarding process relevant to them. However, we were concerned that the provider did not meet acceptable standards of care in a number of areas that we looked at.

People’s privacy and dignity were not always respected. In some cases, this was related to the manner in which care and support was given whilst the unsuitability of the premises ensured privacy and dignity for some people were not always protected, including protection from associated risks.

People were at risk of receiving inappropriate or unsafe care or treatment because of inadequacies in the assessment, planning and evaluation of their care and support, which was increased by the absence of accurate records. The quality monitoring system was not effectively implemented.