3 The Causeway is a three storey house situated in a residential setting close to local facilities including a shopping complex, restaurants, a cinema and a bowling alley. The home’s ground floor comprises a kitchen dining room and a separate laundry area. The first floor has one bedroom, a lounge and an office, the third floor has two bedrooms, each bedroom has ensuite facilities. At the time of the inspection there were two people living in the home.

This announced inspection took place on 25 November 2016; we gave the service 24 hours’ notice of the inspection because it is small and we needed to know that people and the registered manager would be in. The last inspection of the service took place on 13, 20 and 27 February 2015. The registered provider was non-compliant with the regulation pertaining to safeguarding vulnerable adults.

During this inspection we saw that the registered provider had taken action to ensure people who used the service were protected from abuse and avoidable harm which meant they had achieved compliance with the regulation.

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.

The people who lived at the home had complex needs which meant they could not tell us their experiences. We used a number of different methods to help us understand the experiences of the people who used the service including the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experiences of people who were unable to speak with us. It was clear that the people who used the service trusted the staff who supported them. Staff looked for visual cues as well as listening to the tone and pitch of the sounds people made to understand what they were trying to communicate.

People who used the service were supported by suitable numbers of staff who knew how to keep them safe. The registered provider had developed plans to deal with foreseeable emergences. Staff had been recruited safely following the completion of appropriate checks. Medicines were ordered, stored and administered safely and people received their medicines as prescribed.

Staff were supported effectively and had completed relevant training to enable them to meet the assessed needs of the people who used the service. Staff understood how to gain consent from people who used the service; the principles of the Mental Capacity Act 2005 were followed when people could not make specific decisions themselves. People were supported to eat a healthy diet and drink sufficiently to meet their needs. People who used the service were supported by a range of healthcare professionals to ensure their needs were met effectively.

People who used the service were supported by caring and attentive staff who understood their needs and knew their preferences for how their care and support should be delivered. Staff explained things in a way that people could understand they made eye contact and changed their tone of voice when speaking. Staff treated people with dignity and respect and supported people in an inclusive and nurturing atmosphere.

The staff and registered manager were responsive to people’s changing needs. Reviews of people’s care took place on a regular basis; people and their appointed representative were involved in the initial and on-going planning of their care. Care plans had been created which focused on supporting people to maintain and develop daily living skills whilst remaining safe. People took part in a range of activities and went to social events. The registered provider had a complaints policy in place that had been created in a format that made it accessible to the people who

Staff we spoke with told us, “We know the people in the service very well and it is very clear when a person gives consent or not. It is known to all staff that some verbal sounds of consent can change and we always update a person’s care plan to reflect this so that other staff are also aware of their needs.”

We looked at two care records of people who used the service and saw that there were various entries of other health care professional’s intervention.

The overall building maintenance was kept to a generally high standard and the grounds outside were sufficiently well kept and security gates were fitted which ensured people were kept safe.

Records we looked at included a staff induction programme that all new staff would be expected to complete. This ensured that all new staff received a consistent approach to induction that followed the common inductions standards skills for care.

A visiting relative we spoke with told us, ”I completed a survey last time round in august this year which asked us our views of the service.”

We used a number of different methods to help us understand the experiences of people who used the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke with two staff, the manager and three relatives.

A relative told us: “Staff at the home are wonderful and the management are really good people. They have just introduced coffee mornings with staff, management and other relatives which gives me the opportunity to share experiences.”

We spoke with a visiting health care professional and comments included; “This home is pretty well run and one thing that really stands out for me is that the staff are keen to be here and the enthusiasm shown towards the people who use the service, proves that.” “The staff engage very well with other services and they ring us for specialist advice when they need it.”

Staff told us that they used a series of questioning and checking their reaction, monitoring responses and observing different emotions for people who lacked capacity. This ensured people who use the service understood basic instructions and allowed them flexibility to make their own decisions.

We looked at specific medications that were administered to two people that used the service. We found that the quantities of medication administered, was accurate with the Medication Administration Record (MAR) entry.

Staff also told us that; “I love working here and we have a good team.”

Due to people's needs we were unable to talk directly to people about living in the home.

3 The Causeway is a three storey house situated in a residential setting close to local facilities including a shopping complex, restaurants, a cinema and a bowling alley. The home’s ground floor comprises a kitchen dining room and a separate laundry area. The first floor has one bedroom, a lounge and an office, the third floor has two bedrooms with en-suite facilities. At the time of the inspection there were three people living in the home.

This inspection was unannounced; it took place on 13, 20 and 27 February 2015. At the last inspection on 19 November 2013, the registered provider was compliant with all the regulations we assessed.

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.

People were not always protected from abuse and avoidable harm. Incidents of violent and aggressive behaviour were not always reported to the Care Quality Commission or the local authority safeguarding team as required. Investigations were not always completed; care and support plans were not updated to prevent future incidents taking place. We found that [the registered person had not protected people against the risk of abuse and avoidable harm. This was in breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A quality monitoring system was in place that consisted of audits, checks, monthly assessments and stakeholder surveys. We saw that when shortfalls were noted; action was taken to improve the service as required. However, the system required developing to ensure all shortfalls in care, treatment and support were highlighted as incidents of violent and aggressive behaviour that took place within the service were not always addressed or managed.

A formal supervision process was not in place which led to staff not receiving supervision and support as required. When we asked staff if they felt supported we received mixed responses.

The people who lived at the home had complex needs which meant they could not tell us their experiences. We used a number of different methods to help us understand the experiences of the people who used the service including the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experiences of people who could not talk with us.

People had their health and social care needs assessed, support plans were developed which stated how staff should provide care and support using the least restrictive options. People were treated with dignity and respect throughout the inspection.

We saw that staff gave encouragement to people who lived at the home and supported them to make choices about their daily lives.

Staff were aware of people’s preferences for how care and support was to be delivered. We observed staff gaining people’s consent from non-verbal cues before support was provided. We witnessed staff giving encouragement to people and supporting them to make choices about aspects of their daily lives.

Staff did not always have the skills to communicate effectively. Although staff understood people’s non-verbal communication; what people were trying to convey with sounds and actions was not recorded accurately in a communication support plan.

People were supported to maintain a healthy balanced diet. When required, relevant professionals had been contacted for their support and guidance in this area.

Medicines were ordered, stored, administered or disposed of safely. Personalised support plans had been developed to ensure people received the medicines in line with their preferences and needs.

People were supported by suitable numbers of adequately trained staff who had been recruited safely. We saw evidence to confirm staff had completed a range of training deemed as mandatory by the registered provider.

Staff followed the principles of the Mental Capacity Act 2005 when people lacked capacity to make informed decisions. We saw evidence that best interest meetings were held accordingly. We found the home was meeting the requirements of the deprivation of Liberties safeguards (DoLS). These safeguards provide a legal framework to ensure that people are only deprived of their liberty when there is no other way to care for them or safely provide treatment.

People were supported by staff to undertake a range of social activities in the home and the local community.