HF Trust – St Teath Site is a residential care home for up to ten people with a learning disability or autism. There are two properties on one site: Rendle House and Valley View. Each can accommodate up to five people. At the time of the inspection nine people were living at the service. The service is part of the HF Trust group who run a number of residential, supported living and domiciliary care services throughout Cornwall, and nationally. This announced comprehensive inspection took place on 19 September 2018. We last inspected St Teath on 17 and 20 June 2016, when the service was rated Good.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is required to have a registered manager and there was one 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.

The service was operating in line with the values that underpin 'Registering the Right Support' and other current best practice guidance. This guidance includes the promotion of the values of; choice, independence and inclusion. The service was working with people with learning disabilities that used the service, to support them to live as ordinary a life as any citizen. People had access to private spaces and were able to choose where they spent their time. Staff supported people to access the community regularly. People’s independence was respected and they were encouraged to develop and maintain skills.

The service requires a registered manager and there was one 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.

People were protected from identified risk. Staff were aware of the support people needed to help keep them safe. Any changes in people’s behaviour or health was monitored to try and identify causes and triggers. Action was taken to learn from any untoward events.

The premises were clean and largely well maintained. People had access to safe outdoor spaces. Any maintenance was carried out quickly and there was a programme of redecoration in place. People’s bedrooms were personalised and reflected their tastes and interests.

There had been a high level of vacancies at the service with a large number of agency staff being used to ensure people were supported according to their care plans. A recent recruitment drive had been successful and, at the time of the inspection, there was only one staff vacancy. Planned rotas showed people were to be supported by a consistent staff team. Each site had their own distinct staff team which was overseen by a senior support worker. Key workers had responsibility for monitoring individual delivery of care. Relatives told us key workers were very familiar with people’s needs.

There had been a high level of medicine errors at the service, over a prolonged period of time. We looked at systems for the management and administration of medicines and found there were suitable arrangements in place, including when people went for days out or weekends away. Training was regularly refreshed and there was a system of competency checks in place. We concluded the mistakes were due to human error. We have made a recommendation about ensuring the environment is calm when staff are administering medicines.

Staff were supported by a system of induction, regular training and su

We carried out this unannounced inspection on 17 and 20 June 2016. The service was last inspected in September 2014; we had no concerns at that time.

HF Trust – St. Teath Site is owned and operated by Home Farm Trust (HFT). There are two properties on one site: Rendle House and Valley View. Each property provides care and support to adults who have a learning disability and/or autistic spectrum disorder. Each property can accommodate up to a maximum of five people. At the time of our inspection nine people lived at the service.

The service is required to have a registered manager and there was one 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.

Due to the complexities of people's care needs we were unable to speak with anyone who lived at the service to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

There were quality assurance systems in place to make sure that any areas for improvement were identified and addressed. Some areas, such as medication audits, maintenance and checks on appropriate supervision arrangements were not thorough.

Maintenance required by the service was not appropriately prioritised or recorded to demonstrate when action had taken place.

On the day of our inspection there was a relaxed and friendly atmosphere at the service. We saw that people were comfortable and at ease approaching staff at HFT – St. Teath and staff interacted with people in a caring and respectful manner. Relatives of people who used the service were mainly positive about the level and quality of care provided to people. Comments included, “In my experience the care provided at St. Teath is good. There is a genuine concern to provide the best for people.” And, “On the whole communication is good between myself and management and staff.” One relative commented that they recently raised a concern about the welfare of a person who lived at the service. The registered manager was open about this and we saw the incident had been appropriately investigated and an action plan put in place to prevent a repeat of the incident.

People took part in a range of group and individual activities of their choice including work and social activities. Relatives spoke of the ‘busy’ and ‘active’ lives people lived. This helped to prevent people from becoming socially isolated and promoted their emotional well-being.

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Some relatives expressed concern about the turn-over of staff at one of the houses and the use of agency staff commenting, “It is just a pity the staff turnover is frequent.”. We saw evidence that the rate of use of agency staff had reduced significantly over the last 12 months.

Staff completed a thorough recruitment and induction process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

People had access to healthcare services such as occupational therapists, GPs, chiropodists and dieticians. Relatives told us they were confident that the service could meet people’s health needs and they were always kept informed if their relative was unwell or a doctor was called. The service demonstrated good management of people’s health conditions. Relatives told us how management had worked effectively to bring together a group of health professionals; this ensured treatments were provided with the least amount of stress to the person involved.

Staff supported people to maintain a balanced die

We carried out this inspection to check if the compliance actions set at our inspection on 12 June 2014 had been met. During this inspection we did not receive any information from people who used the service.

At this inspection because we only looked at care records and quality monitoring records we were unable to answer all of our five questions. 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. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found from a records perspective the service was safe.

At our inspection on 12 June 2014 we found people’s care records were held electronically and in paper form, which resulted in information being inconsistent and fragmented between the two systems. This meant people’s care records were not always kept up to date and were not always reflective of people’s care needs.

At this inspection we found the service had carried out a review of the whole care records process. This had resulted in the service reducing the number of different paper records and using the electronic system as the main source of information. We found a review of each person’s care needs had taken place and information from all previous documents had been amalgamated into the electronic records.

We found paper care plans were kept in folders in each of the two houses where people lived. We looked at the paper and electronic care plans for four people who used the service. We found care plans, kept in paper form, had been printed from the information held electronically and therefore information was consistent. All care plans had been updated and accurately reflected people’s needs.

This meant that people were protected from the risk of unsafe or inappropriate care because care plans contained accurate information about how people’s care and support needs.

At our inspection on 12 June 2014 we found records did not show if the provider had considered the impact of any restrictions put in place for people that might need to be authorised under Deprivation of Liberty Safeguards (DoLS). At this inspection we found the provider had carried out a DoLS assessment for everyone who used the service. This had resulted in the provider submitting several applications to the local authority because restrictions were in place for people.

We therefore found the service understood the legal requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (MCA & DOLS) provide a legal framework that protects people who lack the mental capacity to make decisions about their life and welfare.

Is the service well-led?

We found from a quality monitoring perspective the service was well-led.

At our inspection on 12 June 2014 we found the provider had systems in place to monitor the quality of the service being provided. However, these systems were not always effective in identifying areas which required improvement. This included not identifying inconsistencies in care plan documentation. We also had concerns that senior managers in the organisation were validating the quality monitoring audits without visiting the site to check the content of the audits.

At this inspection we found improvements had been made to the consistency of care plan documentation. We also found that a senior manager had visited the site to check if actions from the quality monitoring audits had been completed.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

This is a summary of what we found-

St Teath had been subject to local authority safeguarding authority procedures. At the time of our inspection the systemic safeguarding alert had been closed. However, feedback from relatives expressed that although they had seen some improvement, work was still required to improve staffing stability, care documentation, communication and confidence in the management of the service.

Is the service safe?

At the time of the inspection the service was safe.

Due to the complexities of people’s care needs we were unable to speak with them to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

During our inspection we observed staff supported people in a dignified, respectful and adult to adult manner. We spoke with some relatives/representatives of those living at Rendle House and Valley View to obtain feedback about the service. Overall, people felt that their relatives were safe. However, one relative told us, in response to being asked whether they felt there relative was safe, with “I think so” and one relative explained to us that they had lost confidence in the management of the home and told us that there had been too many “negatives” surrounding the care of their relative.

We found Rendle House and Valley House to be clean and there were no unpleasant odours.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DOLs) which applies to care homes. The recent judgement made by the Supreme Court on 19th March 2014 places a responsibility on providers when a person is deemed to lack mental capacity to ask two key questions; is a person subject to continuous supervision/control? and is the person free to leave? If a person is subject to both continuous supervision/control and not free to leave, then a person is being deprived of their liberty. We found there was a key code to the entrance, which meant people who lived at Rendle House and Valley View where unable to come and go as they pleased. However, it was not clear from people’s care plans how the provider had considered this having regard to the DOLs legislation. People who lived in both houses were also supported on a one to one basis, some of whom were supported for 24 hours a day.

People were kept safe from the associate risks regarding the administration of medication.

There was a safe and robust recruitment process in place for new staff which ensured people who lived at the care home were not placed at risk.

We found people were not always protected from the risks of unsafe and inappropriate care and treatment because accurate and appropriate records were not maintained. Care plans and associated documentation was excessive, making it difficult to find relevant and accurate information. We found that due to the fragmentation of information, care plans were not always kept up to date and were not always reflective of people’s care needs.

Is the service effective?

At the time of the inspection the service was effective.

People’s health and care needs were assessed and individual care plans were in place to guide and direct staff to meet a person’s health and social care needs. However, improvement was required as care plans were not always reflective of a person’s care needs.

We spoke with a relative who was concerned about the use of agency staff, particular male agency staff at night time as their relative preferred female support. They told us that the agency staff did not always know what people’s care needs were and on one occasion had had to explain to the member of staff about the support their relative required. One relative told us “I have faith in some of the staff”.

Is the service caring?

At the time of the inspection we found the service to be caring.

Due to the complexities of people’s care needs we were unable to speak with them to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

We observed staff provided care and support to people in a caring and respectful manner. Staff showed compassion in the way in which they spoke with people and supported them.

Relatives we spoke with were complementary of the staff. However, one relative told us, “You just trust that staff are caring and patient”. During our inspection we found staff to be attentive to people’s care needs. We saw staff engaged in friendly conversation with people.

Is the service responsive?

At the time of the inspection we found the service to be responsive.

People’s care records showed that staff involved external health care professionals such as GP’s, psychologists, and social workers to support people with their changing care needs.

We spoke with a relative who told us that actions from an annual care review had failed to be carried out. As a result of this, the staff had failed to support the person to access a local youth club.

During our inspection we observed staff to respond to people’s need when requested.

Is the service well-led?

At the time of the inspection we found the service to be well-led.

We spoke with some relatives/representatives of those living at Rendle House and Valley View to obtain feedback about the service. Overall people felt that communication had improved and were complementary of the role of their relative’s keyworker. Key workers are used to provide a person and family with a key contact. One person told us that due to a change in management of the service communication had been a problem. They told us it was difficult know “who my point of contact is”.

The service had a manager who was registered with the Care Quality Commission. The manager had recently returned to the service following time off, in her absence the service was being run by two managers. We met with all three managers on the day of our inspection and found them to be knowledgeable and passionate.

It was clear from our observations that the managers were actively involved in the care and support of people who lived at Rendle House and Valley View. Staff we spoke with told us they enjoyed working at St Teath. The staff were complementary of the managers and used words such as “approachable” and “supportive” to describe them.

We found the provider had systems in place to monitor the quality of the service being provided, however, these systems were not always effective in identifying areas which required improvement.

We conducted this inspection in response to receiving information from St Teath site, which had also been shared with the local authority about an incident relating to a person living at the site and issues around medicine management. We spent time observing the care people were receiving and spoke to five members of staff, which included the registered manager. We looked at two people’s care files and reviewed information provided to us by the management team about how they ensured the quality and safety of the service.

Throughout our visit we saw that staff were observant to people's changing moods and responded appropriately. We observed that staff communicated appropriately with people, and we saw the relationships between staff and people in the home were positive.

Medicines were not kept safely. We saw that the medicines cupboard keys were kept in a key cupboard in Valley View which we saw was unlocked. This meant that any member of staff could access the keys at any point. The medicines keys were also bunched with other keys, for example money tins. Medicines keys should be held separately to others and allocated to a designated member of staff to avoid multiple uses by various staff members which would allow for a clear audit trail.

Auditing at a local level was not happening which would allow for issues to be flagged up in a timely manner and for a more proactive approach to attending to arising issues to be adopted.

We conducted an unannounced visit to HF Trust - St Teath Site on Saturday 6 October 2012 as part of our schedule of inspections. We met each of the people who were living in each house at the time and spoke to one about their experience of being there. Most were unable to communicate verbally and so we observed staff providing them with support and looked at records. We spoke to six members of staff. Following the visit we asked the provider for additional information, which we received.

We were told that a lack of access to the internet was having a big impact on one person’s life, with this affecting their access to information and social contacts. People were otherwise well supported to make decisions and where necessary decisions were made in their best interests. One of many examples was around dental treatment.

People’s emotional, physical and social care needs were understood by staff that were skilled and knowledgeable in their work. Physical and health care needs were well met. Risk was well understood and there were measures in place to reduce risk. However, a lack of staff was impacting on both risk and the level of activities available to people.

Staff understood how to protect people from abuse and uphold their rights. They received training which included all aspects of health and safety and that which pertained to people’s individual needs, such as a learning disability and autism.

Staff received supervision of their work, but were unsettled by recent changes in staff and management, which they said had made their work stressful. They said that they felt their concerns were not being heard. The organisation had identified areas of concern which needed to be addressed as a priority and had recently made temporary arrangements to cover the role of manager at the home.

On the first day of our visit we were told that there were nine people living at St Teath site and on our second visit there were eight, with one person moving to alternative accommodation.We spent time observing the care people were receiving and spoke to 11 members of staff, which included the registered manager. We looked at four people’s care files in detail, observed interactions and reviewed information provided to us by the management team about how they ensured the quality and safety of the service.

Staff ensured that people had access to things that reassured them, for example having access to a favourite object.This information was reflected in people’s care files, which were detailed and helped staff support people in a person centred way.

We spent time with people living at the home, staff members and observing how people’s safety was maintained. We observed a relaxed atmosphere, where people appeared happy in their surroundings and with the staff supporting them.

Staff confirmed that people’s needs were met in a timely manner and felt that there were sufficient staffing numbers.

We saw evidence throughout our visits that the wider organisation and staff at St Teath site had worked hard to resolve the issues identified earlier in 2013. This could be demonstrated by better ways of working with other health and social care professionals, reviews of support plans and risk assessments and appropriate measures put in place to safeguard people from abuse.