4 Orchard Close is a residential care home providing care for up to seven people with a learning disability. All of the people using the service also had a range of physical disabilities and healthcare needs. This meant staff were required to work closely with other health and social care providers to provide specialist care and support.

This inspection took place on 18 and 24 October 2017 and was unannounced. At our previous inspection on 29 October 2015 we found that the service was meeting all the legal requirements we looked at and was rated as good.

At this inspection we found the service remained Good.

There was a registered manager in place at the time of 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.

Everyone we spoke with who either used the service, relatives, and a healthcare professional praised staff for their caring attitudes. The service was tailored to not only meet people’s needs but to do so in the most caring and unique way possible, taking account of people as individuals and not making people fit around procedures or processes. Care plans showed that considerable emphasis was given to how staff could ascertain each person’s wishes including people with limited verbal communication. Staff demonstrated not only that they knew the people they supported but went the extra mile to care about people’s best interests and enhance their life experiences. Staff were committed to this by doing as much as they could to promote people’s emotional as well as physical wellbeing.

The service is owned and run by the London Borough of Islington and used the local authority’s borough wide safeguarding adults from abuse procedures. The provider ensured that staff had training about safeguarding people from abuse and members of staff, whether management or care staff all told us they were trained about protecting people from abuse, which we verified on training records.

Potential risks to people were assessed and responded to, this too helped to keep people safe from known risks and avoidable harm. These assessments were detailed, and were regularly reviewed.

There were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make decisions for themselves were protected. The service was applying MCA and DoLS appropriately and making the necessary applications for assessments when these were required.

Most people had complex healthcare needs which were assessed, and care was planned and delivered in a consistent way. Staff knew about, and were very familiar with people’s needs and the information and guidance provided to staff was clear.

The staff team demonstrated that there was a real commitment to providing the most caring and person centred support possible. This meant the staff team took time to really get to know people and support them, not least when people needed to spend time in unfamiliar places such as hospital, to looking to make a positive impact on people’s life and life experience opportunities. Assumptions about people and their support needs were not made and significant effort was put into exploring the possibilities for real effective and beneficial changes, this effort achieving notable success and praise from families and other professionals alike.

Significant efforts continued to be made to engage and stimulate people with activities whether these were day to day living activities or those for leisure time. People received the support they required to engage in these activities, maintain contact with family and friends and to maximise their opportunities to engage

4 Orchard Close is a residential care home providing care for up to seven people with a learning disability. All of the people using the service also had a range of physical disabilities and healthcare needs. This meant staff were required to work closely with other health and social care providers to provide specialist care and support.

This inspection took place on 29 October 2015 and was unannounced. At our previous inspection on 17 November 2014 we found that the service was meeting the regulations we looked at although we did recommend three areas for improvements. We found at this inspection that the service had taken action to address the recommendations that we made.

At the time of our inspection a registered manager was employed at the service. 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 staff of the service had access to the organisational policy and procedure for protection of people from abuse. The service is owned and run by the London Borough of Islington and used the authority’s borough wide protection procedures. The members of staff we spoke with said that they had training about protecting people from abuse, which we verified on training records and these staff were able to give detailed responses about the action they would take if a concern arose. We found that staff had a sound level of understanding of how to keep people safe from harm and this knowledge helped to protect the people using the service.

We saw that risks assessments concerning falls, healthcare conditions and risks associated with daily living and activities were detailed, and were regularly reviewed. The instructions for staff were clear and described what action staff should take to reduce these risks and how to respond if new risks emerged.

There were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make decisions for themselves were protected. The service was applying MCA and DoLS safeguards appropriately and making the necessary applications for assessments when these were required.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way. People using the service had complex needs and we found that the information and guidance provided to staff was clear.

It was clear that significant efforts were made to engage and stimulate people with activities whether these are day to day living activities or those for leisure time. One to one time was provided for people to maximise their opportunities to engage in normal life experiences.

Everyone we spoke with who used the service, and relatives, praised staff for their caring attitudes. The care plans we looked at showed that considerable emphasis was given to how staff could ascertain each person’s wishes including people with limited verbal communication and to maximise opportunities for people to make as many choices that they were meaningfully able to make. We saw that staff were approachable and friendly towards people and based their interactions on each person as an individual, taking the time needed to find out how people were feeling and what they could do to help.

Staff views about the way the service operated were respected as was evident from conversations that we had with staff and that we observed. We saw that staff were involved in decisions and kept updated of changes in the service and were able to feedback their views at handover meetings, staff team meetings and during supervision meetings.

The service complied with the provider’s requirement to carry out regular audits of all aspects of the service. The provider carried out regular reviews of the service and regularly sought people’s feedback on how well the service operated.

At this inspection we found that the service met all of the regulations that we looked at.

4 Orchard Close is a residential care home providing care for up to seven people with learning disabilities. Some people using the service also had a range of physical disabilities and healthcare needs. This meant staff were required to work with other health and social care providers to provide specialist care and support.

At the time of our inspection a registered manager was employed at the service. 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.

From our observations of interactions between staff and people using the service and our conversations with relatives we found that people were usually satisfied with the service. Relatives we spoke with were confident about approaching the manager and staff to talk about the things that they wished to and felt that there was openness in the way the service communicated with them.

We saw that there were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). These systems ensured that people who could not make decisions for themselves were protected and not unlawfully deprived of their liberty. We saw that the service was applying these safeguards appropriately and making the necessary applications for assessments when these were required.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way. People using the service had complex needs and we found that the information and guidance provided to staff was clear. Any risks associated with people’s care needs were assessed and plans were in place to minimise the risk as far as possible to keep people safe. However, we found that in some cases these risk assessments had not been updated regularly.

During our observations we saw that staff knew how to support people in ways that were most appropriate to their needs and known wishes. On the day we inspected we found that sufficient numbers of staff were being provided to meet people’s needs.

Staff had the knowledge and skills they required to support people. They received training to enable them to understand people’s diverse needs and work in a way that was safe and protected people. However, we found that staff supervision was not as regular as expected by the provider.

Staff respected people’s privacy and dignity. They knocked on people’s doors and explained to people what they were going to do where it was possible for people to have an understanding of this. Where it was not staff were able to describe how people made it known if they were uncomfortable or in other ways not satisfied, as well as when people were happy and contented.

Social and daily activities provided suited people and met their individual needs. People’s preferences had been recorded and we saw that staff worked well to ensure these preferences were respected.

People and / or their representatives knew how to make a complaint if they had any concerns. We saw that where people had raised issues these were taken seriously and dealt with appropriately. People could therefore feel confident that any concerns they had would be listened to. 

Relatives and health and social care professionals who had regular contact with the service all told us that they gave their views about the quality of the service to the manager or other staff. The service accepted that there was no internal way of doing this or any quality assurance report. However two other independent organisations were involved in seeking views of people using the service and relatives and we found that these views were acted upon. We found that verbal feedback was provided directly to the service by people, who told us this. 

We spoke with people using the service who due to their disabilities were not able to directly express their views. Staff demonstrated an understanding of people’s gestures and words. A relative told us '' The staff know what they are doing and understand what people are trying to say. You just have to give them time and be patient.'' We observed that people’s privacy and dignity were respected.

Peoples personal needs had been assessed and they had care plans to ensure their needs were met. Staff interactions with people were kind and friendly, they introduced themselves and explained what care they needed to provide before carrying it out. We saw that families were involved in decisions about future care to ensure people’s best interests were represented. A relative we spoke with said ‘’you only have to look to see how well cared for everyone is, I am happy with everything and don’t have to worry.’’

Medicines were securely stored and administered safely by staff that had been appropriately trained.

The provider had effective recruitment procedures in place to ensure people were cared for by suitable staff that were appropriately qualified.

People’s personal and medical records were accurate and fit for purpose. We saw that the environment appeared well maintained and this was reflected in the maintenance records we inspected which showed all safety checks were up to date.

The majority of people who use the service had limited verbal communication. We spent time observing the care being provided. We saw good interaction between the people using the service, whose wishes and preferences were acted upon by the care staff.

We spoke with the deputy manager, three care staff and a senior manager in Islington’s Housing and Adult Social Services department. We also spoke with two healthcare professionals involved in the people’s care, who are regular visitors to the home and whose comments were positive. One said they were “very impressed with the home” and that the management team was “very, very good.” Another said they had a “good working relationship with the managers and staff.”

We found evidence that improvement and compliance actions set following our last visit had been met. We have highlighted some issues, mostly relating to record keeping, which the provider may find useful to note.

The people using the service when we visited had difficulties in communicating verbally. We therefore spent time during our visit observing the care provided.

We observed that people using the service appeared comfortable and settled within the home. We also observed that staff promoted dignity and showed respect to people using the service when assisting them. Staff understood the behavioural and non verbal cues of people using the service and appeared to respond appropriately to these.

People using the service were involved in activities of their choice within the home and in the community. Staff provided sensitive support at mealtimes, and people who use the service appeared to enjoy the meals provided. The homes fridge and freezer were well stocked; however staff had not been recording and monitoring the temperatures of the fridge and freezer.

We found that the accommodation was appropriately adapted to meet the diverse needs of people using the service. We were concerned that staff were not carrying out and recording regular fire alarm tests.

Each person using the service had an individual plan; however some of those we looked at had not been regularly reviewed or updated.

We found that the home was staffed by suitably qualified and experienced staff, but we found that some staffs core training was out of date or had not been provided. We also noted that insufficient staff were on duty on the day we visited to adequately provide care and participate in an assessment by another professional.