Manon House is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Manon House accommodates up to six people in one adapted building. The service specialises in supporting people with mental health needs. At the time of our inspection there were three people using the service.

This inspection took place on 8 January 2019. At our last comprehensive inspection of the service in June 2016 we gave the service an overall rating of ‘good’. However, we rated the key question ‘is the service safe?’ as ‘requires improvement’. This was because the provider had not undertaken risk assessments with people to ensure they were capable of understanding and managing their own medicines. At a follow up inspection in August 2017 we found the provider had taken action to improve and meet legal requirements. However, we did not improve the rating for the key question ‘is the service safe?’ because to do so required consistent good practice over time.

At this inspection we found some aspects of the service had deteriorated resulting in the overall rating for the service changing from ‘good’ to ‘requires improvement.’

The service continued to have a registered manager in post. We found the registered manager had not fully met their legal obligation to submit notifications to CQC of events or incidents involving people at the service. Failure to notify CQC of these incidents meant we could not check that the provider had taken appropriate action to ensure people's safety and welfare in these instances.

The provider's systems to monitor and assess the safety and quality of the service were ineffective. In the absence of regular checks and audits they had not identified concerns we found during this inspection about the quality and safety of the service. This put people at risk of receiving unsafe and unsuitable care and support.

Aspects of the premises posed a risk of injury and harm to people. The provider did not formally assess and manage risks posed by the premises to identify potential hazards to people. However, the provider carried out some maintenance and servicing of the premises and equipment to ensure areas covered by these checks remained in good order and safe to use.

The provider had no system in place to monitor cleanliness and hygiene at the premises. Parts of the premises were not clean or hygienic which put people at risk of acquiring infections and illnesses that could arise from poor cleanliness and hygiene. The registered manager told us they would make immediate arrangements for a deep clean of the premises after this inspection.

Staff had not received all the support they needed to deliver effective care to people. They were not provided with all the training required to meet the specialist needs of people using the service. However, staff had regular supervision (one to one meetings) with senior staff to help them improve their working practices and the quality of support provided to people

Medicines were stored safely and securely, and people received them as prescribed. However, staff’s current working practices did not reflect national guidance and best practice when maintaining appropriate records related to people’s medicines. We have made a recommendation about improving the management of medicines administration.

People knew how to make a complaint if they were unhappy with any aspect of the service. The provider continued to maintain arrangements for dealing with people’s complaints or concerns if these should arise. However, the current complaints procedure was out of date and did not give people the correct advice about how to take their complaint further. The registered manager said they would update this immediately after the inspection.

Notwithstanding the issues above, people spoke positi

We carried out a comprehensive inspection of this service on 10 June 2016 at which a breach of legal requirements was identified. We found no risk assessments had been undertaken with people to ensure they were capable of understanding and managing their own medicines. After the inspection, the provider wrote to us with a plan for how they would meet legal requirements in relation to this breach.

We undertook this focused inspection on 10 August 2017. We checked the provider had followed their plan and made the improvements they said they would to meet 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 Manon House on our website at www.cqc.org.uk

Manon House is a small service which provides care and accommodation for up to six adults. The service specialises in supporting people with mental health needs. At the time of our inspection there were five people using the service.

At this inspection we found the provider had taken the action they said they would and were now meeting legal requirements.

Risk assessments had been undertaken with each person using the service to determine whether they could take and look after medicines themselves. Where people required assistance to take their medicines the reasons for this were detailed in their records and people had consented to the support that was provided.

Where a person was able to self-medicate their individual risk assessment set out the support they required to do this safely whilst maintaining their independence to do so. They had been provided a secure lockable medicines cupboard to keep their medicines safe. The provider reviewed risk assessments every 3 months, or sooner if required, to check that current arrangements continued to meet people's needs.

We visited Manon House on the 10 and 13 June 2016. The inspection was unannounced.

At the previous inspection, in September 2015, the service was found to be breaching a number of regulations and required improvements in the following areas: person centred care; safe care and treatment; safeguarding; receiving and acting on complaints; good governance; and, staffing. The

specific details of what required improvement in these areas are outlined in the report. We found the service had made improvements in response to the September 2015 inspection and were meeting the regulations. However, at the inspection in June 2016 we found improvements were needed in the management of medicines.

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.

Manon House provides care and treatment for up to six males with mental health conditions. There were four people using the service at the time of the inspection.

The service did not always manage medicines safely. We found the service did not have appropriate risk assessments in place for people who were managing their own medicines. Otherwise, medicines were managed safely. People told us they felt safe. Staff knew how to recognise the various types of abuse and the procedures for reporting abuse. They were aware of how to escalate concerns and understood whistle blowing procedures. Staff were confident that they could report any concerns and had completed safeguarding training. People’s needs were assessed and risk assessments created. There were sufficient, suitable staff to meet people’s needs. The environment was a safe place for people, staff and visitors.

Staff were supported with training and supervision. The service was working within the principles of the Mental Capacity Act. People had sufficient food to eat and liquids to drink. People were supported with their healthcare needs.

The service was caring. Staff were respectful, attentive and knew people well. People were very positive about staff. Staff respected people’s privacy and dignity and encouraged independence. People were involved in their care and treatment.

People received personalised care. People’s needs were assessed before they came to the service. Care plans were developed with people taking into account their needs and preferences. The views of people using the service were sought to improve service provision. People were confident they could raise issues with staff. A complaints system was in place.

There was a system of audits, formal and informal checks and reviews to assess and monitor service provision. People and staff said the manager was approachable and accessible. Staff worked closely on a daily basis with the manager due to the small size of the service and provided regular feedback on a one-to-one basis. Staff could call the manager at any time of the night or day.

During the inspection we found:

• Risk assessments of people using the service had not been regularly reviewed and there were no plans in place showing how identified risks would be managed or mitigated.
• When restrictions were placed on people there were not always care plans in place to explain this.
• The service did not have safe arrangements in place for the storage and disposal of medicines.
• The manager failed to recognise safeguarding concerns even when these were being investigated by the local authority safeguarding team.
• There was no incident logs and incidents were not routinely recorded or reviewed so that the staff and manager could learn from these.
• People’s needs were not assessed comprehensively and recorded.
• People’s care plans contained limited information and were not holistic or recovery orientated.
• Some information about people was placed in another person’s care records.
• There was no record that staff had received any training since 2013-2014.
• Staff had a poor understanding of the Mental Capacity Act and guiding principles. There was no record that they had received training.
• There was little evidence of people’s involvement in planning their care.
• People using the service were not encouraged or supported to develop independent living skills.
• There were no planned or structured activities being arranged for people who required support and encouragement.
• There was no system for recording formal or informal complaints. There was no information for people using the service about how they could complain.

• There was no system in place to assess and monitor standards of care in order to identify improvements in quality and safety.

However,

• We observed kind and caring interactions between staff and the people using the service.

• The food was of good quality and snacks and drinks were available at all times and dietary needs were met for those of different ethnicities and religions.

The follow up inspection was carried out by an inspector during one afternoon. We did not review any information in relation to the questions ‘Is the service safe', 'Is the service caring' 'Is the service responsive' 'Is the service well led'. This was because this was a follow up inspection to check that a compliance action made at the last inspection had been met.

During this inspection we met with two of the people using the service and two support workers.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service effective?

We found there were care plans and suitable arrangements in place for everyone using the service. These plans responded to the physical health, mental health, social, financial and cultural needs of people who used the service. The service had arrangements in place to identify and manage appropriately risks presented. Staff received the training they required to ensure they had the skills and knowledge to support people who used the service. People were supported by support staff in accordance with their care plans.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found.

The summary is based on our observations during the inspection, speaking with three of the six people using the service, speaking with three staff and from looking at records. We requested additional information from the provider, and we spoke with three community based mental health care professionals who were care coordinators for people using the service.

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

This is a summary of what we found:

Is the service safe?

People we spoke with told us they felt safe in the home. People told us there were enough staff to make sure people received the care and support they required.

Staff also told us there were usually enough staff available to meet people’s needs, but felt a need to keep staffing levels under review since the service increased the numbers of people using the service.

The home was safe and well maintained. Arrangements were in place for regular health and safety checks and for the servicing and maintenance of equipment.

People living in the home had assessments of possible risks to their mental and physical health and these were reviewed at least quarterly, they had systems in place to manage these appropriately.

Is the service effective?

Care plans in place identified the physical health, mental health, social, financial and cultural needs of people who used the service. People were supported by staff in accordance with their care plans. A care co-ordinator from the local NHS mental health trust told us they found that people using the service received the care and support they required.

Staff received the training required to ensure they had the skills and knowledge to support people who used the service.

The service had not developed suitable care plans for every individual who used the service. One person recently admitted did not have a care plan, and as result staff did not have the necessary information they needed to support the person.

This lack of information could lead to the risk of the person receiving inappropriate care and support. This resulted in a breach of Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010.

Is the service caring?

People using the service told us staff were kind and patient. People found their views were acknowledged, they were offered choices and staff knew about and respected their preferences and daily routines.

Staff meetings and training included topics on promoting dignity and respect, and staff were able to tell us how they included this in their work with people in the home.

Is the service responsive to people’s needs?

People were supported to express their views and were actively involved in making decisions about their care, treatment and support. Staff were responsive to people’s needs and care and support was delivered in line with their interests and preferences. People were offered opportunities to engage in activities they enjoyed and to develop independent living skills.

People knew who to speak to if they had concerns. We saw that complaints made had been responded to quickly, including explaining to people why certain processes were in place. People had the opportunity to discuss the service and identify any concerns or suggestions through regular meetings for people who lived there.

Is the service well-led?

There were basic processes in place to monitor the quality of the service, but further work could be undertaken to ensure that these are effective in driving improvement and best practice at Manon House.

The registered manager has been absent from the home for some months, temporary management arrangements were in place to address this. The registered manager/provider will need to keep the Care Quality Commission informed on the future plans for managing the service.

On the day of our visit we met with the registered manager who was also the owner of Manon House and we met with a senior support care worker. Out of the three people living at the home we spoke to one person. We also reviewed the recent questionnaires that had been completed in August 2013 and we saw the comments from the people who lived in the home. The comments included ‘I like my room’, ‘staff involve me in running the home’, ‘staff are very helpful’, ‘staff listen to me’, ‘staff are interested in my difficulties and are discussed regularly’, ‘varied meals with good nutritional balance’, ‘regular care plans are completed often’ and ‘I am consulted and discussed with’. We did not see any comments to suggest any improvements.

When we spoke to the person living in the home about the complaints procedure they told us “It has been explained to me and I know it’s outside near the telephone,” “I don’t have any complaints” and “I would speak to the owner if I need to complain.”

The person we spoke with told us they were satisfied with the care and support they received at the home. They reported that they were treated with dignity and respect.

When we looked at the care plans we found these were in line with the needs and risks assessed at the initial assessment.

Staff had received up to date training to support the needs of people who lived in the home.

The feedback received had been generally very positive, with favourable comments being made about the home and the support being provided by staff. People we met told us that staff always treated them well and listened to what they had to say. Comments included, “I like living here” and “the place is better from the last one I used to live at.

We spoke to some of the people living at Manon House at the time of our visit and

all of them gave us positive feedback about the home and the staff. They told us they were happy with their treatment and care. They told us they were able to express their views and have their privacy respected.