This inspection took place on 21 and 23 August 2018 and was unannounced. Marshlands is a ‘care home’ for people who may have a learning disability or autistic spectrum disorder. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 18 people in one adapted building. Two people had their own personal flats external from the main house. All people had access to two communal lounge / dining areas, kitchen and shared bathrooms. There was a large garden which people could access. At the time of our inspection, there were 14 people living at the service.

Marshlands was last inspected on 12 May 2017 and was rated as Requires Improvement in the safe and well-led domain, and Requires Improvement overall. Shortfalls identified at that inspection included tools being left unattended within the service placing people at potential risk, actions identified by the fire service had not been implemented, and work was needed on the structure of staffing and their understanding of their responsibilities. At this inspection, the provider had made improvements in these areas and worked through an action plan of the issue we identified during our inspection. Environmental risk assessments had been put into place, and staff were aware of the risks of leaving tools unattended. The provider had installed a ramp at the front of the building as recommended in the risk assessment completed by the fire brigade. Following concerns raised at the previous inspection, staff received the support they needed from a structured management team. This service has been rated Good overall.

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. A new manager had been appointed and was in the second week of the induction when we visited. The new manager was in the process of submitting an application to take over the management and registration of the service from the registered manager. They are referred to throughout this report as the manager.

The care service had not been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Marshlands was designed, built and registered before this guidance was published. The provider has not developed or adapted Marshlands in response to changes in best practice guidance. Had the provider applied to register Marshlands today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. The service accommodates more than the recommended number of people, and is not based within a community setting with easy access to local amenities. However, the service was working within the principles of promoting choice and impedance, and was in the process of reviewing the service with the goal to create a more person-centred service, which would meet the guidance for registering the right support.

People told us they were safe at the service. Staff were trained in safeguarding and knew how to report any concerns.

Risks to people and the environment had been assessed and minimised and people were supported to take positive risks such as accessing the community independently, a

This inspection took place on the 12 May 2017 and was unannounced. Marshlands provides accommodation and support for up to 18 people who may have a learning disability or autistic spectrum disorder. Some people display behaviour which may challenge others. At the time of the inspection 16 people were living at the service. One person lived in the penthouse at the top of the service which has its own bathroom, bedroom and lounge. Two people had their own personal flats external from the main house which had a kitchen, bathroom and bedroom/lounge. All people had access to two communal lounge/dining areas, kitchen, shared bathrooms, and laundry room. There was a large garden which people could access when they wished. Within the grounds was a separate day centre which people were able to use.

Marshlands was last inspected on 25 and 26 October 2016 where six breaches of our regulations were identified. The well led domain was rated as inadequate, an overall rating of requires improvement was given at that inspection. The breaches of regulation related to care and treatment, dignity and respect, medication, the environment, staffing and leadership. The registered manager and provider was issued with a warning notice for a continued breach of regulation 17, which related to the leadership of the service.

The previous registered manager had left the service and was in the process of de-registering with The Commission. 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. A new manager had been appointed and was present throughout the inspection; they had started the process of registering with The Commission.

At this inspection the provider had made significant improvements, but more were needed to improve the outcomes people experienced.

Although there was a comprehensive set of environment risk assessments, tools had been left out in the garden which had not been assessed. This posed a risk as some people’s behaviour could result in them throwing objects which could harm others or themselves. People had their own individual risk assessments according to their needs. Risk assessments had been completed to support people to remain safe.

The atmosphere in the service was more inclusive, open and relaxed. There was a positive change in how staff supported and interacted with each other and people. The manager said that more work was to be done to stabilise the staff team and change the culture of the service but this would take time. Staff were generally positive about the improvements made although some staff fedback further improvement was necessary in how the team worked together and communicated.

Staff said they felt well supported and now received more regular supervision. There were safe processes for storing, administering and returning medicines. Staff were trained to administer medicines and dispensed them in a person centred way.

There were enough staff available to support people with their needs and throughout the inspection we noticed how the quality of engagement by staff had improved since the previous inspection. Robust recruitment procedures helped to ensure people were protected against the risks of receiving support from unsuitable staff.

Staff were trained in safeguarding and understood the processes for reporting abuse or suspected abuse. Appropriate checks were made to keep people safe. Safety checks had been made regularly on equipment and the environment. There was good management and oversight of accidents and incidents. Incidents were recorded and audited to identify patterns.

The manager demonstrated a clear understanding of the Mental Capacity Act (MCA) 2005 and the process that must be followed if people were deemed

This inspection took place on the 25 and 26 October 2016 and was unannounced. Marshlands provides accommodation and support for up to 18 people who may have a learning disability or autistic spectrum disorder. Some people display behaviour which may challenge others. At the time of the inspection 17 people were living at the service. One person lived in the penthouse at the top of the service which has its own bathroom, bedroom and lounge. Two people had their own personal flats external from the main house which had a kitchen, bathroom and bedroom/lounge. All people had access to two communal lounge/dining areas, kitchen, shared bathrooms, and laundry room. There was a large garden which people could access when they wished. Within the grounds was a separate building which was called the day centre which people were able to use.

Marshlands was last inspected on 16 and 17 December 2015 where five breaches of our regulations were identified, an overall rating of requires improvement was given at that inspection. The breaches of regulation related to medication, risk assessment, safeguarding, staffing and leadership. The provider had made some improvements, but more were needed in a number of areas, and not enough improvement had been made regarding the management and leadership of the service.

The service is run by 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 registered manager was not present on either day of the inspection. Two senior managers were present throughout both days of the visit.

The provider had not deployed staff to ensure people had their needs met and had ongoing engagement. We witnessed several incidents involving people which were managed by the people themselves but could easily have escalated as staff had not been present to intervene.

People were at risk of receiving their medicine inappropriately because staff did not have up to date and clear information to refer to.

Not all areas of the service were clean or well maintained, staff were expected to perform cleaning duties as well as support people with their individual needs.

Staff did not have a clear understanding about how to respond appropriately to some of the behaviour people displayed. Staff did not always act in accordance with people’s individual behaviour guidance.

Some of the language used in records were not dignified or respectful and was judgemental. There were some positive and engaging interactions between people and staff, although at other times this was limited.

Although people’s care files were written in an easy read format which included pictures to help people understand its content it was not always clear that what happened in practice was a reflection of the information in the care plans. People’s individual needs had not always been thought about or supported well. Other parts of the care plans were detailed, informative and person centred.

When areas of improvement had been outlined it was not always clear what action the provider had taken. There was a culture within the service that the registered manager and senior managers were seeking to change. Staff were unsettled and team relationships were fractured with a ‘them and us’ culture emerging.

Staff received regular supervision; Staff had appropriate training and experience to support people with their individual needs.

Incidents were recorded and audited to identify patterns. The registered manager or senior staff analysed reports to identify any emerging trends or patterns so that action could be taken to reduce the risk of recurrence and further harm occurring.

People had their own individual risk assessments according to their needs. Risk ass

We spoke with a few of the people at the home, but were unable to speak with most of the people who use the service as they had limited verbal communication. One person told us “I think the home is very good”, and another person said “I like helping the staff; they let me help in the garden”. We observed care given to five people, and noted the positive and warm interactions between staff and people who use the service.

We found that people’s capacity to consent was assessed and documented, and there was access to local advocacy services for people who were unable to make their own decisions. We saw that care plans had been written and regularly reviewed based on assessments of people’s individual needs and contained detailed information. We saw evidence of monitoring and regular evaluations of the support that was provided.

We found that records were maintained which demonstrated that medicines were dispensed accurately and stored safely. Staff told us that they received regular training and assessment in medicines handling and administration.

We saw that there were suitable recruitment and selection procedures in place, and found that personnel files contained current information on the suitability of a staff member for their role. We found that staff were supported through the induction process, and had access to a programme of regular training.

We found that there was information on how to complain in formats which enabled the people who used the service to make their views on the service known. We saw that where people complained or made comments about the service, action was taken to address the concern.

15 people were living at the home at the time of the inspection. During the inspection we spoke with six people, the manager and three members of staff.

People we spoke with said they liked living at the home and they were able to make choices about their lives and things that were important to them. People chose when to get up and go to bed, what to do and what to eat and staff respected their choices.

People had been asked how they liked their care and support to be provided and were supported to learn and maintain independence skills. People chose how to spend their time at home and in the community. They helped with household tasks and to keep their rooms clean and tidy to the level of their ability. People said “I do my laundry on Thursday”, “I help with the washing up” and “I help with gardening and painting”.

People were provided with opportunities to experience a range of activities at home and in the community. People said “I like singing we put on a show” and “I do trampolining and karaoke”.

Staff understood people’s needs and had the training they needed for their roles. People had good relationships with staff and were comfortable in their presence. A person told us “staff are nice “and “I like the manager”.

People were asked for their views about the home and told us they went to house meetings.

The needs of the people currently living at Marshlands varied. Some people were unable communicate verbally,we saw that they were comfortable in the presence of staff and that staff understood and responded to their needs and methods of communication. The people we spoke with told us that they liked living at Marshlands and they liked the staff. Comments included “The staff help you out” and “I like (staff member) and everyone here”.

People told us about the activities that they had attended that day and said they had enjoyed them. They said that they could choose what activities to attend and what to do in their leisure time at home. A person who had been to a session at the organisation’s day centre in the morning told us that they had enjoyed it and what they had done there.

People who showed us their bedrooms told us they liked them, one person said they liked their room as they were able to make their own drinks there.

We saw that people were supported to be independent and to be involved in the running of the service. One person said that they helped with the washing up, and another that they did some gardening.

People told us that they liked the meals at the home and there was always choice, one person said “The meals are nice but I do not like spaghetti Bolognese so then I have a ploughman’s” and another person told us “The meals are all right”.

The inspection took place on the 16 and 17 December 2015, this inspection was unannounced. Marshlands provides accommodation and support for up to 18 people who have a learning disability or autistic spectrum disorder. The service was last inspected in January 2014 and had met our standards of compliance.

At the time of our inspection 17 people were living at the service. 14 people lived in the main house and had their own bedroom either on the ground floor or first floor. One person lived in the penthouse located at the top of the service which had its own bathroom, bedroom and lounge. Two people had their own personal flats, external from the main house which had a kitchen, bathroom and bedroom/lounge. All people had access to two communal lounge/dining areas, kitchen, shared bathrooms, and a laundry room. There was a large garden which people could access when they wished. Within the grounds was also a separate building which was called the day centre which people were able to use.

The service is run by a registered manager who was present on both days of the inspection visit. 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 had undergone many changes since the registered manager had taken up post in July 2015. There had been a large scale recruitment drive resulting in a new staff team and promotion of one staff member to the deputy position. The service had documented the improvements they had made in their internal audits and had identified areas for further improvements, which they were working towards.

Parts of the home were not safe. One person’s bedroom contained an unguarded portable heater which was also a trip hazard. Another person’s bedroom door had been propped open with a chair which would be a risk to the person in an event of a fire. Two windows did not have restrictors in place to minimise the risk of someone falling from the window. A cleaning product which should have been stored securely had been left in the bathroom cupboard and posed a potential risk for people.

Areas of medicine recording and administration were not safe. When people were prescribed occasional medicines it was not well document how staff would be able to identify when the person required their medicine if the person was unable to ask for it. When people were prescribed creams, body maps or other guidance had not been implemented to inform staff where the person required their cream or what quantity they should receive. When the amount of medicine a person was prescribed changed, this had not been updated on the medicine record.

Staff received training so they were able to carry out their roles effectively but not all training was refreshed on a regular basis to ensure staff had the necessary skills for their roles. Staff have received appraisals and felt well supported but regular recorded supervisions were not evident.

Safety checks in fire safety and safe food storage were not conducted on a regular basis. It was not evident that feedback from people had been acted on and views actively sought to improve services.

Staff had received training in understanding how to keep people safe and guidance was available to assist them to raise concerns. However, staff we spoke with were not sure of their responsibilities or the processes to follow if they needed to raise concerns.

There were sufficient staff to meet people’s needs and allow time for people to engage with staff in an unhurried and sociable way. Staff responded quickly to people when they asked for support.

Risk assessments were person centred and clearly described how staff could support people to remain safe. Accidents and incidents were logged and auditing completed to identify if there were repeating incidents which could be prevented.

Capacity assessments had been undertaken for people and there was a good understanding of the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. Where people lacked capacity, applications to deprive them of their liberty had been made in their best interests following the correct processes. People had access to advocacy service if they requested or needed this.

Care plans were person centred, detailed and descriptive to inform staff of how people liked to receive their support. People were encouraged to be involved in their care plans as much as they wished. Each person was allocated a key worker and had monthly meetings with them. Within the care plans there was good guidance about helping people to manage their behaviours. Care plans also contained health action plans to promote peoples wellbeing and address their health needs.

A day centre was available for people to use in the grounds of the service. A lot of work had been put into the day centre to make it a success and there was an employed activities coordinator who planned activities with people if they chose to participate. There were activities going on throughout both days of the inspection which different people took part in.

Staff cared about the people who lived at the service and wanted good outcomes for them. The interactions between staff and people were kind, patient and relaxed. Staff had a positive attitude and understood the values of the service.

Staff felt supported by the registered manager and able to go to them for support and guidance at any time.

We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.