The inspection took place on 3 and 4 December 2018. The first day of the inspection was unannounced, we told the provider we would be returning on the second day.

Martha House is a residential care home for up to 23 adults with a learning disability. There are two houses on the site Martha House and Frances House, both houses were included in this inspection and are registered with CQC under the name of Martha House. There were 13 people living in Martha house and 8 people in Frances house at the time of inspection. The houses were both single level. There is an activity centre on the site which included a hydrotherapy pool. Martha House is a ‘care home’. People in care homes receive accommodation and 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 service had 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.

At the last inspection on 5 and 6 October 2017 the service was rated overall as requires improvement. Following this we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive, effective and well-led to at least good. At this inspection we found that the rating remained requires improvement. This is the second consecutive time the service has been rated Requires Improvement.

There was no registered manager 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. At the time of the inspection the registered manager had left the service but had not yet de-registered. The service told us that the director of operations intended to register as the manager. However, the application had not been received at the time of the inspection.

At the previous inspection we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to assess all risks and did not have sufficient guidance for staff to follow to show how risks were mitigated when managing health conditions and health and safety. Also, the provider had failed to protect people from the unsafe management and administration of medicines. At this inspection we found that risks to people had been assessed. However, where mitigations were in place these were not always monitored. Care plans were updated but the service was in the process of transitioning from paper to electronic care plans and the paper records were not always up to date but were still being used by staff. There continued to be concerns relating to the safe management of medicines. Medicines were not checked in to the service quickly and were not always available when people needed them. Further improvements were needed to be made and the service remained in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the previous inspection we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The systems in place to check the quality of the care being provided were not effective. Records were not accurate and up to date. At this inspection we found that whilst the electronic care plans were up to date the paper care plans were not and the service was still using both to provide care to people. There was a system of auditing in place, but these checks had not identified th

This inspection took place on 5 and 6 October 2017 and was unannounced on the first day and announced on the second day.

Martha House provides nursing and personal care and accommodation for up to 23 young adults with profound and multiple learning and physical disabilities. There were 20 people living at the service and one person on respite care during the inspection. There were two buildings in the service Martha House and Frances House. Both premises are arranged over one floor, containing bedrooms, communal lounges and dining areas. All of the bedrooms are spacious, with hoist systems in place. The shared toilets and bathrooms are spacious, with hoist systems in place. There is parking available on site, and there are other facilities in the complex, including a hydrotherapy pool.

There was no registered manager in post. An acting manager had been appointed recently and was leading the service. They had not yet applied to be registered with CQC. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. We were supported during the inspection by the manager, deputy managers- one based in each house and clerical staff.

Potential risks to people’s health and welfare had not been consistently identified. Risks that had been identified did not always have detailed guidance for staff to manage risk safely. This led to a risk of people not receiving support that was safe and effective. Accidents and incidents had been recorded and investigated to look for patterns to help prevent them from happening again.

Staff received training appropriate to their role. Checks on the environment had been completed but shortfalls had not always been identified and rectified to keep people safe.

People were not protected from the unsafe management of medicines. People did not always receive their medicines when they needed them. Medicines were not recorded or managed safely. Before the inspection, medicines errors had been identified that put people’s health and welfare at risk. The provider had taken action however, shortfalls were found at this inspection.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires, that as far as possible, people make their own decisions and are helped to do so when needed. When they lack the mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

Staff sought consent from people before providing support. However, senior staff had not followed the principles of MCA when making decisions about people’s care and support. Decisions such as the use of bedrails had not been consistently recorded in line with the guidelines of MCA and not all decisions that people were unable to make on a day to day basis had been considered and recorded.

Staff had not received one to one supervisions in line with the provider’s policy. Staff told us that they felt supported by the deputy managers but there were mixed views on the overall communication within the service. Some staff and relatives felt that the communication could be better and there was not an open culture, others were very happy and felt that they were kept informed.

There were plans in place for monitoring the quality of the service. Audits completed by staff at the service were not effective and had not identified the shortfalls found at this inspection. The provider told us that they completed audits every six months but these had not been completed since May 2016.

Each person had a care plan that had information about the person’s life and preferences. The care

This inspection took place on 19 July 2016 and was unannounced.

Martha House provides nursing and personal care and accommodation for up to 23 young adults with profound and multiple learning and physical disabilities. There were 20 people living at the service and one person on respite care during the inspection. People were unable to communicate verbally and used body language, facial expressions and some vocal sounds to make their needs known. There are two buildings in the service, Martha House and Frances House. Both premises are arranged over one floor, containing bedrooms, communal lounges and dining areas. All of the bedrooms are spacious, with hoist systems in place. The shared toilets and bathrooms also have hoist systems in place. There is parking available on site, and there are other facilities in the complex, including a hydrotherapy pool.

A registered manager was no longer leading the service. An acting manager had been appointed and was leading the service. They had applied to CQC to be registered as the manager of the service and were awaiting the outcome of their application at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. There were two deputy managers one based in each of the houses, together with senior staff and they assisted with the inspection process.

At the previous unannounced comprehensive inspection of this service on 6 and 7 May 2015, five breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. At the time of this inspection the provider has complied with the breaches and had met their legal requirements.

Staff had received safeguarding training to protect people and they knew the action to take in the event of any suspicion of abuse. They had a good understanding of how to keep people safe and their responsibilities for reporting any concerns. Systems were in place to ensure that people’s finances were protected.

Risks to people were identified and there were measures in place to reduce risks to keep them as safe as possible. Accidents and incidents were recorded and reviewed to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety. Plans were in place to keep people safe in an emergency.

Checks were carried out to ensure the premises were safe, such as fire safety checks, water temperatures and health and safety. Equipment to support people with their mobility, such as the ceiling hoists had been serviced to ensure that they were safe to use.

People were supported by sufficient staff with the right skills and knowledge to meet their individual needs. The needs of the people had been taken into account when deciding how many staff were required on each shift. Staff told us the training programme was on going and the manager had ensured their training and development needs had been discussed through regular supervision and their yearly appraisal.

Safe recruitment practices were followed before new staff were employed to work with people. Checks were made to ensure staff were of good character and suitable for their role.

Peoples’ medicines were managed and administered safely. However further detail was required to ensure ‘as and when’ medicines were given in line with people’s needs. This was an area for improvement.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). W

We were unable to speak with people at the care home as the people who used the service had limited verbal communication. We observed care given to people at the service, as well as interactions between staff and people, to determine how care was provided.

We found that the home was clean, bright and spacious, and that staff were polite and courteous to people who used the service. We noted that staff spoke clearly to people when providing care. We found that the staff always asked before attempting personal care, and waited for a response. Staff told us that people who had limited verbal communication were represented by family and advocates where necessary, and we saw evidence to demonstrate this in care records.

We found that care plans were comprehensive, personalised and took into account the needs and abilities of the people who used the service. We saw evidence of monitoring and regular evaluations of the support that was provided, together with involvement and liaison with relatives and various health professionals, to ensure they were kept informed of changes in people's conditions when necessary.

We toured the premises and found that the equipment used at the home, including tracking hoists, motorised wheelchairs, and adapted furniture, was in working order and maintained regularly.

Staff told us that they received the training required to carry out their roles well, and that they felt well supported by the management team and other staff. We noted that the manager had implemented regular discussions of the service with staff, as well as a program of appraisal and supervision, to ensure that any issues of concern could be quickly addressed. We found that the provider had implemented ways to gather feedback on the service from people’s representatives.

We did not speak with people at the care home, but we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed eight people in the main lounge, who were undertaking a variety of activities and interacting positively with the staff. We noted that staff members asked people if they wanted drinks, whilst encouraging them to join in an activity.

People who use services expressed that they were happy at the home and that they felt safe and had everything they needed.

People who use services acted positively towards the staff and said that staff supported them to take part in a range of activities and hobbies including going to college.

People had their own rooms which were very personalised and there were lots of communal areas to spend time in with access to a sensory garden. People enjoyed using the on site day centre and hydro therapy pool.

People who use services were involved in the running of the home from keeping it clean to planning meals and meeting prospective staff. Staff had training to learn about and understand physical and learning disabilities which lead to appropriate and effective support for people.

This inspection took place on 6 and 7 Mary 2015, was unannounced. The previous inspection on 20 September 2013 found there were no breaches in the legal requirements.

Martha House provides nursing and personal care and accommodation for up to 13 young adults with profound and multiple learning and physical disabilities. There were 12 people living at the service and one person on respite care during the inspection. People were unable to communicate verbally and used body language, facial expressions and some vocal sounds to make their needs known. There are two buildings in the service, Martha House and Frances House. Both premises are arranged over one floor, containing bedrooms, communal lounges and dining areas. All of the bedrooms are spacious, with hoist systems in place. The shared toilets and bathrooms also have hoist systems in place. There is parking available on site, and there are other facilities in the complex, including hydrotherapy.

A registered manager was in post; however they were not available at the time of the inspection due to annual leave. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 deputy manager, together with senior staff, assisted with the inspection process.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). One application had been made to the DoLS department to depriving the person of their liberty for their own safety.

Risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving the support they needed to keep them as safe as possible. Accidents and incidents were recorded but had not been summarised to identify if there were any patterns or if lessons could be learned to support people more effectively to ensure their safety.

People received their medicine on time however it was not always managed as safely as possible.

Staff told us about the training they had received and there was an on-going training programme in place. Further specialist training was needed to make sure staff had the skills and understanding of people’s individual needs. The service had recognised that the induction training for new staff needed to be improved. Staff were not receiving regular supervisions, including clinical supervision for the nursing staff. Staff appraisals were not up to date to give staff the opportunity to discuss their training and development needs.

People’s needs had been assessed to identify the care they needed, however care plans varied in detail to ensure personalised care was being provided. Some care plans lacked clear detail to show how people were receiving the care they needed. Family members supported their relatives and were involved in their care planning.

Some relatives and staff did not think the registered manager was visible within the service and was not monitoring the quality of service effectively. Actions from the care plan audit had not been implemented within the timeframe agreed to improve the standard of personalised care planning.

Relatives were asked for their feedback about the service, but the views from staff and health care professionals had not been sought to continuously improve the service. Records were not always accurate or completed properly.

Relatives told us that they had confidence that their relatives were safe living at the service. They were also confident to raise any concerns or issues with the registered manager and staff.

Relatives and staff told us that at times there was not enough staff to make sure people received the one to one time they required. The deputy manager told us that new staff had been recruited and this should not happen in the future. At the time of the inspection there was sufficient staff on duty and one to one hours had been allocated to individual staff. Recruitment procedures ensured new members of staff received appropriate checks before they started work. All staff had been trained in safeguarding adults, and discussions with them confirmed that they knew the action to take in the event of any suspicion of abuse. Staff were aware of the whistle blowing policy and were confident they could raise any concerns with the registered manager or outside agencies if necessary.

Checks were done to ensure the premises were safe, such as fire safety checks. Equipment to support people with their mobility, such as the ceiling hoists had been serviced to ensure that it was safe to use.

People were supported to have a varied and balanced diet. Staff understood people’s complex dietary needs and promoted people to eat as independently as possible. Staff were attentive; they treated people with kindness, encouraged their independence and responded to their needs.

People had the opportunity to participate in a varied activity programme. A system to receive, record, investigate complaints was in place so it was easy to track complaints and resolutions.

There was a mission statement on display in the service, which outlined the visions and values of the service, such as treating everyone with dignity and respect, supporting and encouraging, and treating people with compassion. Staff were aware of these values and demonstrated their understanding of how to achieve this by offering people choice, treating them with dignity and responding to their needs.

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