This inspection took place on 11 December 2018 was announced. We gave the service 48 hours notice of our inspection visit because the location was a small residential home for adults who were not accustomed to having strangers enter their home. We needed to be sure that we would not cause them any unnecessary distress. The inspection team consisted of one inspector and one pharmacist inspector.

Fir Tree Lodge is registered to provide accommodation for up to 10 young adults with a physical disability, learning disability, sensory impairment and autism spectrum disorder. At the time of our inspection there were 10 people living in the service.

Fir Tree Lodge is a care home. People in care homes receive accommodation and personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided. Both were looked at during this inspection.

The care service has 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.

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.

At the last inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014.

At this inspection we found the provider had made improvements so they were no longer in breach of two regulations.

At the last inspection we found the provider had failed to provide person centred care and had delivered care which was task orientated and was not designed around people’s individual needs or preferences.

The provider had also failed to appropriately document decisions about people’s care and treatment made in their best interests. In addition, staff were not always able to identify the principles of the Mental Capacity Act 2005 and how they should be applied when caring for people.

At this inspection we identified one new breach and two continued breaches of the regulations.

Medicines were not managed safely. We had received several statutory notifications from the provider about medicines incidents since our last inspection.

Staff did not always follow best practice guidance for infection control.

The provider could not produce evidence that staff were appropriately trained to administer some types of medicines for people.

The registered manager used systems and process for assessing, monitoring and improving quality and safety within the service. These were not effective, as they failed to prevent reoccurrence of medicines errors.

The provider had systems and processes in place to protect people from harm and abuse. Staff had completed safeguarding training which was regularly refreshed.

The registered manager deployed sufficient numbers of staff to maintain people’s safety. They used safe recruitment processes to ensure only staff who were suitable to work in a care setting were employed

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received care from trained staff. Staff were supported with regular supervision and training to help develop their knowledge. Staff were aware of the legal protections in place to protect people who lacked mental capacity to make decisions about their care and support.

People were supported to maintain a balanced diet. People were supported to maintain a healthy weight. Referrals were m

This inspection was unannounced and took place on 6 and 7 February 2018. The service was last inspected in September 2015 when it was rated as Good but had one breach of Regulation 17. At this inspection we found that the required improvement had not been made therefore this service is now rated overall as Requires improvement.

Fir Tree Lodge is a bungalow which has been adapted to provide accommodation for 10 young adults with a physical disability, learning disability, sensory impairment and/or autism spectrum disorder. There were 10 people living at the service at the time of our inspection. Each person had their own room and bathroom. Rooms have their own enclosed garden space in addition to a communal outdoor space. The bungalow is on the same site as other services that the provider manages.

Fir Tree Lodge is a ‘care home’. 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.

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.

Medicines were not managed safely; there had been a number of medicines related incidents, which the provider had told us about. We found that the service had not always learned lessons from these incidents. Records relating to medicines were not securely stored.

Good practice in infection prevention and control had not been followed at all times.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. Where people had their liberty restricted, the service had completed the related assessments and decisions had been taken but there was no record of what options had been considered and what had been discussed at best interest meetings.

People using bed rails did not have bed rail risk assessments, guidelines regarding the safe use of bed rails had not been sought so safety measures were not in place.

Person-centred care was not delivered consistently and the principles of this approach were not always followed by staff. People were moved in their wheelchairs without prior warning, staff did not always introduce themselves to people prior to intervention and people were not always told what was happening in their immediate environment.

Activity at the service was at times provided in large groups. People were not able to access the hydrotherapy pool at the time of the inspection. This meant the service did not always have a person-centred approach to activity provision.

There was a lack of governance at the service. Auditing systems were not robust enough to make sure the service was compliant with regulations and as a result, they had not identified the concerns we found during our inspection.

Staff were recruited safely, the necessary recruitment checks had been completed. Staff were supported with regular supervision and told us they felt supported. They had safeguarding training and knew signs of abuse and how to report concerns.

People had access to healthcare professionals. Health needs were recorded and guidance was available to inform staff what action to take in the event of a health related emergency.

Complaints were managed according to the provider policy. Records of complaints were kept following investigation.

We found four breaches of the Regulations. You can see what action we told the provider to take at the back of the full version of the report.

On the date of the visit, there were six people living in the home and one of these was away for a long weekend. We spoke with the Registered Manager (RM) and five other staff members. Later, we spoke by telephone, with four people who were relatives of the people living in Fir Tree Lodge.

We reviewed the care plans of four people using the service and found them to be informative and comprehensive. We saw that care plans clearly identified the needs of the person and included information on how their care was to be delivered. Records were kept both in paper format and electronically. The family members we spoke with told us how staff listened to them and really worked together to ensure people living in the home were well cared for.

We found that people were safeguarded from abuse and that where people did not have capacity themselves to make decisions, meetings with the family, staff from the home and local health professionals took place. We viewed written and electronic minutes of the meetings and decisions made.

We found that all staff were well trained and this was documented in the training records. We spoke with six staff in all. Staff told us they felt supported in the team.

We saw questionnaires to assess the quality of the service provision and resulting action plans. The actions had either been completed or were part done.

We spoke with the families of three people from the home. They told us how staff listened to them and really worked together to ensure people living in the home were well cared for.

We reviewed the care plans of four people using the service and found evidence that there were procedures in place to ensure appropriate assessment and that consent was gained in relation to the care provided for them. Where people were unable to make these decisions they were made in their best interests with the family, staff from the home and local health professionals. We saw that care plans clearly identified the needs of the person and included information on how their care was to be delivered.

People were given information about the complaints procedure so that they knew how to make a complaint. Complaints were investigated and improvements were made to the service when needed. One person told us about a problem they had and how this was resolved to their satisfaction.

We found that all staff were well trained and this was documented in the training records. We spoke to staff who told us they felt supported in the team.

People who lived at Fir Tree Lodge had complex needs and were not able to tell us what they thought about the care and support provided.

To help us to understand the experiences of people, we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

We observed a lot of positive interactions between staff and people who lived at Fir Tree Lodge. Staff provided support to people in a very calm, professional way. We observed that staff let people do things at their own pace. We observed that staff enabled people to do as much as possible for themselves. Staff included people in everything that was happening, for example, people were always told who was entering or leaving the room.

We inspected SeeAbility - Fir Tree Lodge Residential Home on 2 and 3 September 2015. This was an unannounced inspection.

The service is a purpose built bungalow and each bedroom has an en-suite bathroom and access to a small private garden. On site facilities include a sensory suite, Jacuzzi baths and access to the provider’s on site activity and resource centre, including an indoor hydropool and other specialist activity rooms. The service also offers access to a guest suite, by arrangement with the provider’s neighbouring nursing home, to promote family relationships and maintain people’s family links.

The service provides accommodation and support for up to ten adults with visual impairment, learning disabilities and healthcare needs. At the time of the inspection there were ten young adults living in the service. Some people had very limited verbal communication skills and they required staff support with all aspects of their personal care, nutrition, mobility and community activities.

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.

There was a positive atmosphere within the service and staff put people at the heart of the service. People and their relatives were encouraged to be involved in the planning of their care. Staff were highly motivated and flexible which ensured people’s plans were realised so that they had meaningful and enjoyable lives.

The work done by the service to respond to people’s needs while finding creative ways to develop people’s skills and independence was outstanding. We heard many examples of how people had been supported to develop their communication skills, self-care abilities and to have increased enjoyment in the community.

Staff had a positive approach to keeping people safe. Staff had received training in safeguarding and were able to demonstrate an awareness of abuse and how concerns should be reported. People’s safety risks were identified, managed and reviewed and the staff understood how to keep people safe. Systems were in place to protect people from the risks associated with medicines. We have made a recommendation that the provider refers to best practice guidance in relation to standards of medicine record keeping

There were enough staff to keep people safe and support people to do the things they liked. The provider was employing new staff and had increased the use of agency and bank staff to manage the staff vacancies. The provider’s recruitment process had been effective at identifying applicants who were suitable to work with people.

People living at SeeAbility - Fir Tree Lodge Residential Home received care from knowledgeable staff, who had been trained to support people with multiple disabilities and health needs. Many of the staff had supported the people living there for many years and demonstrated an in-depth knowledge of people’s needs and aspirations. Staff were supported to undertake training to support them in their role, including nationally recognised qualifications. Staff received regular supervision and appraisal to support them to develop their understanding of good practice and to fulfil their roles effectively.

Quarterly quality monitoring visits were undertaken by the regional service manager. However, some of the daily checks overseen by the shift leaders were not completed consistently to ensure the registered manager would be alerted to any shortfalls in practice that could impact on the quality of care people received. Regular health and safety checks were carried out to ensure the physical environment in the service was safe for people to live in.

Staff sought people’s consent before they provided their care and support. Where some people were unable to make certain decisions about their care the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed. Where people had restrictions placed upon them to keep them safe, the staff ensured people’s rights to receive care that met their needs and preferences were protected. Where people were legally restricted to promote their safety, the staff continued to ensure people’s care preferences were respected and met in the least restrictive way.

People were supported to have their health needs met by health and social care professionals including their GP and dentist. People were supported to have a healthy balanced diet and when people required support to eat and drink this was provided in line with professional’s guidelines.

The culture of the service was positive, people were treated with kindness, compassion and respect and staff promoted people’s independence and right to privacy. The staff were highly committed to enhancing people’s lives and provided people with positive care experiences. They ensured people’s care preferences were met and gave people opportunities to try new experiences.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.