This unannounced inspection of The Brambles took place on 12 and 13 September 2016. The home provides accommodation and support for up to six people who may have learning disabilities or autism. The primary aim at The Brambles is to support people to lead a full and active life within their local communities and continue with life-long learning and personal development. The home is a detached house, with a substantial rear garden, within a residential area, which has been furnished to meet individual needs.

We last inspected The Brambles on 30 September and 1 October 2015 and found the provider to be in breach of regulations in relation to staffing and good governance. We issued warning notices for the breaches of regulations. The provider was required to meet the regulations relating to the warning notices by 31 January 2016. During this inspection we found the provider had taken action to ensure the requirements of the regulations had been met.

The service did not have 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 previous registered manager had deregistered on 11 August 2016. A recently appointed home manager was currently responsible for the day to day running of the home. They had submitted an application to CQC to become the registered manager.

People were protected from abuse because staff were trained and understood the actions required to keep people safe. Staff had completed the provider’s required safeguarding training and had access to guidance to help them identify abuse and respond appropriately if it occurred. Staff were able to demonstrate their role and responsibility to protect people.

Risks specific to each person had been identified, assessed, and actions implemented to protect them. Risks to people had been assessed in relation to their mobility, social activities and eating and drinking. Staff were able to demonstrate their knowledge of individual risk assessments and how they supported people in accordance with their risk management plans.

The home manager completed a daily staffing needs analysis to ensure there were always sufficient numbers of staff with the right skills mix and experience to keep people safe. We reviewed staff rotas between January 2016 and September 2016 which confirmed that people had been supported by sufficient numbers of suitable staff to keep people safe, in accordance with the staffing needs analysis, including times when increased staffing ratios were required.

Staff had undergone pre- employment checks as part of their recruitment, which were documented in their records. These included the provision of suitable references in order to obtain satisfactory evidence of the applicants conduct in their previous employment and a Disclosure and Barring Service (DBS) check. Where DBS checks had raised concerns over candidates suitability these issues had been explored in depth by the home manager and subject to risk assessments, to confirm they were suitable for employment.

People received their medicines safely, administered by staff who had completed safe management of medicines training and had their competency assessed annually by the home/registered manager. Staff were able to tell us about people’s different medicines and why they were prescribed, together with any potential side effects. Staff supporting people in the community ensured they took the person’s prescribed emergency medicine in case they experienced a seizure, which was effectively recorded.

The provider’s required staff training was up to date, including safeguarding people from abuse, moving and positioning, the Mental Capacity Act 2005, fire safety, food hygiene and infection control. This e

People received appropriate care and treatment in line with their care plans. We were unable to easily communicate with people living in the home. However, with the support of staff one person was able to confirm that they liked living at The Brambles and they were well looked after.

People were provided with a suitable and nutritious diet. Each person had a comprehensive nutritional care plans which identified people’s needs, likes and dislikes. We observed how staff appropriately supported people with eating and drinking.

People were protected from the risk of abuse because the staff were aware of the different types of abuse and how to report a concern. A relative we spoke with told us that they felt people living in the home were safe and well cared for.

There were adequate levels of staff on duty on the day of inspection with appropriate skills and qualifications. We found people were supported in line with their plans.

The provider had an effective system to assess and monitor the quality of service. People were asked for their views and the provider acted upon these, where appropriate.

On the day of our inspection there were three people living in the Brambles. They all had complex needs and as such were not able to talk to us about their experiences. However, they welcomed us into their home and indicated that they were happy for us to spend some time with them.

We were invited to look at two of the people’s bedrooms and could see that these provided a clean, comfortable and homely environment.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare

People were called by their preferred name and staff treated them with dignity and respect. We observed people being involved in activities, being read stories and undertaking gentle exercise. Staff used Makaton 'sign' language to help them communicate with those people who were familiar with it.

We spoke with three staff members and the manager. They all told us they felt supported. One told us “I love my job; this is by far the best place I have worked”. Another said “there is lots of support, and communication is excellent”. They told us that the training was “excellent and constantly available”

All the people at this care home were unable to communicate verbally and were not able to tell us about their experiences.

Staff told us that they tried to promote an active life for the people living at The Brambles by organising different activities. These included shopping, walks, drives and feeding the ducks which was a favourite pastime. A weekly sensory activity schedule was in place for some residents.

This unannounced inspection of The Brambles took place on 30 September and 1 October 2015. The home provides accommodation and support for up to six people who may have learning disabilities or autism. The primary aim at The Brambles is to support people to lead a full and active life within their local communities and continue with life-long learning and personal development. The home is a detached house, with a substantial rear garden, within a residential area, which has been furnished to meet individual needs.

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. The registered manager told us they had begun the process to deregister as they had also assumed the responsibilities of registered manager at another home within the provider’s care group. A recently appointed home manager had submitted an application to become the registered manager, who was being supported in the day to day running of the home by the registered manager and the provider.

The provider did not make sure there were sufficient numbers of suitable staff to keep people safe and meet their needs. Relatives and health professionals were concerned about the high turnover of staff and the loss of several experienced members of staff. Experienced staff who had left The Brambles had built close relationships with people who had been reassured by their presence. Their departure had left a void in some people’s lives. These experienced staff had also been a point of reference for less experienced staff with regard to people’s complex behaviours.

Everyone at The Brambles had been assessed as requiring one to one support whilst in the home and two to one support whilst accessing the community. The provider could not be assured that people’s needs were met safely because there were not always enough suitable staff on duty to provide the required staffing ratio to meet people’s assessed needs. Records showed that on numerous occasions the required number of staff were not on duty.

The provider had not completed a risk management plan to ensure people’s safety where there were reduced staffing levels. When asked how the provider assured that people were safe when there was insufficient staff, demonstrated by the provider’s rosters, the registered manager said , “The only answer is that there can be no reassurance of their needs being met, but knowing the staff at the Brambles they would have endeavoured to do their utmost to ensure this happened.”

We observed people receiving their prescribed medicines safely, administered in a way they preferred, by trained staff who had their competencies assessed to do so.

Appropriate checks to ensure staff were recruited safely were not carried out. Staff did not always have appropriate references in relation to their previous employment and there was not always evidence supporting how the provider had assessed the applicant’s suitability for the post. Where references had been requested these had not always been received or did not address the suitability of staff to support vulnerable people. Where there were identified gaps in people’s employment history the provider had not ascertained the reasons for this. This meant that the provider could not be assured that staff were suitable to provide care and support for the people living at the Brambles.

The registered manager and provider did not complete regular audits to monitor the quality of the home and plan improvements. The provider did not complete audits of medicines management, staffing needs analysis or care records. They had failed to identify potential risks to people that may compromise the quality and safety of their care.

The provider was not always supportive of staff. Staff told us that the home manager was approachable and readily available but they were disillusioned with the support from the provider. This had led to staff leaving the home, which meant there were not always staff with the right mix of skills, competence or experience to meet people’s needs. Health professionals told us they were concerned that whilst new staff were dedicated they may not have the required level of experience to always meet people’s needs.

The provider did not promote a positive culture, where staff were supported to question practice, and be actively involved in developing the service. Where staff had raised concerns there was no evidence that any action had been taken to investigate or address the issues to improve the service.

The provider recognised that staff required training and support but did not ensure this covered the areas identified as a further requirement to meet people’s needs, for example staff had not completed autism training. Staff were not always supported to provide safe and effective care for people.

Relatives told us they trusted the staff who made their family members feel safe. Staff had completed safeguarding training and had access to current guidance. They were able to recognise if people were at risk and knew what action they should take to protect them. People were safeguarded from the risk of abuse. Staff had responded appropriately to safeguarding incidents to protect people.

People’s safety was promoted through individualised risk assessments. Risks had been identified, and plans were in place to manage these effectively. Staff understood the risks to people’s health and welfare, and followed guidance to safely manage them.

People, or where appropriate their relatives, and care managers were actively involved in making decisions about their care and were asked for their consent before being supported. Staff had completed training on the Mental Capacity Act (MCA) 2005 and understood their responsibilities. The MCA 2005 legislation provides a legal framework that sets out how to support people who do not have capacity to make a specific decision. Where people lacked the capacity to consent to their care, legal requirements had been followed by staff when decisions were made on their behalf. People were supported by staff to make day to day decisions.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide a lawful way to deprive someone of their liberty, where it is in their best interests or is necessary to protect them from harm. The registered manager had completed the required training and was aware of relevant case law. The registered manager had made DoLS applications for each individual which had been authorised, which demonstrated they had taken the necessary action to ensure people’s rights were recognised and maintained.

People were provided with nutritious food and drink, which met their dietary preferences and requirements. People were supported to eat a healthy diet of their choice.

There was a friendly and relaxed atmosphere within the home, where people were encouraged by staff to express their feelings, whilst respecting others. Whenever relatives had raised concerns or issues prompt action had been taken by the registered manager to address them.

People’s dignity and privacy were respected and supported by staff, who were skilled in using individual’s specific communication methods. Staff were aware of changes in people’s needs. Referrals to relevant healthcare services were made promptly when required.

People’s needs were accurately reflected in detailed plans of care and risk assessments, which were up to date. These plans contained appropriate levels of information for staff to provide individualised support.

Staff did not all know the provider’s motto, ‘Creating changes, changes lives.’ However during the inspection we observed staff demonstrate values in their care practice which included compassion, dignity, respect, equality and safety.

People’s and staff records were stored securely, protecting their confidential information from unauthorised persons, whilst remaining accessible to authorised staff.

During the inspection we identified a number of serious concerns about the care, safety and welfare of people who received care from the provider. We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are taking further action in relation to this provider and will report on this when it is completed.