The Mead is a care home that provides accommodation to six people with mental health care needs. At the time of the inspection five people were living at the service. 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.

A registered manager was not in post and the recruitment process was is in place to employ a registered manager. A service manager with day to day management responsibilities was appointed on 15 January 2018. 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.’

Staff told us there had been five changes of managers in 12 months. While staff said they “held the home together” during this period, the records showed they were not knowable about fundamental standards, how to introduce changes of legislation and partnership working. For example, enabling people and working with regulators.

There were systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people who used the service. However, these systems were not fully effective as they failed to identify the shortfalls in all areas of service delivery. Where shortfalls were identified and action plan were devised the progress made on the improvements were not monitored.

Safeguarding processes were not always followed by the staff because when people made allegations of abuse the staff had not reported them to the lead authority in safeguarding. The staff told us and training matrix showed staff had attended safeguarding of adults training. Their comments indicated they knew how to recognise the types of abuse and their duty to report abuse. However, when people asked staff not to report allegations of abuse, the staff had not reported the allegations. The head of services said their instructions to reporting these allegations were not followed. This meant a multidisciplinary meeting to discuss strategies with the person did not take place and opportunities to establish the appropriate support were missed.

Risk management systems were not robust and placed people at risk of potential harm. Individual risks to people included exploitation, addiction, self-harm and eating disorders. While risk assessments detailed how people viewed the risk. Action plans were not in place on managing individual risks or on supporting people to take risk safely. There was a lack of clarity on the staff’s responsibility to update records. Safety management plans that accompanied the risk assessments were poorly completed and lacked guidance for consistency and to keep people safe from potential harm. Where there were potential risks to others risk assessment were in place. For example, the symptoms of a deteriorating mental health or the actions from staff to protect other people from harm such as distraction techniques and moving people from the vicinity.

Where there had been incidents of self-harm risk assessments were not reviewed or updated. We saw there had been an investigation following the reporting of some incidents. There had been a post incident discussion with the person but no further action was taken to minimise the risk.

Staff were not given guidance on consistently administering medicines prescribed to be taken “as required” (PRN). The medicine procedure gave direction for staff to develop “As and When required medication plans.” Medication plans were not developed for PRN medicines prescribed for pain relief, depression and to reduce anxiety. This meant PRN protocols were not developed on how staff were to recognise when people might need these medicines.

The st

The Mead is registered to provide accommodation and support to six people with mental health care needs. The home was last inspected in May 2014 and was found to be meeting all of the standards assessed.

A registered manager was 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.’

Incidents and accidents were not reported to the CQC when people sustained an injury which required attention from healthcare professionals. This meant CQC were not able to take follow up action where appropriate.

People were supported by staff who were competent and trained to carry out their roles and responsibilities. Staff attended essential training set by the provider which included mental health awareness, safeguarding adults and medicine management. "Catch Up" sessions were to replace

one to one meetings and were to happen as needed.

People said they felt safe and having a staff presence at all times in the home made them feel safe. Procedures on safeguarding vulnerable people from abuse were available to staff for reference. Members of staff knew the signs of abuse and the expectations placed on them to report abuse.

Risks to people's health and wellbeing was assessed and action plans developed to reduce the risk. Contingency plans were developed on the safe evacuation of people in the event of an emergency.

Staffing levels ensured people had the support they needed. Staff said the team was stable and they worked well together. People said the staff were caring. They said the main support received from staff was with “reminders and prompting” of personal care and to manage their health. We saw people moving around the home and community independently. People said they had keys to the front door and to their bedrooms. There was an expectation people prepared their meals and with staff support to plan menus and prepare meals.

Medicine systems were safe. People were supported to self-administer or work towards self-administration of their medicines. Staff attended safe handling of medicines before they administered medicines unsupervised.

People had capacity to make decisions. Mental Capacity Assessments (MCA) were undertaken where concerns about people’s ability to make decisions arose. For example, management of finances. People signed consent forms to have their photograph taken, where appropriate have their medicines administered by the staff and to share information with other health and social care professionals involved in their care. One person with capacity refused their medicines and we observed members of staff confirm the decisions made. Staff checked the person was aware of the consequences when decisions to refuse medicines were made. Staff sought support from the mental health team about this decision.

People were helped to assess all aspects of their health and wellbeing. They participated in the development and reviewing of their support plans. Support plans described the steps needed to meet the aim of the plan. Where people had support from the mental health team a care plan was developed on the identified needs. This included were the social and healthcare professionals involved and the timescales for meeting the need.

People knew who to approach if they had any complaints. Members of staff had attended complaints training to help them resolve any complaints received.

Systems to gain people’s views were in place. This included house meetings and surveys.

The quality assurance arrangements in place ensured people's safety and well-being. Systems and processes were used to assess, monitor and improve the quality, safety and welfare of people. There were effective systems of auditing which ensured people received appropriate care and treatment. The system of audits included complaints and medicine management.

We found a breach of the Health and Social Care Act2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Is the service safe?

People told us they felt safe. Staff were trained in safeguarding and those we spoke with understood their role in preventing and reporting abuse. The service worked well with other agencies to help keep people safe. We looked at two situations where staff had taken responsive action.

Is the service effective?

The service aims to provide support which aids people’s recovery, and their independent living. People told us that staff understood their needs and supported them well. Records were detailed, up-to date and the identified goals were reviewed regularly. Staff worked with members of the mental health teams to promote people’s mental well-being.

Staff received training, supervision and appraisals. One staff member said “I feel I have the training, and support from my manager, I need”. We were told that a new system to identify when staff training needed up-dating was being developed. It was found that some staff required further training in the Mental Capacity Act, in order to develop their understanding.

Is the service caring?

We observed staff interacting with people who use the service in a professional and respectful manner. We saw that people were central to the development of their goals and in identifying the support they needed to achieve them. Staff had an allocated keyworker with whom they met regularly to review their situation. A visiting community psychiatric nurse told us that “staff seem very supportive”. Someone using the service told us “whenever I need help staff are here”. Another told us “I really like it here”.

Is the service responsive?

We saw that regular reviews took place, during which people’s progress in relation to their goals were discussed. One person told us that their keyworker was helping them look at other work options. Another person told us how some of their living skills had developed since coming to the home. Staff told us that they could easily contact the manager, when not on-site, to discuss people’s situations and any concerns they may have. People who use the service told us they could talk to staff if they had any concerns or complaints.

Is the service well-led?

We were told that the manager divided their time between The Mead and another service they managed. The manager told us they were in the home two or three days a week, on average, but was available to be contacted at other times. Staff confirmed they were able to get support from their manager when they needed it.

We found a number of quality assurance measures were in place. These included the monitoring of people’s views on the service, health and safety and infection control. We saw that action plans were put in place and reviewed. The manager was supported by an area team, and staff had access to on-call support at all times.

On the day of the inspection there was one staff member on duty. We saw they were aware what kind of care and support each person needed. They were attentive and kind in their manner towards the people who used the service. We saw they responded quickly to requests for assistance from people.

We looked at two people’s care files and saw they contained sufficient information to enable the staff to care for people safely and support their recovery.

Health and safety audits and risk assessments were completed about the use of the premises and equipment. Other checks included fire equipment checks, portable appliance tests, electrical checks and office work place risk assessments.

The staff member told us there was mostly one staff member on duty at weekends. They told us, "we have an on call system and the numbers of crisis workers if we need them. There is two staff on duty in the day during the week. It all depends on what activities people are doing and how the rota works out."

People told us they knew how to make a complaint and were confident the staff team would resolve any complaint they had. People told us the staff asked them about the service they received. One person told us,” if I was not happy I would tell the staff.”

People who used the service told us that they were included in decisions about their care. For example, one person told us” I choose what I do during the day. I talk about it first with the staff so they know where I am going". Another person told us "I wouldn't choose to do household tasks every single day. One day off would be nice". A staff member told us they would discuss this in the team to see if this choice could be included in people's support packages.

We saw the service consulted people who used the service. This included monthly resident’s meetings and one to one meetings with staff. These gave people a forum to give feedback on the things they would like to see at the home. We found evidence that these were acted upon by the provider. For example, people discussed choices about activities and trips.

Staff members told us that people thinking about moving in to the home were always invited to visit in advance of taking any decision. They were able to see the room available and meet the staff and other people who used the service. A staff member told us people were encouraged to spend plenty of time at the home prior to admission.

One person told us “I'm here until I get my own flat. When I first looked around I was pleasantly surprised about how nice it was. I think I have made a good choice".

People told us that they liked living at The Mead and they were getting the support that they wanted. People said that they had become more confident since moving in, and they were benefiting from the service . One person commented ‘I haven’t felt this happy for a long time’.

People had received the information that they needed about the home. They knew that the service was not intended to provide them with a home for life. People appreciated the way that staff worked with them to achieve their goals. One person told us ‘it’s a care home but it feels like my home’. Another person commented ‘its quiet here’ when they told us what they liked about The Mead.

People also liked the home’s location, as they could walk into Warminster town centre. One person had an electric scooter. They were pleased to have a place at the home where they could keep it under cover and charge the battery.

People told us that they were encouraged to take responsibility in the home, which helped to prepare them for when they moved to their own accommodation. We met with people who were cooking their own meals and managing their own medicines. People said that they helped out with the cleaning tasks and were expected to complete the jobs that they were allocated on a weekly rota. The accommodation that we saw looked clean and tidy.

People told us that they got on well with staff. One person who used the service commented ‘good quality staff’ and another person said ‘the staff are very good with people’.

People said that they had the opportunity to express their views about the service. Overall, people told us that The Mead was meeting their needs well.