This inspection took place on the 10 and 17 January 2019. The first day was unannounced and the second day was agreed with the registered manager. This service was last inspected in August 2017 and found to be rated good in all five key questions.

We brought forward this comprehensive inspection because we had received a number of concerns from anonymous sources which indicated that there were not always sufficient staff with the right skills; that new staff had been recruited without their full checks and references being in place; people were not always getting the service they had been assessed as needed, and specifically that some people were not being supported to go out into the community. During our inspection we identified some of these concerns were founded.

The Meadows provides care for up to 14 people with a learning disability and associated conditions such as autism and mental health conditions. On the day of our inspection there were 12 people living at the service.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (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 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 checked the service was working in line with ‘Registering the Right Support’, which makes sure services for people with a learning disability and/or autism receive services are developed in line with national policy - including the national plan, building the right support - and best practice. For example, how the service ensured care was personalised, how people’s discharge if needed, was managed and people’s independence and links with their community.

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. This was compromised when staffing levels fell due to staff leaving or staff sickness. This was because people were not always able to go out into the local community as they had been assessed as needed one to one support or two to one support to keep them safe. However the registered manager had tried hard to ensure that people did get to go out for their activity days.

We received information of concern which said there were not always enough staff with the right skills. We also received information from two healthcare professionals who said they were not assured staff always had the right training to keep themselves and people safe. This included breakaway training (safe techniques used when someone presents with challenging behaviours which places themselves and or others at risk). We found there had not always been staff in sufficient numbers and with the right skills. The service was currently dependent on agency staff to fill some gaps. Of three agency staff we spoke with on the second day, none said they had received training in breakaway techniques. We saw a new person had been admitted with high support needs. The staffing rota had not been changed since their arrival despite them being assessed as needing a significant portion of each day in a one to one staff ratio.

Some staff had not been trained in administering rescue medication for people with epilepsy. One staff member confirmed they had not been trained but did take the person out into the community without other trained staff. This placed the person at risk. We gave immediate feedback about t

The Meadows provides accommodation with care and support for up to 14 people with complex needs who have a learning disability and/or mental health issues. At the time of our inspection there were ten people living at the service.

At the last inspection in May 2015 the service was rated Good.

At this inspection we found the service remained Good.

Why the service is rated good:

The service continued to provide safe care to people. One person commented: “I feel safe here with the staff.” Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service.

People were supported to maintain a balanced diet, which they enjoyed. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

There were effective staff recruitment and selection processes in place. People received effective care and support from staff who were well trained and competent.

The service was caring and people had built strong relationships with each other and staff. People engaged in a wide variety of activities and spent time in the local community going to specific places of interest.

Staff spoke positively about communication and how the registered manager worked well with them and encouraged their professional development.

A number of methods were used to assess the quality and safety of the service people received and made continuous improvements in response to their findings.

During our inspection we met and spoke with five people who lived at The Meadows. We spoke with seven staff including the unregistered manager and deputy manager. We observed the interactions between people and staff and reviewed five people’s care records in detail.

People commented: “I love the staff”, “I can’t eat pork, so I’m given alternatives” and “I’m really happy here.”

Staff demonstrated a good understanding of people’s individual needs. Care plans reflected people’s preferences and showed people were given choices.

Staff confirmed they felt they had sufficient staffing numbers to meet people’s needs. We saw staffing rota’s which demonstrated staff had the right knowledge, skills and experience to support people.

Staff stated they were well supported, their training needs were met. All staff felt they were competent to carry out their role.

We saw evidence that The Meadows had systems in place to monitor the quality of the service people received. They had appropriate arrangements in place to ensure it recorded and evaluated the information it gathered. This enabled The Meadows to manage risk and deliver safe and effective care.

We saw that all records were kept securely, were accurate and remained confidential.

You can see our judgements on the front page of this report.

We had received information to suggest that people’s needs were not being met by the staff at the home and concerns about staffing related issues. We did not find evidence to substantiate these concerns. We also followed up on two of the compliance actions set at our previous inspection in July 2013.

We spoke with three people living at the home, spent time observing the care people were receiving, spoke to six members of staff, which included the unregistered manager and looked at two people’s care files in detail.

People commented: “I am happy here and the staff look after me”; “I am going shopping this afternoon” and “I have been able to choose my key workers and I get on well with them.”

Staff confirmed that people’s needs were met in a timely manner and felt that on the whole there were sufficient staffing numbers. We observed this during our visit when people needed personal care support or wanted to participate in particular activities.

Debriefing sessions were now in place and staff supervisions were started on 7 October 2013, with these to be scheduled on a six weekly basis and appraisals to be completed on a six monthly basis. We saw evidence of debriefing sessions and supervision taking place which covered any difficulties being experienced, support needs and future training needs.

There were eleven people living in The Meadows at the time of this visit. We spoke with or observed all of them.

People told us the staff were helpful. They told us about places they had been and things they had been doing. One person said it was too noisy in the home. Staff told us they were changing shared spaces within the home to provide a quiet room and a second television lounge.

The registered manager was not working in the home at the time of this visit and an interim manager had been appointed very recently. Health and social care professionals were involved within the home giving guidance on care planning and behaviour management and providing staff training. Staff had many ideas about activities they could introduce to enrich people’s lives. We found there was a clear need for leadership, to ensure that the professional guidance and the good ideas of the staff were put into practice and supported.

We had received information which said The Meadows was not able to provide support in a safe way to all the people who were living there.

During our visit we looked round the home, met with seven people who lived there, six staff members, the registered manager and another manager employed by the company.

We looked at the records of incidents for three of the people living in the home. Staff recorded what happened beforehand (antecedents), the behaviour, and the consequences, known as ABC charts. There were several accounts of incidents when people had been aggressive and had been restrained by staff.

We saw six accounts over a six month period of incidents where people who lived in the house had been punched, kicked or had things thrown at them by other people who lived there.

We spoke with the registered manager, who told us that they had made changes, including moving people to different rooms so they would not meet so often, and creating a separate television lounge.

All the people we spoke to said they liked the staff, and they could easily talk with the manager - “We have some really nice staff.” One health care worker who had visited the home said the person they supported was happy now with each and every staff member and that this was remarkable. A different person told us they were “happy and relaxed at The Meadows.” They said what a lovely time they had on holiday with their keyworker and another staff member.

People told us of activities they enjoyed. One person told us their favourite thing was to go to a martial arts class with their keyworker. Another person told us they had enjoyed highland dancing and we were told about another person benefiting from salsa dancing. People had enjoyed their regular days out, when they had staff to support them to go shopping and had lunch out, visit relatives or went to other venues of their choice. Two people were out on such an outing on the day of our visit. However other people told us they had missed their outing recently because there had not been enough staff to support them.

We raised an alert with the Devon County Council safeguarding team for vulnerable adults with respect to the people who had been punched, kicked or had things thrown at them, so that further action would be taken to ensure their safety.

During this unannounced inspection we spoke to seven of the people who live in the home and to three in more detail about their experiences of living at the service. People were very positive and comments included

‘I like all the staff here’

‘I am going on holidays with staff’

‘’I have been going out more, I like to keep busy and I love the art group.’

We observed staff interacting with people living at the service in a positive and respectful way. We saw that staff share their lunchtimes with people living in the home and that mealtimes were a fun and social occasion.

We looked in detail at three plans of care and spoke to staff about the needs of the individuals they cared for. We heard that staff worked well as a team and provided individuals with care and support in a consistent manner that helped them to feel safe.

We saw that there had been fewer restrictions placed on people who may for some reason present with challenging behaviours. For example we saw that care plans gave clear details of triggers to possible escalation of behaviour that challenges, and that staff had clear instructions to spend time with the individual to calm them down, where in the past they may have been excluded from communal areas and restricted to their bedrooms.

Staff told us they had good training and support to do their job effectively and we observed them working in a professional manner with people with complex needs. We saw that individuals respect and dignity was being upheld and that their human rights were being considered as part of their care planning.

Good systems were in place to ensure that individuals who live at the service could have their say in how the service should be run.

This unannounced inspection took place on 7 May 2015. Our inspection in October 2014 found a number of breaches of the Health and Social Care Act (2008). The breaches were in relation to staffing levels and training, staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) and how they applied to their practice, involving people in their care and treatment and record keeping. The provider sent us an action plan as a result of the breaches. We arranged with the registered manager to return on 14 May 2015 to go through their action plan in detail. This inspection confirmed that improvements had been made.

The Meadows provides accommodation with personal care and support for up to 14 people with complex needs who have a learning disability and/or mental health issues. At the time of our visit there were eight people receiving a service from The Meadows

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.

People said they felt safe and staff were able to demonstrate a good understanding of what constituted abuse and how to report if concerns were raised. Risk management was important to ensure people’s safety. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the home followed the appropriate processes.

People received personalised care and support specific to their needs and preferences and their views and suggestions were taken into account to improve the service. They were supported to maintain a balanced diet and encouraged to be involved in preparing meals with staff support. Health and social care professionals were regularly involved in people’s care to ensure they received the right care and treatment.

Staff relationships with people were strong, caring and supportive. Through our observations and discussions, we found that staff were motivated and inspired to offer care that was kind and compassionate.

Staffing arrangements, which included recruitment, were flexible in order to meet people’s individual needs. Staff received a range of training and regular support to keep their skills up to date in order to support people appropriately. Staff spoke positively about communication and how the manager worked well with them, encouraged team working and an open culture.

A number of effective methods were used to assess the quality and safety of the service people received.