What life is like for people using this service:

• People enjoyed living at Tithe Barn and were cared for by staff who understood their preferences and were kind.

• Systems were in place to identify people’s individual safety risks and to promote people’s safety. Staff were available to meet people’s safety needs and reassure them when needed. The risk of accidental harm or infections was reduced as staff used the resources and equipment provided to do this.

• Staff administered people’s medicines safely. Staff provided people with support to have the medicines they needed to remain well and people’s medicines were regularly reviewed and checked.

• People were supported to enjoy a wide range of activities which reflected their interests, and enhanced their lives. Staff sought ways for people to continue to do things they liked, whilst maintaining their safety.

• People, their relatives, staff and other health and social care professionals worked together to assess people’s needs and plan their care. This was done so people’s needs and preferences would be met, and they would enjoy an enhanced sense of well-being.

• People were supported by staff to make decisions about their care. Staff used their knowledge of people’s preferred ways of communicating, to assist people to make their own choices.

• Staff promoted people’s right to independence, dignity and respect.

• People received support to keep in touch with family and friends who were important to them and to express their individual lifestyle choices.

• Staff supported people to have timely access to external health care. This improved health and well-being outcomes for people living at Tithe Barn.

• Staff had received a comprehensive induction and on-going training to develop the skills they needed to care for people.

• People, their relatives and staff were encouraged to make any suggestions for developing the care provided further.

• The provider and registered manager checked the quality of care provided and developed action plans to improve people’s care, so people would continue to enjoy living at Tithe Barn.

• We found the service met the characteristics of a “Good” rating in all areas; More information is available in the full report

Rating at last inspection: Good. The last report for Tithe Barn was published on 29 July 2016.

About the service: Tithe Barn is a is a residential care home, providing personal care and accommodation. There were thirteen people with learning disabilities or autistic spectrum disorders living at the home at the time of the inspection.

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service remained rated Good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

Tithe Barn is located in Upper Moraston, Herefordshire. The service provides accommodation and care for up to 13 people with learning disabilities. On the day of our inspection, there were 12 people living at the home. The home is divided into five self-contained flats.

The inspection took place on 13 June 2016 and was unannounced.

There was a registered manager at this home, but they were not present on the day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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’s individual needs were known by staff. Staff understood that keeping people safe included upholding their rights and reducing their anxieties. People’s freedom was promoted, whilst ensuring their safety. Staffing levels and deployment were based on the needs of the people living at the home. People received their medicines from trained and competent staff.

People were supported by staff who understood their individual health and wellbeing needs. People were supported to eat and drink and to enjoy a healthy and varied diet. People received specialist input from a range of health professionals and staff followed the guidance given by them. Staff understood the need to offer people choices and obtain their consent.

People enjoyed positive relationships with staff. People were treated with dignity and respect. People’s individual communication needs were known and they were encouraged and supported to try different communication methods so that their views could be heard.

People’s changing needs were responded to by staff. People were supported to maintain individual hobbies and interests, as well as encouraged to try new opportunities. Information about how people could complain was provided in a way which they could understand.

There was an open and inclusive culture in the home and feedback from people, staff and relatives was encouraged and acted upon. Staff were supported in their roles by the registered manager and were motivated and positive about their roles and the running of the home. The registered manager and provider carried out regular quality assurance and competency checks and took appropriate action where issues were identified.

We carried out a visit on 9th April 2014. We talked with the manager, the staff and we reviewed information given to us by the provider. We observed the people living at Tithe Barn and the staff working with them. We met six people of the twelve people living at Tithe Barn. They were not able to express their views about the service due to their learning disabilities and special needs. However, everyone we saw and spent time with appeared to be happy and relaxed.

Below is a summary of what we found. The summary is based on our observations during the inspection, observations of people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read our full report

Is the service safe?

From our observations and from the information we saw set out in care plans, policies, procedures and audits the provider’s safety systems were robust. The staff showed that they had a clear understanding of their role in providing care and safeguarding the people they supported. The staff demonstrated that they knew the people well and had read and understood the instructions set out in individual care plans.

We saw evidence that people were supported to make as many decisions for themselves as possible. The care plans set out detailed instructions for staff as to how each person could give consent. When people lacked the capacity to make important decisions, meetings were held to make decisions for them that were in their best interests.

We found that medicines were safely stored, handled and administered. Medicine records audited on a regular basis and staff received regular training.

The staff we spoke with understood about the risk management plans that had been written for all the people and how these met with their particular needs. Staff showed that they understood how to show people respect and maintain people’s dignity at all times.

The registered manager told us that there were no deprivation of liberty safeguards in place for the people living at Tithe Barn. They said that they had previously contacted the service for advice.

The staff rotas showed that the manager had taken people’s care needs into account when making decisions about the number of staff required, the skills mix and experience staff would need. The rotas showed where additional staff had been used by way of bank workers, overtime and more recently agency to ensure safe staffing levels were maintained. The night time staffing levels and on call system showed that out of main hours the staffing provision was safe.

There were systems in place to make sure that management and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This meant that people were benefiting from a service that was taking on board lessons learnt.

Is the service effective?

People’s health and care needs had been assessed and care plans were in place. There was evidence of people and their representatives being involved in assessments of their needs and planning their care, particularly people with epilepsy.

Specialist health care needs were always assessed and included in care plans and health action plans. Specialist health and social care professionals regularly gave input to the service. All care, activity and risk assessment plans were being reviewed regularly. Every person had a representative and advocacy services were available if required.

Is the service caring?

We observed during our visit and saw in people’s care plans that people were supported and encouraged to live full and active lives. People took part in a wide range of leisure and social activities. Activities were organised to include families and promote friendships. We saw that everyone was supported to access the activities they enjoyed.

The staff we spoke with demonstrated to us that they were committed to providing the best levels of care and to facilitate activities for the people who used the service. They demonstrated to they were aware of potential risks, people's rights and their responsibilities.

Is the service responsive?

We found that care plans were person centred and contained lots of information about people's choice and preferences. We saw that everyone’s care plans contained detailed information about each person’s support preferences.

We found that people's health and care needs were being regularly assessed. There was regular input from external social care and health professionals when needed.

We saw that a new service satisfaction questionnaire had been developed to allow families and representatives to comment more easily and responsively to the service provided at Tithe Barn.

We saw when we reviewed the complaints log that action had been taken in all instances to address any concerns expressed regarding the care and support provided at Tithe Barn.

We were told about and we saw that staff received regular training to meet the support needs of the people who used the service. For example training had been provided about the care and support of people with epilepsy. In the future new autism training is being developed.

We were told by the registered manager how people were supported when a hospital admission was required. This support was provided by the provision of additional staffing from Tithe Barn and support from community nurses. When a person went into hospital they took with them a hospital passport with information about the person and their care needs.

Is the service well-led?

The service has had stable management for some years. There is a clear management structure within the service and the provider organisation. From the discussions with the registered manager, they were knowledgeable about the service, the people and staff. They met with their managers and peers regularly to maintain up to date their knowledge

The service had a quality assurance system in place. Records seen by us showed that any shortfalls identified had been addressed. There were systems in place to provide feedback to staff about changes and developments by team meetings, the communications book and training.

The staff we spoke with had a good understanding of the provider’s policies and procedures. Information was available around the building on posters about safeguarding and whistleblowing. All of the staff we spoke with said that if they witnessed poor practice they would report their concerns

Staff we spoke with told us that they had work with the people for some time and enjoyed their work. They told us that there was a good team spirit and that they were supported by the managers.

None of the people we met at the home were able to tell us about their experiences at the home due to their learning disabilities and special needs. After the inspection we spoke to three people’s relatives to get their views about the service. One relative said, "I have nothing to complain about". Another said, "I can’t fault the staff". They told us that they had confidence in senior staff and were able to raise any concerns.

We found that people were supported to make their own decisions where possible but most people needed others to make decisions for them on a daily basis. Some decisions made in people’s best interest had been recorded as required by the Mental Capacity Act 2005 but there was scope to improve this area.

We found that people’s health and care needs had been assessed and their care plans had been kept under review. People’s wellbeing and any concerns were taken seriously and external professionals were involved when needed. People were encouraged to do activities they liked. Staffing levels limited how often some people could access the community due to individual funding arrangements.

Systems were in place to support staff and appropriate training was provided. Staff felt reasonably well supported with their work but team morale needed improvement.

The senior management of the home had remained stable. There were effective leadership arrangements in place to manage the care service and monitor health and safety risks.

When we visited Tithe Barn we met six of the thirteen people who lived there and visited two of the five flats where accommodation was provided.

None of the people we met were able to tell us about their experiences at the home due to their learning disabilities and special needs. After the inspection we spoke to relatives of two of the people to get their views about the service.

We met six of the care staff who were on duty. A team leader and the deputy manager helped us with the inspection. After the inspection the registered manager gave us some information.

The relatives told us that they were kept informed and involved in all important decisions. One relative said, “I no longer drive and the staff kindly bring my son to visit me”. Another said, “My son is always happy to return to the home after staying with us”. They told us that they had confidence in senior staff and were able to raise any concerns. One said, “I have been very impressed with the devotion shown by staff”.

The people we met were well presented and comfortably dressed. We saw care staff supporting them with their daily routines and encouraging people to be independent whenever possible.

As a result of our findings at the inspection in November 2011 we issued a compliance action about staffing levels. The provider and registered manager told us they would take action. At this inspection we found that the situation had not changed and staffing levels on some days meant that one flat could not be staffed, meals had to be cooked centrally and access to the community was limited.

After the feedback from the inspection the registered manager and regional manager committed to take immediate action and ensure sufficient staff were always provided. We therefore agreed to re-issue the compliance action and we will review the improvements in the near future.

When we visited Tithe Barn we met people who lived there, some of the senior staff and the registered manager.

The people we met who lived at the home were not able to tell us about how they were supported with their medicines due to their condition.

We carried out this review following a report from the registered manager about a medication administration error. There had been six other errors reported during 2011. None of the errors resulted in people at the home being harmed but they indicated concerns with the systems or staff competency.

We found that suitable systems were in place but there were areas that could be improved. The organisations regional manager told us that there were issues at the service with senior staff not following the procedures but these had been addressed by the registered manager.

When we visited Tithe Barn we met people who lived there and staff who worked there.

Many of the people who lived at Tithe Barn were not able to tell us much about their experience at the home due to their condition. We saw that staff at Tithe Barn supported people well and wrote down what help everyone needed. Staff said they were trained to help them understand how to meet people’s needs and give people the support they wanted.

We saw that staff interacted with people who use the service in a friendly and courteous manner. Staff demonstrated they were aware of people’s care and support needs.

We saw that people were very relaxed and at ease with staff and within their home environment. The atmosphere was calm and relaxed with staff attentive to people’s needs and moods as they changed throughout the afternoon and evening.

We looked at care records for two people living at the home. We found that most of their records provided clear information for staff to follow so they could give people the care and support they needed. Some of the records had not been fully completed.

Activity records showed that people had been into the community and had taken part in a variety of activities. There had been a shortage of staff on some occasions which had limited how often people could go out. There were periods when people had stayed within the property and grounds for up to four days at a time

The home seemed clean but there was an unpleasant odour in one area. The deputy manager said that this was being addressed and new sofas and carpets were on order for some of the five flats.