This inspection took place on 6 December 2016 and was unannounced. A second announced day of inspection took place on 7 December 2016.

United Response – 21 North View is a purpose built, six bedded care home providing personal care for people living with a learning disability. At the time of the inspection there were six people using the service.

All of the bedrooms and communal areas are situated at ground level, with a spacious kitchen, dining room and lounge. A garden area was available for people to use during warmer weather and bedrooms were of a good size, with overhead tracking if needed by people using the service.

We last inspected United Response – 21 North View on 18 and 24 November 2015 and found it was not meeting all legal requirements we inspected against. Specifically the provider had breached. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used the service, and others, were not protected against the risks of inappropriate or unsafe care because an effective system for monitoring the service was not in place.

Following the inspection the provider submitted an action plan detailing how they would meet the legal requirement. They said they would be compliant by 1 February 2016.

During this inspection we found that the registered provider had implemented actions and improvements had been made.

A registered manager was in post and had been registered with the Commission since April 2016.

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.

An effective system for monitoring the quality of the service had been implemented. Any areas for action were noted with a timeframe for completion and a responsible person. Where action was required this had been completed in a timely manner.

We have made a recommendation about the recording of best interest decisions.

The registered manager had made applications to the supervisory body for Deprivation of Liberty Safeguards to be approved which included the use of bedrails and wheel chair lap belts.

Staff understood people’s individual communication methods and engaged proactively with people, encouraging and supporting them to make decisions about their life and the care they received. Relationships were warm and caring. It was clear from the laughter and smiles that people were relaxed and enjoyed spending time with their staff.

People were safe, and staff understood safeguarding procedures. Risks were assessed and risk reducing actions were included within a section of the support plans.

Any incidents and accidents were recorded and analysed for lessons learnt to improve the quality of the service provided.

Medicines procedures had been improved following medicine errors and they were managed in a safe way.

Support plans were person centred, detailed and provided staff with the information they needed to support people safely and appropriately. Alternative support plans were included as it was recognised people may need slightly different support if they were feeling unwell.

Staff were trained, and had attended specific training to support them to meet the needs of the people living at 21 North View, this included nutrition, autism and behaviour training. This enabled staff to support people with specialist dietary requirements.

People had a range of healthcare professionals involved in their care and staff actively engaged with them as needed.

People and staff were involved in team meetings and staff told us they were useful and supportive. Staff said the registered manager had made great improvements and the staff team were working well together. The registered manager said. “I'm proud of the staff. We are moving i

We inspected 21 North View on 24 November 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

21 North View is a six bedded care home providing personal care to people with a learning disability. It is a purpose built house situated close to local shops and amenities.

No registered manager has been in place since August 2015. 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. It is a condition of the provider’s registration to have a registered manager. A new manager was appointed in September 2015 and is just in the process of applying to become the registered manager.

In recent months seven staff resigned and although new staff have been recruited at the time of the inspection there continued to be vacancies. The registered provider was ensuring that the staffing levels remain in line with those required either via the permanent staff completing additional shifts or the use of relief staff who know the people. They were also actively recruiting new staff. However we have not been notified of these difficulties and should have been.

We found the care records were comprehensive and well-written. The care records included pictorial images to assist the people who used the service understand the content. However, we found that the monthly evaluations had not been completed since the registered manager had left.

We met with four of the people who used the service and we were able to chat to one person and a relative. Three of the people who used the service were unable communicate verbally but we found that staff could readily interpret their facial and body language. We observed staff practices and saw that the people were treated with compassion and respect. We saw that people were very comfortable with each other and staff presence and there was lots of laughter.

We saw there were systems and processes in place to protect people from the risk of harm. We found that staff understood and appropriately used safeguarding procedures.

We saw that staff were aware of how to respect people’s privacy and dignity. We saw that staff supported people to make choices and decisions.

We saw that people were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments. We saw that people had hospital passports. The aim of a hospital passport is to assist people with a learning disability to provide hospital staff with important information they need to know about them and their health when they are admitted to hospital.

Staff had received a range of training, which covered mandatory courses such as fire safety, infection control and first aid as well as condition specific training such as working with people who have learning disabilities.

Staff had also received training around the application of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The staff we spoke with fully understood the requirements of this Act and were ensuring that where appropriate this legislation was used.

People and the staff we spoke with told us that there were enough staff on duty to meet people’s needs and we observed that were sufficient staff on duty to meet people’s needs. We saw that four to five staff were on duty when people were at home and one waking night and one pe

We did not speak to people during this visit.

We found there was an effective system in place to monitor the quality of service provided.

We haven’t been able to speak to all of the people using the service because some of the people had complex needs, which meant they were not able to tell us their experiences. However, we spoke with one person who told us “I am happy ” and “ It is pancake day soon and we are going to have a get together”.

We undertook a short observational framework for inspection (SOFI) exercise to observe the interactions between the people who used the service and the staff. SOFI is designed to be used when inspecting services for people who have some difficulty in communicating their opinions on the services they receive.

During the SOFI, we observed people being offered choices; for example, people were offered a choice of drinks and a choice of meals. Staff were seen to be attentive and gave people the information about the drink and meal options in a way that was appropriate to their needs. One person was supported by staff to choose their own snack and a drink. We observed another person being supported to make their own hot drink. In addition, we observed staff trying to engage people in discussions about the activities they had taken part in that day. We observed staff discreetly speaking to one person when they were showing signs of becoming anxious.

Throughout the inspection, the staff members on duty were observed speaking to people in a kind and respectful way. We also observed that the people were clean and well groomed.

People who were using the service had complex needs which meant they were unable to tell us their views. Because of this we used a number of different methods to help us understand their experiences. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found –

Is the service safe?

Most of the people who lived at the home were unable to tell us their opinions about it because of their disabilities. We observed that they were happy and relaxed in their communications with staff. We spoke with five relatives to find out their opinions of the service. They told us they were confident their relatives were safe at the home. One commented, "I feel confident in her safekeeping. I think they are fine. The (staff) seem nice people." Another told us, “I’ve never had a problem where he is. I think they do an excellent job.”

We saw that risks to people’s safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe. We observed that staff were attentive to people in ways that kept them safe. For instance, a member of staff linked arms with a person with visual impairment to keep them safe in the vicinity of the stairs. We asked relatives if the staff were aware of any risks around their relative’s care. They were positive about this aspect of care. One commented, “I know they strap him into a wheelchair to keep him safe.” This showed care and treatment was planned and delivered in a way that ensured people’s safety and welfare.

We found that appropriate arrangements were in place to manage medicines.

Appropriate checks were undertaken before staff began working at the home which helped ensure that the staff were fit and proper people to work with vulnerable adults.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The provider had made six applications under these safeguards and notified CQC about this.

Is the service effective?

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We found that people who used the service were receiving the care and support they needed. The staff we spoke with were well informed about the assessed needs of the people they were providing with care and we saw that they put this into practice. Relatives told us people received good, effective care. Their comments included, “The staff know what they are doing” and “(My relative) is thriving.”

Relatives acting on behalf of people using the service were given appropriate information and support regarding their relative’s care and treatment and understood the care and treatment choices available to them.

We found people were supported to be able to eat and drink sufficient amounts to meet their needs. Staff understood how to support people with nutrition in ways that kept people safe.

Is the service caring?

We saw that staff were caring and had good relationships with people using the service, who we noted enjoyed contact with the staff team. We saw that staff were confident when carrying out their roles and there were enough of them, so that care of people was never rushed or pressured.

Care was individualised and centred on each person. Staff communicated effectively with people using the service, no matter how complex their needs. Relatives were satisfied with the way care was provided. One told us, "She's happy. She seems to be cared for beautifully." Another relative commented, “We’ve never had any problems with the care.” Another relative who had raised concerns about some aspects of their relative’s care told us, “They have improved their care a lot and they are trying to get permanent staff. It has improved since Linda (the manager) came. She is trying to get on top of everything.”

Is the service responsive?

People’s needs were kept under review and advice was sought from external care professionals, when appropriate. People participated in a range of activities both within the care home and out in the wider community. They were supported to maintain relationships with their families.

We found that the service acted promptly on any concerns about people’s health and wellbeing.

We spoke with the local authority commissioning officer who told us they had been working with the service to make improvements and that the new manager was working well with them.

Is the service well-led?

A manager was in place who was registered with the Care Quality Commission. Staff felt supported by her. One commented, “It’s really improved. It’s much more organised; she has made sure there is a better skill and personality mix of staff. The people living here seem happier."

Relatives and health and social care professionals spoke positively about the manager and her leadership. A relative told us, “It has improved since Linda (the manager) came."

Relatives told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. A relative commented, “Linda is alright. She is doing her best.”

There were effective quality assurance systems in place. Audits were carried out to check people were cared for appropriately, for instance, to make sure medicines were managed safely and address any issues promptly.