This inspection took place on 16 and 19 November 2018 and was unannounced.

Wilton House is situated close to Taunton town centre. The home can accommodate up to 12 people and it specialises in providing care to adults who have a learning disability and concurrent physical disability. Twelve people were living in the home at the time of the inspection.

The care service has been developed 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.

At the time of the inspection there was a registered manager in place. 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.

At our last inspection we rated the service good with one domain outstanding. At this inspection we found the evidence had improved with two domains rated outstanding this meant the overall rating for the service moved to outstanding.

The registered manager and staff went above and beyond what was expected of them to ensure people received care and support in a caring, respectful and dignified way. Even with limited verbal communication people could express an opinion about the care provided and contributed to their care plans.

People received responsive care and support which was personalised to their individual needs and wishes. Staff were innovative in finding ways to improve people’s lives and help them to achieve their goals and expectations. People were supported to live meaningful and active lives with staff emphasising what people could do not what they could not do. Staff were passionate about ensuring people continued to have a say about the way they were supported and the activities they took part in. People enjoyed a variety of activities which included joining in at local clubs and going on holiday.

Staff used and explored innovative ways to assist people to express their views and enhance their ability to communicate. The provider employed an assistive technology development manager who provided support and training to staff and people who lived at the home.

People indicated they felt safe living at Wilton House. One relative told us, “[The person] is really safe living here, the staff are brilliant and very well trained, but above all they really care about the residents.”

There were processes and practices in place to keep people safe. The provider had a robust recruitment programme which meant all new staff were checked to ensure they were suitable to work with vulnerable people. All staff had received training in safeguarding vulnerable people. All staff spoken to were able to tell us what they would look for and how they would report anything they thought put people at risk of harm or abuse.

People received effective care and support from staff who had the skills and knowledge to meet their needs. All staff attended an induction which included the companies’ mandatory training before they started to work with people. The in-house induction was focused on people’s specific needs and the way they preferred to live. Staff also received training about specialist needs people had for example, the safe management of epilepsy.

People were supported by a team that was well led. Everybody spoken to said they thought the service was well led. Staff, relatives and health professionals spoke highly of the registered manager. They all said they were open, approachable and honest. The registered manager was passionate about making people’s lives meaningful and different; this was reflected by all the staff we spoke to. During the inspection we no

This inspection took place on 6 April 2016 and was an unannounced inspection.

Wilton House is situated close to Taunton town centre. The home can accommodate up to 12 people and it specialises in providing care to adults who have a learning disability and concurrent physical disability. The home is staffed 24 hours a day. The home has a range of aids and adaptations in place to assist people who have mobility difficulties. All bedrooms are for single occupancy. The home is staffed 24 hours a day.

At the time of our inspection there were 12 people living at the home, this included one person who was in hospital. The people we met with had very complex physical and learning disabilities. One person was able to tell us about their experiences of life at the home. We therefore used our observations of care and our discussions with staff to help form our judgements.

There was a registered manager 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.

From the management down; staff were committed to making sure people were safe, happy and received the care and support they needed and wanted. Staff were very kind, caring and patient when they interacted and assisted people. One staff member said “This is their home and we are privileged to be able to come here and support them.” Throughout the day we heard laughter and friendly banter. People were seen to respond positively to gentle and appropriate touch from staff.

Staff were skilled at communicating with people, especially where people were unable to communicate verbally. The service was using and exploring innovative ways to assist people to express their views and enhance their ability to communicate. The provider employed an assistive technology development manager who provided support and training to staff and people who lived at the home.

Satisfaction surveys showed health and social care professionals and people’s relatives were very positive about the care people received. Comments from people’s relatives included “I could not ask for better people to care for my [relative]. They are all amazing. It’s just like a home from home.” And “I am very happy with the care and attention [person’s name] receives. The staff are very caring.” Comments from health and social care professionals included “There is a very caring and open atmosphere where residents’ needs are clearly uppermost.” And “At all times staff are totally professional, caring and sympathetic and above all; put the care of each resident as a priority. Exceptional care.”

Routines in the home were flexible and were based around the needs and preferences of the people who lived there. People were able to plan their day with staff and they were supported to access social and leisure activities in the home and local community. The registered manager told us they were “passionate about ensuring people had choice and control about their lives.” Another member of staff said “We will always push the boundaries. We will never say no just because of a person’s disability. We will explore every option possible for people to do what they want.”

The home was a safe place for people. Staffing levels were good and staff understood people’s needs and provided the care and support they needed.

Staff knew how to recognise and report abuse. They had received training in safeguarding adults from abuse and they knew the procedures to follow if they had concerns.

People’s health care needs were monitored and met by staff who received excellent training and support. People received good support from health and social care professionals.

People were unable to look after their own medicines. Staff made sure medicines were stored securely

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

We found the service to be safe because they had a range of policies and procedures in place to protect the people who lived in the home. The staff we spoke with had a good understanding about how to report any concerns.

We observed that staff were competent and professional in their interactions with people who lived at the home. During our inspection we observed people were calm and appeared very content with the care and support provided.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Care and treatment was planned and delivered in a way that ensured people’s safety and welfare. Care plans included a range of individual risk assessments and agreed actions for managing these risks. We saw risk assessments around specific behaviours which included triggers that may cause the behaviour as well as actions for staff to minimise these risks. However the provider may find it useful to note that these risk assessments did not detail the action staff should take should behaviours escalate.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We saw that all medicines had been stored securely and had only been administered by senior staff who had received training in the management and administration of medication. We observed staff during the administration of the lunch time medications. We saw staff administered medicines in accordance with the home’s medication policy.

We observed that staff supported people to access the community in accordance with their plan of care. We saw that people were supported by appropriate numbers of staff.

Is the service effective?

We found the service to be effective because people's care treatment and support achieved good outcomes. We also found that people's rights and choices were respected by staff.

We saw staff recorded information about each person on a daily basis. Information included how people had spent their day and how they had responded to activities of daily living. This meant the effectiveness of people’s care plans could be fully reviewed.

We saw that people's prescribed medicines had been regularly reviewed by their GP or specialist health care professional. This meant that people received medicines which were appropriate to their needs.

Staff used a range of methods to assist people to make choices about their day to day lives. Examples included objects of reference and photographs. We observed staff offering people choices in accordance with their needs and preferences.

The service was effective in promoting people’s independence and community involvement. People were supported to engage in the local community in a variety of ways. Examples included trips out, home visits, shopping trips and activities.

Is the service caring?

Staff interacted with people in a gentle and kind manner. The majority of people were unable to communicate verbally with us. However we observed people responded in a positive way to the staff who supported them. For example one person smiled and held the staff members hand. Another person made a sound which indicated they were happy. One person told us “all the staff are very kind. I don’t have any favourite staff because they are all lovely. I like them all.”

The staff we spoke with had a very good understanding about the needs and preferences of the people they supported. They understood and responded to people’s needs and requests where individuals were unable to make their wishes known verbally. This demonstrated that staff knew people well. A key worker had shared one person’s wish to have ‘a toy or teddy’ with them. We observed the individual had a toy with them throughout our visit.

Is the service responsive?

The service was responsive to people's needs. We observed people were supported in accordance with their needs. For example, one person preferred to eat their lunch in a quiet environment. We observed this person being supported by staff in an area away from the other people who lived in the home.

Each person was allocated a keyworker who they would meet with on a regular basis. We saw the keyworker was involved in the review of people's care needs and preferences with other professionals.

Staffing levels and staff deployment had improved. We found there were sufficient numbers of staff on duty to meet people’s needs. We also found a good mix of staff skills and experience. Senior staff were available on every shift and the home operated an on-call system. This meant that staff could contact either the manager or deputy manager outside of office hours.

People’s health care needs were monitored and responded to appropriately. Information about people’s health needs and contact with health and social care professionals had been recorded. We were informed that the service received good support from health and social care professionals and there were no problems obtaining their input for people when required.

Is the service well led?

The service was well led because there were systems in place which monitored the quality of the service provided.

People who lived in the home and their representatives were provided with opportunities to express a view about the quality of the service provided. We looked at some quality assurance surveys which had been completed by people’s relatives. These showed a high level of satisfaction with all aspects of the service provided. Comments included ‘thank you for providing an exceptionally high level of care’ and ‘I visit and phone regularly. I love visiting and I am always kept up to date.’ Another person described the staff team as ‘fantastic.’

A manager had recently been employed. They told us they were in the process of submitting an application to be registered with us. The manager was supported by a deputy manager and an administrator. We saw that senior staff were always available to support less experienced staff.

All the staff we spoke with were positive about the support they received and they confirmed that they received regular supervision sessions. Staff files contained detailed records of supervision sessions. These showed that staff received regular supervisions where their on-going performance and competencies were discussed.

We saw that staff had the opportunity to attend regular staff meetings. We looked at the minutes from a recent meeting. These showed that a range of topics had been discussed which included policies and procedures, staffing and information about the people they supported.

We found procedures were in place to minimise any risks to the people who lived at the home. Regular internal audits had been carried out which monitored the on-going health and safety of people. Internal audits included checks on the home's fire systems, environment, care planning and the management of people's medicines.

On the day of our visit there were 12 people living at the home. We met with all of these people and spent time with each of them. Due to their complex care needs, we were unable to have meaningful conversations with the majority of the people but we observed them discreetly throughout our visit.

We spoke with one person, one relative and ten members of staff. The deputy manager assisted us with the inspection. The previous deputy manager (who now works at a 'sister' home) and the registered manager (who was on annual leave) also came in to the home.

Throughout our visit we saw that people appeared comfortable, relaxed and at ease with staff. There was humour and fun at times. One person told us "I am happy here" and "I feel safe". One relative told us "it's the best place ever".

The home employed staff who were committed, enthusiastic and felt supported in their work. One person told us "I like them (the staff) - all of them". A relative told us that staff were "so caring". Staff showed a good understanding of safeguarding procedures and the appropriate action to take.

We saw that plans of care were in place for each person with suitable assessments of risk completed. Specialist advice was sought from the appropriate professionals.

Staff had the necessary pre-employment checks carried out. We saw that there was not enough staff on duty at the beginning of our visit but that this was rectified. There was a suitable complaints procedure in place.

When we visited 12 people were using the service. The people who lived at the home had very complex needs and the majority were unable to engage in conversations with us. We were however able to observe how staff interacted with people and we spoke to staff about the experiences of the people they supported.

Care plans were personalised to the individual and gave details about their preferences as well as their physical and mental health needs. This meant that staff could provide care and support in line with people’s needs and preferences.

Staff were skilled in recognising and responding to people who were unable to express their needs and wishes verbally. We saw that people responded positively to staff interactions. This demonstrated that staff knew people well.

We found all areas of the home to be well maintained. The standard of décor and furnishings were of a high standard and helped to promote a homely feel. People had access to the specialised equipment they needed.

Staffing levels ensured that people’s physical, emotional and social needs were met. There was a clear staffing structure in place which meant that senior staff were available to support less experienced staff. We found staff morale to be very good.

The home had a range of policies and procedures in place to protect the rights of the people who lived at the home. Staff had received training in the Data Protection Act 1998 and confidentiality. All records had been stored securely.