This inspection visit was unannounced and took place on 16 November 2016. At our last inspection on 30 June 2015 we asked the provider to make improvements to the level of staffing, assessments when people lacked capacity and the management of the home. The provider sent us an action plan in August 2015 explaining the actions they would take to make improvements. At this inspection, we found improvements had been made although further improvements were needed when assessing capacity. The service was registered to provide accommodation for up to 50 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 30 people were using the service.

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.

People were supported to make choices, however the assessments did not always reflect the person’s level of understanding in different situations. The home had enough staff to support people’s needs. Any staff who had been employed had received a range of checks to ensure they were suitable to work in the home. The manager and provider had established a range of audits to support the improvements within the home. We saw feedback was sought from people, relatives and professionals and any areas raised had been considered and responded to.

We found staff had established positive relationships with people. Staff showed respect for people’s choices. They ensured they maintained people’s privacy and dignity at all times. People were able to choose the meals they wish to eat and alternatives were provided. We saw that medicines were managed safely and administered in line with people’s prescriptions. Referrals had been made to health care professionals and any guidance provided had been followed.

Staff obtained information from the person and family or relatives to support the completion of the care plan. People were encouraged and supported with activities they wish to engage in. Any complaints had been addressed and resolved in a timely manner. There was a whistle blowing policy which was responded to in confidence and any concerns raised investigated.

Staff felt supported by the manager and there was a clear process in place to cascade information about the service and the needs of people. Staff had received training and the provider had invested in further training to expand the staff knowledge in dementia.

The Home is situated in its own grounds on the edge of a small, modern housing estate which overlooks the North Staffs moors. We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

We inspected this service on 30 June 2015. The inspection was unannounced. At our previous inspection in June 2014, the service was meeting the regulations that we checked.

The service provided accommodation for up to 50 people. Thirty five people were living at the home on the day of our inspection. Some of the people were living with dementia.

There was a registered manager in post at the time of our inspection. 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. The registered manager was not at the home on the day of our inspection but there was a deputy manager on duty.

We received information, that staffing numbers in the home were low and this raised concerns for people’s safety. We found staff were not provided with the knowledge and guidance they needed to support people safely. The provider reviewed staffing levels but did not take into account people’s changing needs to ensure there were sufficient staff to meet people’s needs at all times.

Staff received induction and ongoing training but there were no arrangements in place to check their competences and knowledge to ensure they had the right skills to care for people. Staff told us they felt supported by the manager and able to raise their concerns. However, we found inconsistencies in the way the provider’s management team responded to those concerns.

The manager and staff did not fully understand and follow the legal requirements of the Mental Capacity Act 2005 (MCA). For a person who lacked the capacity to make decisions, there was no evidence that the decision to use a door sensor had been made in their best interest.

People were supported to eat and drink enough to maintain good health but the provider did not ensure that mealtimes were a pleasurable, sociable experience.

The manager and the provider’s quality team monitored the quality and safety of the service but the checks carried out were not effective in identifying shortfalls in care plans and the effectiveness of staff training.

Staff knew people’s preferences and people told us they received support in accordance with their wishes. People told us they liked the staff and found them to be caring and patient. Staff promoted people’s dignity and encouraged people to remain as independent as possible. People were encouraged to form friendships at the home and were able to see friends and family as they wished. Staff kept relatives informed of changes in people’s care and support.

People received their medicines as prescribed and had access to health professionals to support and maintain their health. People were supported to have sufficient to eat and drink to maintain good health and to access health care services when they required.

The provider had recruitment processes in place to assure themselves that staff were suitable to work in a caring environment which minimised risks to people’s safety.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the report.

During this inspection we spoke with six people who used the service, two relatives who were visiting and six members of staff.

To understand people’s experiences of care, we always ask the following five questions of every service and provider;

Is the service safe?

The home provided adequate staff to meet the needs of all the people living in the home. One relative told us, " I feel my X (the person who used the service) is looked after safely here".

We saw that staff reported adverse incidents which occurred and these were investigated, however the provider did not always provide management plans to reduce the risk of incidents reoccurring.

Staff were aware of the categories of abuse that people might be subjected to and felt confident to report safeguarding concerns internally or directly to the local authority. Staff were also aware of the process for whistleblowing if they had concerns which they would not want to raise directly with the provider.

People’s individual risks and specialised equipment needs, such as assistive technology were assessed and reviewed on a regular basis.

People had access to specialist health care professionals to maintain their physical and mental health.

There were established health and safety procedures in place to ensure the food served to people was stored and cooked safely. One person told us, “We get good, down to earth food here. Just what I like”.

Is the service effective?

The people who used the service had detailed care plans which provided staff with the information they required to care for people. People’s individual preferences on care, for instance the time they liked to wake in the morning, were recorded and respected.

There were effective processes in place to regularly review and update the care records to ensure they remained current.

Is the service caring?

During our inspection we observed people receiving kind and respectful care from staff. All requests for personal support were met in a timely manner with discretion.

Staff knew people well and were able to support them in the way they preferred.

One person told us, “There’s nice company here. It’s a lovely calm atmosphere”. Another person told us, “They’re (the staff) very good here”.

Is the service responsive?

We saw the provider responded to changes in people’s well-being which might affect their health, for instance, weight loss was reported to the person’s GP.

There was a complaints system in place and people felt supported to raise concerns. One person told us, “If I wasn’t happy I’d go into the office and tell them”. Another person said, “The girls are really good but if I wasn’t happy I’d tell them”.

Some people were able to participate in activities but these did not always meet the needs of all the people.

Is the service well-led?

The provider was regularly monitoring and assessing the quality of service provided through a range of audits so that, if necessary, improvements could be made. People’s care records were audited to ensure they were completed correctly and contained up to date information. Staff signed to confirm they had made the required amendments.

There was a contingency plan in place to provide additional staff, if required, during an emergency.