The inspection took place on 23 November 2016 and was announced. We last inspected the service in September 2014 and at that time the provider was meeting the regulations we checked.

74, Coombe provides care and accommodation for up to four older people, some of whom are living with dementia. On the day of the inspection three people lived at the home.

The service had a registered manager. 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 told us they felt safe. Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk of harm or if they needed to report any suspected abuse.

Our inspection of care records showed risks to people were assessed and there was guidance for staff as to how those risks should be managed to reduce the likelihood of harm.

There were sufficient numbers of staff to meet people’s needs. Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed.

People received their medicines safely from appropriately trained staff.

Staff received training and support they said helped them with their role of providing good, effective care to people in the home. Staff communicated with people effectively and they received support from staff as necessary in a careful and, dignified manner.

The registered manager took appropriate action to ensure the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were followed. We saw and heard staff encouraging people to make their own decisions and giving them the time and support to do so.

People were supported to maintain a healthy balanced diet and adequate hydration. People told us they enjoyed their meals, there was plenty of food and we observed people were not rushed.

People had access to health care services to ensure their health care needs were met.

People and their relatives said that staff were kind, caring and compassionate. Staff knew people well and were able to provide care in the way they needed and wanted. Staff also recognised people's right to privacy, promoted their dignity and respected their wishes.

People's care was planned with them and their relatives so they were able to say how they wanted their needs met. Their care records were personalised and reviewed regularly or as their needs changed. People's care records detailed people's preferences.

Where possible people had choice and control over their lives and were supported to engage in various activities within the home and in the community.

People, relatives and staff were positive in their comments about the registered manager. They said they promoted an open and positive working environment that they felt able to contribute positively to the development of the service.

We saw there were informal quality assurance audits in place. However the registered manager recognised that this needed to be more formalised and told us they planned to implement a monthly written report that would provide valuable information to develop and improve the service.

Where suggestions or comments were received the registered manager used the information to develop and improve the service.

During our last inspection of the service on 13 May 2014, we identified the provider had not taken proper steps to protect people against the risks of receiving care that was inappropriate or unsafe. We found records had not been maintained accurately and appropriately and there was no effective system in place to assess and monitor the quality of service people experienced. We also found people were not protected from the risk of abuse, because they had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Following that inspection we asked the provider to send us an action plan setting out the steps they had taken to achieve compliance, which they did on 9 July 2014. During this visit we checked these actions had been completed.

This visit was carried out by a single inspector who helped answer two of our five questions: Is the service safe? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with the provider, who was also the registered manager.

Is the service safe?

We found at this visit the provider had taken appropriate steps to protect people from abuse and prevent the risk of this occurring. Training in safeguarding of vulnerable adults for staff had been planned. Staff had also received one to one support from the provider to check their current understanding and awareness of their responsibilities for identifying abuse, what this constituted and what actions they must take to protect people, if they suspected they were at risk.

We were assured of the provider’s understanding of their role to ensure that proper authorisation was sought to deprive people using the service of their liberty in a safe, correct way and where this was in their best interests to do so. People’s care records showed applications had been made, where this was appropriate.

People’s care records had been reviewed and now contained accurate information about their current care and support needs. Risk assessments had also been reviewed regularly which meant there was up to date information about how to protect people from known risks to their health, safety and welfare.

Is the service well led?

The provider had taken appropriate action following our last inspection to make improvements that were needed, and in a timely manner. This included undertaking a review and update of care records and staff files, introducing more training and support for staff and improving work practices in relation to staff recruitment. The provider had also put in place arrangements to regularly check the quality of the service provided.

During our last inspection of the service on the 13 May 2014 we identified serious concerns about the provider’s recruitment procedures. We found appropriate and necessary checks had not made before staff commenced work at the service. We took enforcement action and issued a warning notice to the provider, who was also the registered manager, as they had failed to comply with Regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

We carried out this visit to check the provider had taken appropriate steps to comply with the warning notice. We found there had been improvements.

This visit was carried out by a single inspector who helped answer one of our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with the provider. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found at this visit the provider had ensured appropriate checks had been undertaken of staff employed by the service to ensure they were of good character, physically and mentally fit to perform the work and had the necessary qualifications, skills and experience to care for people using the service. We saw new recruitment processes had been introduced to ensure that appropriate checks were undertaken before people were able to start work at the home.

During this inspection we spoke with the manager and two people who used the service. Many had complex needs, which meant that few were able to communicate their views. At the time of this inspection there were four people using the service.

At our previous inspection on 2 August 2013 we asked the provider to make improvements in relation to the recruitment checks of new employees and record keeping to demonstrate that people were receiving safe and appropriate care. During this inspection we checked whether the provider had made the necessary improvements.

The focus of the inspection was also to answer five key questions: is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found.

Is the service safe?

People were cared for and supported in a clean and tidy environment, and relatives we spoke with told us this was always the case.

People could be placed at risk of poor care and support because the home did not carry out recruitment checks on all new staff to ensure they were suitable for the role. Staff were allowed to start work without a criminal records check, a full and satisfactory employment history and checks to ensure that they were physically and mentally fit to work at the service. Qualifications and experience, as well as skills such as English language ability, were not assessed during recruitment. This meant that some staff were unable to communicate with people in English. We have asked the provider to tell us how they plan to improve their recruitment practices.

The commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We found that staff and management did not fully understand their responsibilities under this act and therefore might not be ensuring the safety of people. There was no evidence that some decisions were made in people’s best interests, involving the right people and at the right level. Staff did not have a good knowledge of safeguarding adults and their responsibilities in relation to this. We have asked the provider to tell us how they plan to improve this.

Whilst, people and relatives were satisfied with many aspects of the service, we found that the provider did not operate safe staff recruitment processes to make sure that only suitable staff were chosen to work with people using the service.

Is the service effective?

Records of care showed that the service was delivered in line with people’s care plans, which meant that most needs people were assessed as having were being met. We saw that the service was meeting people’s needs, and one person told us, “[The manager] gets to know your likes and dislikes.”

Is the service caring?

People using the service and relatives all commented that the staff were very caring and we saw many interactions between staff and people using the service where staff showed warmth and kindness. We heard how the manager went to great lengths to care for people, making fresh fruit and vegetable juices daily for people every day, and staying with people for long periods while at hospital.

Is the service responsive to people’s needs?

Staffing levels were appropriate to meet people’s needs. The manager was familiar with people and was able to demonstrated they knew the needs of people using the service well. We heard examples of how the manager had noticed early signs of ill health and supported people to seek medical attention quickly. However, the provider did not always respond appropriately to peoples changing needs in relation to deteriorating mobility.

Is the service well-led?

The home had an experienced registered manager in post who had run the service for around 30 years. People using the service and relatives spoke highly of the manager and commented that they provided a high level of care and attention to people. Relatives felt well listened to, and told us they had not had reason to complain but felt that they would be listened to if they needed to.

The system in place to regularly assess and monitor the quality of the service provided to people, was not always effective to make sure people were protected from the risks of poor and inappropriate care and support. During this inspection we found a number of areas where the provider needed to make improvements. These included improving the arrangements in place to protect people from abuse, having appropriate recruitment processes in place and keeping accurate and appropriate records.

We saw that people were encouraged to be as involved in the day to day activities of the home as much as they wished. Care staff took time to chat to people, to eat and drink with them and to make time for any questions by relatives or visitors. We observed the way staff interacted with people and saw that that people were assisted and supported adequately in a kind and helpful manner.

People we spoke with were very pleased with the quality and choice of food provided at the home. "The food is excellent", one person told us. Another told us: "The food is always hot and beautifully served".

We saw that there were policies and procedures in place to protect people who use the service and staff from the risk of infection.

We saw that all areas of the home were clean, well-decorated and free from hazards. People were able to move safely and freely from house to gardens and had easy access to their rooms at all times. The manager had ensured that rooms were aired and kept cool during the hot weather.

We spoke with three of the people living at Anne Residential.

Overall comments received about the home included 'I'm happy here', 'it's a nice place', 'staff listen and help', 'the food is very good' and 'the home is always clean and fresh'.

People we spoke with said they are treated with respect. Our observation was that staff were kind and respectful.