This was an unannounced inspection which took place on 04 January 2018.

Belamie Gables is a residential care home which is registered to provide a service for up to twenty older people. Some people were living with other associated conditions such as dementia and physical and sensory difficulties.

At the last inspection, on 08 February 2016, the service was rated as good in all domains. This meant that the service was rated as overall good. At this inspection we found the service remained good in all domains and overall good.

Why the service is rated good.

There is not a registered manager running the service, currently. However, the service has been managed to a good standard by an interim and acting manager since the registered manager cancelled their registration. 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 provider and managers ensured people, staff and visitors were protected from harm and the service remained as safe as possible. The staff team were trained to maintain and promote people’s health, well-being and safety.

People were protected by staff who understood how to protect the people in their care and knew what action to take if they identified any concerns. They made sure that people were not subjected to any poor practice or abuse.

The service continued to identify general risks and risks to individuals and appropriate action was taken to reduce them, as far as possible.

People benefitted from adequate staffing ratios which ensured there were enough staff on duty to meet people’s diverse, complex and individual needs safely. Recruitment systems were in place to make sure, that as far as possible, staff recruited were safe and suitable to work with people. People were supported to take their medicines, at the right times and in the right amounts by trained and competent staff. They were encouraged to take some responsibilities for their own medicines, as was safe and appropriate.

People continued to be cared for by trained staff who were supported to make sure they could meet people’s varied and sometimes complex needs. Staff dealt effectively with people’s current and changing health needs. They worked closely with health and other professionals to ensure people received the best care possible.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People continued to be supported by a caring and committed staff team who continued to meet people’s needs with patience and kindness.

The service was person-centred and responsive to people’s needs and preferences. Activity programmes were designed to meet people’s needs and interests. Care planning was individualised and regularly reviewed which ensured people’s needs were met and their equality and diversity was respected.

There was no registered manager in post, currently. However, the service was being managed by an acting manager who had worked in the home for a number of years and was beginning the registration process. The acting manager was supported by a strong and experienced team of senior staff. Staff described the manager and management team as open, approachable and supportive. The manager and staff team were committed to ensuring there was no discrimination relating to staff or people in the service. The quality of care the service provided was assessed, reviewed and improved, as necessary.

This was an unannounced inspection which took place on 8 February 2016. At the last comprehensive inspection undertaken on 7 November 2014 the service was rated as requires improvement. At the follow up inspection completed on 12 May 2015 the provider had made the improvements we had asked for but had not had time to demonstrate they could sustain them.

Belamie Gables Care Home is registered to provide care (without nursing) for up to 20 older people. Some people were living with varying degrees and types of dementia. There were 14 people resident on the day of the visit, one person was in hospital. The house offers accommodation over two floors in 19 rooms. One room is a ‘double’ currently used for a couple. Individuals have their own bedroom and one is en-suite. The shared areas within the service have limited space but the staff team make best use of them to suit the needs and wishes of people who live in the home.

There is a registered manager running the service. 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.

Staff were trained in the safeguarding of vulnerable adults and health and safety and were consequently able to keep people who use the service, visitors and themselves safe. They were able to describe their responsibilities and methods for keeping people safe from all forms of abuse and harm. The service took health and safety issues seriously to ensure people, staff and visitors to the service were kept as safe as possible.

People received safe care because there were a sufficient amount of staff, effectively deployed on duty. A robust recruitment procedure helped to ensure that staff employed were suitable and safe to work with people who live in the service. People were given their medicines in the right amounts at the right times by properly trained staff.

People’s human and civil rights were acknowledged. The staff team understood the relevance of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards (DoLS) and consent issues which related to the people in their care. The Mental Capacity Act 2005 legislation provides a legal framework that sets out how to act to support people who do not have capacity to make a specific decision. DoLS provides a lawful way to deprive someone of their liberty, provided it is in their own best interests or is necessary to keep them from harm. The staff team took any necessary action to uphold people’s rights and the registered manager made the appropriate DoLS referrals to the Local Authority.

The service made sure that people’s health and well-being needs were met. People were supported to obtain any healthcare from appropriate professionals, as necessary. Staff were trained in all relevant areas, so that they could meet the variety and diversity of needs of the people in their care.

People were recognised and treated as individuals. Staff had built strong relationships with them and were knowledgeable about and knew how to meet their particular needs, in the way people preferred. The service respected people’s views and encouraged them to make decisions and choices for themselves. People were treated with dignity and respect at all times.

The service was well managed. Meeting people’s needs was the priority for staff and the registered manager. The registered manager was described by staff as very supportive and approachable. The service had ways of making sure they maintained and improved the quality of care provided. Improvements had been made as a result of listening to the views of people, other professionals, the Care Quality Commission, people’s relatives and the staff team.

We carried out an unannounced comprehensive inspection of this service on 7 November 2014. Breaches of four legal requirements were found. We issued a warning notice for a breach in relation to the provider always ensuring sufficient staffing to meet people’s needs. We issued compliance actions for breaches relating to staff training and skills, notifying the Care Quality Commission (CQC) of safeguarding incidents, and ensuring records were securely stored and accurate to inform staff of people’s needs, wishes and preferences.

The provider was required to meet the regulations relating to sufficient staffing by 31 January 2015. We reviewed staff rosters in February 2015 which indicated that this regulation had been met. The provider told us they would meet requirements relating to all the breaches by 31 March 2015.

This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Belamie Gables Care Home’ on our website at ‘www.cqc.org.uk’.

Belamie Gables Care Home provides residential care for up to 20 older people without nursing needs, but with other care needs, including dementia care. At the time of our inspection 11 people were living in the home.

Since our inspection in November 2014, the person managing the service had completed their application and was now the home’s 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 and associated Regulations about how the service is run.

At our focused inspection on the 13 May 2015, we found that the provider had taken action to ensure the requirements of the Regulations had been met.

Staff understood people’s care needs, and took appropriate actions to ensure they were supported safely. People and their relatives said staff were prompt to support them, although they would enjoy staff having more time to sit and chat with them.

Improvements had been made to ensure sufficient staff were employed and deployed on a daily basis to meet people’s care needs. The registered manager still regularly worked as part of the care worker team, and the provider had supported people with their care needs to cover short notice unplanned absence. This continued to impact on the amount of time available for the registered manager to implement and drive changes to improve the quality of people’s care. However, this did not impact on the ability of staff to meet people’s personal care needs.

The provider had taken action to ensure that staff understood and followed the provider’s policies and procedures, including reporting safeguarding concerns. Notifications had been submitted appropriately to the local authority and CQC in response to safeguarding incidents.

Staff training had been refreshed and staff had the skills and knowledge to meet people’s diverse needs, including dementia care and managing behaviours that challenge staff. Staff told us additional training had given them the confidence and understanding to support people safely. They took effective action to reduce people’s restlessness and manage their anxieties.

Improvements had been made to the way records were kept and information was being used to inform and reflect people’s care. People or those lawfully able to represent them had signed consent to their planned care. Confidential records were kept securely to maintain people’s privacy. People’s care plans had been reviewed and updated to reflect their preferences, wishes and interests. This information was used to guide activities provided in the home, and to distract and reassure people when they were anxious. There was evidence that some activities had been increased in response to people’s preferences, such as more regular church services. The provider had reviewed people’s engagement in activities and used this information to influence the activities provided, although this had not been formally recorded.

Further improvements were required to embed effective communication methods between staff and the provider. Care workers were not always sure who to report concerns or issues to, as the roles and responsibilities of the registered manager and provider were not clearly defined.

Concerns had been raised to the local authority and CQC regarding the level of cleanliness in the home. Although the cleaner was on leave, the provider had taken appropriate steps to ensure the home remained clean. The home was clean and odour free on the day of our inspection.

The provider had taken sufficient action to meet the requirements of the warning notices and compliance actions in relation to safeguarding people, supporting staff, maintaining accurate records, and storing these securely.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We carried out this inspection on 7 November 2014. It was unannounced, which meant that people, staff and the provider were not aware we would be visiting.

Belamie Gables Care Home provides residential care for up to 20 older people without nursing needs, but with other care needs, including dementia care. At the time of our inspection 15 people were living in the home. The house consisted of two floors, with bedrooms and bathrooms on each floor, and a communal lounge on the ground floor. Stairs and a lift provided access between floors. People had access to a fenced garden. The front door was secured, and exits were alarmed, to alert staff should people leave the home when they were not aware of dangers that could affect their safety.

A registered manager was not in post at the time of our inspection, but the person acting as manager had submitted an application to take up this 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.

At our previous inspection on 29 May 2014 the provider was not meeting the requirements of the law in relation to consent to care and treatment, the care and welfare of people, safeguarding people from abuse, and assessing and monitoring the quality of the service. Following the inspection the provider sent us an action plan stating they would make the required improvements by 31 July 2014. During this inspection we checked to see if these improvements had been made. We found that they had for some of the concerns identified, but not for all of them.

There were not sufficient staff to meet people’s identified care needs at all times. One person requiring one to one support did not always receive this. Another person’s behaviour was not effectively managed to meet their needs, or to reduce the impact of this on others.

People were supported by care staff who had completed required training to meet their basic care needs, such as mobilising safely. However, staff told us they did not always feel sufficiently skilled or confident to meet people’s dementia care needs, and that not all training was effectively delivered to meet their learning needs.

People told us they felt safe with staff. Staff understood the signs of abuse, and the processes to notify and address incidents. However, we noted that one incident had not been identified as a risk of abuse, and therefore had not been notified to the safeguarding authority or the Care Quality Commission (CQC) as required until we requested that they do so.

Records did not always document people’s current needs, preferences or wishes. They did not always document how people had been involved in or consented to their plan of care. Complaints records were not always kept confidentially.

People were supported by caring and kind staff. We observed staff engaging with people respectfully, providing reassurance and comfort when people were anxious. A range of activities were provided throughout the day, and people were encouraged and thanked for joining in meaningful activities, such as preparing tables for meals. Mealtimes were a social occasion, and staff ensured people’s preferences and needs were met in the range of meal choice provided.

Risks affecting people’s safety had been identified, and actions taken to reduce the risk of harm. As people’s care needs changed, care plans and risk assessments were reviewed to ensure people’s needs were met. Medicines were stored and disposed of safely. Staff had been trained and assessed to administer medicines safely.

People’s comments were welcomed through surveys, residents meetings and direct conversation with the manager and provider. Relatives stated complaints had been satisfactorily resolved when raised. The office was open for people and relatives to meet with the provider and manager throughout the day if they wished.

Staff had opportunities to raise issues and request support through staff meetings and individual supervisory meetings. Action plans demonstrated progression to address issues identified through the manager’s reviews of care and safety. Although most of the staff spoke positively about the manager, the manager’s ability to develop and improve the home was limited by the amount of time they spent providing personal care to people, due to staff absence.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

The inspection was carried out by one Care Quality Commission (CQC) adult social care inspector. On the day of our inspection 13 people used the service. Because people nearly all lived with dementia to some degree we were not able to speak with them, but we did speak with three people’s relatives.

We spoke with seven care workers and one member of the housekeeping staff. In addition we spoke with the two co-owners, who are referred to in this report as ‘the provider’. At the time of this inspection the registered manager was in the process of de-registering having left the service in March 2014. They had not been replaced.

We observed how staff supported people, and looked at documents including care plans and management reports.

We considered information from a number of sources to decide on the focus of the inspection. All of the evidence we had gathered under the outcomes we inspected was used 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 caring?

Overall the service was not caring. Staff appeared caring and their interactions with people we saw during the inspection were generally positive. However, relatives reported difficulty in obtaining up to date information on their loved ones care and well-being. The absence of a key worker for people was identified as a problem.

One told us that when their relative was taken into hospital from the service, “I had to provide the hospital staff with my relative’s medical history and details of their medication. This was because the staff on duty at Belamie Gables said they didn’t know where to find the information”.

We noted that in two of the four care plans we had reviewed that ‘essential information’ including next of kin details had not been recorded. We noted that the emergency contact information in the four care plans we reviewed was out of date.

All three of the relatives we spoke with expressed concern about the lack of stimulation provided by the service in the form of activities and opportunities to access the community.

Is the service responsive?

The service did not respond promptly to feedback from staff or relatives and we found that at times this impacted adversely on people’s care and well-being. Staff provided several examples of matters affecting the comfort and dignity of people and staff where the provider had been slow to respond. One matter concerned a shortage of continence pads where we considered that the provider’s response was not only delayed but initially inappropriate which resulted in people not receiving the aids they need to support their continence.

The provider’s complaints policy provided a formal opportunity for people to raise concerns. However, we found that staff had taken to using the service complaints book inappropriately as a means of recording issues they had raised with the provider in an attempt to stimulate a response.

We found that the service’s care plan review practices did not generally involve people or their relatives. As people’s needs changed we saw that care plans were not always updated to reflect the changes in the care they required. For example, to support people with reduced mobility or to address nutritional concerns. Staff expressed concern in one case that management had failed to respond to deterioration in the health of a person whose care had apparently not been reviewed for three months.

Is the service safe?

The service is not safe at this time. Although, we saw that in general, people who use the service were relaxed, and appeared to enjoy the company of staff. This indicated to us that people felt safe with staff.

Recruitment procedures were effective and this meant that the provider had opportunities to make informed decisions about the suitability of applicants to work in the service.

An overview of staff training was not available so it was not possible to confidently state that staff had been trained to care for and support people safely, or that training considered mandatory by the provider had been refreshed appropriately.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes such as Belamie Gables. The provider appeared unclear on the appropriate actions to complete to assess the need to apply for a Deprivation of Liberty authorisation. During the inspection we became aware of one occasion when the correct procedure had not been followed.

Risks were not always identified, and on at least one occasion a person’s safety was compromised by the absence of plans to reduce the risk of harm to people and others who use the service.

Is the service effective?

The service is not considered to be effective at this time. The service has not recently sought feedback from people or their relatives on the quality of the facilities and services in order to help monitor its effectiveness. Although a recent staff meeting and the complaints and comments book had provided opportunities for raising concerns.

Although care plans detailed people’s care needs and wishes, there was no effective review process in place to ensure that changes in people’s care needs were identified and responded to appropriately.

We found a general lack of systems to monitor care standards and performance and the provider has allowed existing systems to fall into disuse. Staff were unsure about the threshold for recording accidents and incidents in the service and whose responsibility this was. This meant that incidents which should be reported to the local authority for consideration under their safeguarding guidance had not been.

Is the service well led?

The service was not well led. We noted that the previous registered manager had left the service in March 2014. It appeared that no effective handover of their responsibilities had occurred because a number of systems designed to monitor the quality of care had either lapsed or been discontinued. This included, staff supervision, the monitoring and scheduling of staff training and the monthly auditing of the service.

We noted that staff and relatives appeared unclear on lines of reporting since the departure of the registered manager. In particular, uncertainty was expressed regarding the role of one of the owners who had been appointed to manage administration matters but who had later assumed duty manager responsibilities including providing ‘on call’ support to staff. Staff expressed concern that this owner repeatedly consulted their co-owner when issues were raised.

The provider was unable to produce some key policies and procedures at the time of the inspection and displayed knowledge gaps relating to the implementation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.