We undertook an unannounced inspection of Buxton House on 21 November 2017. When the service was last inspected in June 2016 no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, at the last inspection we found that improvements could be made in relation to risk management, the submission of Deprivation of Liberty (DoLS) applications and the overall quality monitoring and governance. During this inspection we found that improvements had been made.

Buxton House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is able to accommodate up to 64 people. At the time of the inspection there were 64 people living at the service.

There was a registered manager in post at the time of this 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.

People at the service told us they felt safe and that staff supported them well. People’s relatives also spoke positively. There were systems in operation to ensure that safeguarding concerns were identified and responded to timely. People’s risks were assessed and managed safely, and where risk management plans were in place we saw evidence this had been done in the least restrictive way. There was learning from adverse incidents such as accidents and falls. The premises and equipment was maintained to ensure it was safe. We received some mixed feedback on staffing and have made a recommendation on increasing the frequency of reviewing the staffing dependency tool. Recruitment was safe and people received their medicines when they needed them from competent staff. The service was clean.

People’s physical, mental and social needs were assessed. Nationally recognised tools for the identification of skin damage or weight change were used to achieve positive outcomes. People said they received effective care from staff. Staff had received appropriate training to meet the needs of the people they supported. New staff received an induction aligned with national accreditation and there was an ongoing programme of supervision and appraisal. People received support to eat and drink sufficient amounts.

Staff worked together to communicate people’s needs and people were supported moving between services. No concerns were raised by people or their relatives in relation the adaptation or design of the service. Staff understood their obligations under the Mental Capacity Act 2005 and we saw capacity assessments and best interest meetings had been completed where required. The service had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005.

People told us staff were caring and supported them in a kind and compassionate way. We made observations to support this. People’s relatives were mostly positive about the care provided in the service and were complimentary about staff. We reviewed a selection of compliment cards sent to the service that reflected the verbal feedback we received. Staff understood the needs of the people they supported and recognised the importance of using people’s care records to understand their care needs. People told us that staff treated them with dignity and r

The inspection took place on the 9 and 10 June 2016.

Buxton House is registered to provide accommodation and personal care for up to 64 people in a residential area of Weymouth. At the time of our inspection there were 60 older people living in the purpose built home that was comprised of four separate units over two floors. The first floor of the building was designated for the care of people living with dementia and at the time of our inspection 28 people were living there.

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 home was last inspected in August and September 2015 and found to be in breach of regulations relating to: the deployment and support of staff; safeguarding; how people were treated with dignity and inspect; person centred care; quality assurance and safe care and treatment including concerns about the safe administration of medicines. The provider told us they would make improvements and at this inspection we found that improvements had been made; people were receiving better quality care and staff felt supported.

We also found some areas where further improvement was necessary. We discussed these with the registered manager and senior managers and they described the plans they had in place to address these issues or took immediate responsive action.

The registered manager had not made appropriate checks on the agency staff who worked in the home. We highlighted this and the checks were put in place during the course of our inspection.

Audits whilst largely effective had missed some areas identified by inspectors. The registered manager and senior managers told us they would consider the scope of the audits to address this.

Staff used their knowledge of people’s preferences and communication skills to develop caring relationships with people. They also sometimes audibly discussed care tasks with reference to people in communal areas which did not promote dignity and respect. The registered manager described work that was being done to promote dignity and respect.

Deprivation of Liberty Safeguards (DoLS) had not been applied for when people needed their liberty to be restricted for them to live safely in the home. This had been due to recent changes in personnel in the home and was addressed immediately.

People felt safe but some people’s risks were not reduced effectively because their care plans were not followed or records were not kept to review how these plans were working. However, most people were supported in ways that reduced the risks they faced because staff who understood these risks and the care the person needed to reduce them. This was an area for improvement and the registered manager and senior managers described the measures in place to ensure these plans were monitored and reviewed effectively.

Staff understood how people consented to the care they provided and encouraged people to make decisions about their lives. They understood the principles of the Mental Capacity Act 2005 and described how they applied them in their work.

People had support and care when they needed it from staff who had been safely recruited. These staff understood people’s care needs and spoke confidently about the support people needed to meet those needs. They told us they felt supported in their roles and had undertaken training that provided them with the necessary knowledge and skills. There was a plan in place to ensure staff received the training they needed to stay up to date with the care needs of people living in the home.

People were at a reduced risk of harm because staff knew how to identify and respond to abuse. Information

During our inspection we saw people’s individual needs and risks were assessed. People and their relatives told us that their needs were met, and spoke positively about the staff within the home. One person told us “I get really well looked after here”. One person’s relative told up “All of my Mum’s needs are met, everything is wonderful here.”

Medicines were appropriately stored, however the recording of some medicines administered was not specific regarding the dose given. We saw that the opening dates on some liquid medicines and inhalers had not been recorded by staff as required.

The home had systems to monitor the quality of service provided. However, the absence of the regular auditing of medication and care plan documentation had not ensured that certain documentation had been completed accurately by staff.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time. There was no registered manager in post at Buxton House at the time of our inspection.

We used the SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences were. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. This includes looking at the support that is given to them by the staff.

We spoke with five people about the care they received at the home. They told us that they felt safe at the home. They told us that staff respected their dignity and gave them choices about want they wanted to do. The people living at the home and people important to them told us there was enough staff to meet people's needs.

We observed that people were given time to complete tasks at their own pace for example to eat their meals in a unhurried manner. We observed staff interacting with people in a professional and empathic manner.

The management at the home told us about what they had improved by way of audits and assessments and the plans they had in place to ensure that the home complies with the national minimum standards.

We used the SOFI2 (Short Observational Framework for Inspection) tool to help us see what people’s experiences were. The SOFI2 tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. This includes looking at the support that is given to them by the staff.

People told us that staff ensured their privacy was maintained during personal care. One person told us that staff always knocked before entering their room. They also told us that staff support them with the things they find hard to do for themselves. We observed staff assisting people when they could and found that the interactions were empathetic and caring.

People who could tell us their views told us they felt safe at the home. We spoke to staff one told us of their safeguarding concern. We found that the home had not followed its own safeguarding procedures and had not reported these concerns to the local authority.

The people living at the home and people important to them told us there was not enough staff to meet people's needs. We observed a person waiting for up to 25 minutes to get assistance with their personal care needs.

We looked at care records and found that these were either incomplete or not up to date. The staff told us they did not have time to complete them. People were put at risk of unsafe or inappropriate care as the records did not inform staff how people’s needs should be met.

People told us that staff are supportive and kind and spend time listening to them.

People also told us that sometimes in their opinion there are not enough staff to support them in the way they want at certain times of the day and they have to wait.

This unannounced inspection took place on 18, 25, 28  August 2015 and 03 September 2015. The home is a residential care home and provides support, assistance and personal care for up to 64 older people, including people who have dementia. At the time of our inspection there were 61 people using the service. The home is purpose-built and comprised of four units spread out over two floors, a ground floor and a first floor, accessed by stairs and a lift. The first floor was designated for the care of people with dementia. There was an outdoor garden space and a court yard for people to use.

The home was last inspected on the 13 May 2013 and found not to be meeting the standards in the management of medicines and assessing and monitoring the quality of the service. People were not protected against the risks associated with medicines and care plan audits had not identified inaccurate information. A medication audit did not identify medication recording and procedural errors.

There was a registered manager who had recently started work at the service from 30 June 2015. The registered manager had begun to identify some areas for improvement and development at the home, including changes to shift patterns and shift handover sessions. 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.

There was not enough suitable staff to keep people safe and meet their needs. People were not receiving the care they needed because staff had left or were absent due to sickness or holiday and new staff had not been replaced in sufficient time. People and their relatives told us that staffing levels were not consistently sufficient to keep people safe or meet their needs.

People were not protected from abuse because two staff did not recognise the signs of abuse and were unaware of the risks that some people’s behaviour presented. People were at risk from physical and psychological harm from each other yet two staff accepted that this was usual behaviour.

There were inconsistencies in how risks to individuals were assessed and care plans did not always reflect people’s current care and support needs. Risks relating to falls and poor balance had not been updated following changes to their needs.

Plans were discussed with staff, actions taken and changes were made in response to recent emergencies so that learning from these events improved safety.

Medicines were not being managed safely. Medicine charts for 12 people were found to have gaps, making it difficult to tell whether people had received their prescribed medicines on time.

In June 2015 a fire inspection by the fire service found that certain fire equipment and system checks had not taken place and fire drills and staff training was not adequate. However since the fire inspection findings, action was taken to resolve and address this.

People were cared for by staff that did not have up to date plans to develop their knowledge and skills. There were inconsistencies in staff’s experience of recruitment, training, supervision and support. Staff reported mixed experiences which meant that some staff received regular support and training while others did not.

People told us that the food was ‘excellent’. There was variety and choice of meals including fruit, nutritional snacks and refreshments throughout the day.

People were given support to maintain their health through regular contact with health professionals including dentists, occupational therapists and GPs.

Where people lacked mental capacity to make decisions for themselves they were assessed and staff were made aware of how to support people with their decisions. Staff explained that some people had best interest decisions made to help keep them safe.

On several occasions we saw staff from one unit carry out care that did not respect privacy or reflect dignity when supporting people with their meal and when checking someone’s skin. Staff comforted people when they were distressed. They asked people questions to clarify and understand their concerns and promote their well-being

People and their relatives told us staff respected them, acknowledged their choices and called them by their preferred name.

Some people did not receive individual care and support in a personalised way to meet their needs. Arrangements to regularly assess, record and review people’s care needs did not always take place. Care needs were not always reviewed and managed in a practical way to reflect changes.

Equipment and resources were made available to help people retain their independence. These included rim edged bowls and plate guards to help people manage their food and hand rails to support people when they moved about the home.

Written complaints had been investigated, explored and responded to, although some people and relatives told us that while their verbal concerns were acknowledged, these were not always fully addressed and resolved. Compliment letters sent by friends and relatives about people who had died or moved on expressed positive comments about peoples experiences.

While quality checks were used to measure, monitor and review the delivery of care not all checks identified gaps in care or changes that required redress. Emerging themes from quality checks were not picked up and follow up actions from these checks did not show how some gaps we identified were being addressed.

Care records and other records including staff training plans were not robust and did not sufficiently reflect what was happening on a day to day basis.

Staff told us there had been a lack of clear leadership and management of the home until recently and this had led to confusion about roles and responsibilities and low staff morale. People and their relatives expressed concerns about the changes in management and how this had affected their care.

The recently appointed registered manager was aware of the responsibilities involved in delivering an effective and well-led service and had started to address some of the challenges.

You can see what action we told the provider to take at the back of the full version of the report.