Catherine Miller House is a residential care home for up to 30 older people some of whom may be living with dementia. When we inspected there were 27 people living in the service.

At the last inspection, the service was rated as good overall. However the manager had not registered with us, therefore the well-led question was rated as requires improvement. At this inspection we found that the manager was now registered with us and the service remains good.

People received a safe service and were protected from the risk of harm. Sufficient staff had been safely recruited to ensure that people’s needs were met. Medication management was good and people received their medication as prescribed.

People were cared for by experienced, well trained and supported staff. The service ensured that people had the support they needed to have as much choice and control over their lives as possible. People received sufficient food and drink to meet their needs and preferences and their healthcare needs were met.

Staff knew the people they cared for well and displayed kind, caring and compassionate qualities. People were encouraged and supported to remain as independent as possible. Staff treated people with dignity and respect and maintained their privacy at all times.

People were fully involved in the assessment and care planning process. Their care plans had been reviewed and updated to reflect their changing needs. People were encouraged and supported to take part in a range of activities that suited their individual needs. The service had a pet dog and people enjoyed taking her for a walk in the local park. Complaints and concerns were dealt with appropriately in a timely way.

People were positive about the quality of the service. The registered manager and staff were committed to providing people with good quality person-centred care that met their needs and preferences. There were good systems in place to monitor the quality of the service and to drive improvements. The service met all relevant fundamental standards.

Further information is in the detailed findings below.

The inspection was completed on 11 December 2014 and there were 29 people living at the service when we inspected.

Catherine Miller House provides accommodation and personal care for up to 30 older people.

A manager was in post but they were not registered with the Care Quality Commission. 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 last inspection on 26 August 2014 found that the provider was not meeting requirements in relation to consent to care and treatment, safeguarding, supporting workers and records management. They had also failed to implement a system to effectively monitor the quality of the service. During this inspection we looked to see if these improvements had been made. We found that improvements had been made.

People and their relatives told us the service was a safe place to live. There were sufficient staff available to meet their needs. Appropriate arrangements were in place to recruit staff safely. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure their and others’ safety.

Staff understood the different types of abuse and the relevant safeguarding processes to follow. Risks to people’s health and wellbeing were appropriately assessed, managed and reviewed and improvements had been made to ensure that risk assessments were accurately completed.

Improvements had been made to ensure that the management of medicines within the service was safe. This meant that people received their prescribed medicines as they should and in a safe way.

Staff received opportunities for training and this ensured that staff employed at the service had the right skills to meet people’s needs. Staff were better supported by the introduction of a new senior management team.

The dining experience for people was positive and people were complimentary about the quality of meals provided.

People who used the service and their relatives were involved in making decisions about their care and support. People told us that their healthcare needs were well managed. Care plans accurately reflected people’s care and support needs.

Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests. The manager was up-to-date with recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were being protected.

Staff demonstrated a good understanding and awareness of how to treat people with respect and dignity.

People and their relatives told us that if they had any concerns they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns were listened to, taken seriously and acted upon.

There was an effective system was in place to regularly assess and monitor the quality of the service provided. The manager was able to demonstrate how they measured and analysed the care provided to people, and how this ensured that the service was operating safely and was continually improving to meet people’s needs.

This inspection was conducted by two inspectors. During our inspection we spoke with a total of five of the 28 people who used the service and one relative. We also spoke with the manager, deputy manager, team leader, two members of staff and two healthcare professionals.

We looked at three people’s care records. We also looked at the provider’s arrangements for obtaining, and acting in accordance with, the consent to care and treatment for people who used the service. In addition, we looked at the provider’s arrangements for safeguarding, staffing the service to meet peoples care and support needs, records relating to staff training, supervision and appraisal and; the provider's arrangements to monitor the quality of the service provided.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

Records showed that the manager had not responded appropriately where abuse had been suspected and we had not always been notified of safeguarding concerns raised. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safeguarding people who used the service against the risk of abuse.

We looked at staffing levels at the service. On the day of our inspection we found that there were sufficient staff available to meet people’s care and support needs. Care provided for people who used the service was observed to be undertaken in a timely manner.

CQC monitors the operation of the Deprivation of Liberty Safeguards [DoLS] which apply to care homes. At the time of our inspection no DoLS applications had been submitted or considered, even though there were people who were being deprived of their liberty.

An assessment for those people who lacked the capacity and ability to make some specific day-to-day decisions about their care and support had been completed. However, we found that contradictory information was recorded for one person about their level of capacity and had not been consulted about the use of a sensor mat. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the Mental Capacity Act [MCA] 2005 and DoLS.

We found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to records.

Is the service effective?

The provider and manager were not able to demonstrate that they had an effective system in place to support staff so that they could carry out their roles and responsibilities. This referred specifically to newly employed staff not receiving a comprehensive induction or regular supervision and appraisal. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.

Is the service caring?

People told us that they were happy with the care and support they received. We found that staff relationships with people who used the service were seen to be caring, kind and considerate. Staff we spoke with were able to demonstrate a good understanding and knowledge of people's individual care needs.

People who used the service had a care plan in place detailing their specific care needs and the support to be provided by staff. We found that not all of the information recorded accurately reflected their needs and the care and support to be provided.

Is the service responsive?

An effective system was in place to deal with comments and complaints received from people who used the service, those acting on their behalf and other third parties.

Our observations showed that people who used the service were supported to participate in a range of meaningful daytime activities.

People who used the service were supported to maintain important relationships that mattered to them.

Is the service well-led?

The provider and manager were not able to demonstrate that there were suitable arrangements in place to assess and monitor the quality of the service provided. Our findings showed that lessons had not been learned from previous inspections and a proactive approach had not been taken to drive and maintain improvement. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

As part of our inspection, we spoke with four of the 24 people who used the service. We also spoke with three staff members, the apprentice, an agency member of staff and the manager. We looked at four people's care records. We also looked at the provider's arrangements for obtaining, and acting in accordance with, the consent to care and treatment for people who used the service. In addition we looked at medication practices and procedures, the provider's arrangements to safeguard people from abuse, staff recruitment procedures, staffing levels and; the provider's arrangements to monitor the quality of the service provided.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a member of staff checked our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service. They also told us that they would feel able to speak up if they had concerns or worries and felt that they would be listened to.

Since our last inspection to the service in November 2013, we found that there had been two safeguarding concerns. Records showed that the outcome of one safeguarding concern was unsubstantiated and the outcome of the other safeguarding concern was substantiated. We saw that the majority of staff had received training in safeguarding of vulnerable adults from abuse. This meant that staff were provided with the information that they needed to ensure that people were safeguarded. Records showed that the manager had not responded appropriately where abuse had been suspected. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safeguarding people who used the service against the risk of abuse.

We found that people who used the service were protected against the risks associated with the unsafe use and management of medicines.

The provider was able to demonstrate that they had an effective recruitment procedure in place.

We looked at staffing levels at the service. This showed that staffing levels told to us by the manager had not always been maintained. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to there being sufficient numbers of staff at the service.

Is the service effective?

Our observations and discussions with the manager demonstrated that people who used the service received regular support and access from a variety of health and social care services and professionals as their conditions and circumstances required.

Records showed that not all staff had received Mental Capacity Act [MCA] 2005 and Deprivation of Liberty Safeguards [DoLS] training. Not all staff spoken with were able to demonstrate a good understanding and awareness of MCA and DoLS. We found that although people who used the service had had their capacity to make day-to-day decisions formally assessed, improvements were required to ensure that documentation was robust. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to having suitable arrangements in place for the consent to care and treatment and; in line with the Mental Capacity Act 2005.

Suitable arrangements were not in place to ensure that staff who worked at the service received specialist training for the needs of older people, supervision and appraisal. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to having suitable arrangements in place for staff employed to receive appropriate training, supervision and appraisal.

Is the service caring?

People told us that they received the care they needed. People living in the service told us that they were happy living there. Our observations showed that care and support was provided in a timely manner.

People who used the service had a care plan in place which detailed their specific care needs and the support to be provided by staff.

Is the service responsive?

People's preferences and diverse needs had been recorded in accordance with people's wishes.

Our observations during the inspection showed that visiting times were flexible.

Is the service well-led?

The provider was able to demonstrate that some systems were in place to assess and monitor the quality of the service provided. The views of the people who used the service and staff had been sought. People's views about the service were noted to be positive. However, whilst the provider did have some systems in place to monitor the quality of the service provided, it was apparent from our inspection that the absence of robust quality monitoring maybe a contributory factor to the failure of the provider to identify non-compliance or any risk of non-compliance sooner.

As part of this inspection process we spoke with the manager, two members of staff, three people who used the service and two visitors.

Our observations showed that people living at the service were happy, that they felt safe and were well cared for. It was evident that people who used the service had a good relationship and rapport with the staff who supported them. Comments included, "The staff are very nice", "It's very nice here" and, "I'm alright." We spoke with two relatives and they confirmed that they were very happy with the care and support provided for their member of family and/or friend.

People's health and personal care needs were assessed and there were care plans in place for care staff to follow so as to ensure that people were supported safely and in accordance with people's individual preferences and wishes. Staff spoken with demonstrated a good understanding of people's health and personal care needs and how each person wished to be supported.

The provider was able to demonstrate that improvements had been made with regards to previous identified shortfalls. We found that people were protected against the risks associated with medicines because the provider had improved arrangements in place to manage medicines. We also found that people were protected from the risks of inadequate nutrition and dehydration. There were enough staff to meet people's needs.

At the time of our inspection the provider did not have a registered manager in post.

Our observations showed that improvements were being made by the manager and management team of the service to address previous identified shortfalls. However there was an acknoweldgement by the manager that improvements relating to staff attitudes and institutional care practices were proving difficult and challenging to change; and that these would take time to achieve compliance.

People who use the service told us that they liked living at Catherine Miller House and found the staff to be kind and caring. Staff spoken with told us that they found the manager to be understanding, approachable and "hands on". Staff told us that they could see the improvements at the service.

Each person was noted to have a care plan detailing their care and support needs. Staff interactions with people who use the service were much improved and improvements were noted in relation to changing the focus from a 'service led' to 'person led' service at Catherine Miller House. Mandatory and specilaist training had been provided for staff and the majority of staff had received at least one formal supervision. We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording of medicines. In addition there was insufficient guidance for staff on the use of some medicines.

People who use the service were supported and protected by the service's robust recruitment practices. People spoken with told us that they liked living at Catherine Miller House.

We directly observed care within the service so as to help us determine what it was like for people living at Catherine Miller House. We found that where staff interactions took place with people who live at the home these were not always positive. The majority of interactions were seen to be routine, task based, not person led and on some occasions people had their requests dismissed and/or ignored by staff. No opportunities for stimulation through leisure and recreational activities were afforded to people.

We found that improvements were needed to ensure that medicines management were robust and safe. Records showed that not all staff received appropriate training, supervision and appraisal.

It was apparent from our findings at this inspection relating to outcome two (consent to care and treatment), outcome four (care and welfare of people who use services), outcome nine (management of medicines), outcome 14 (supporting workers) and outcome 16 (assessing and monitoring the quality of service provision) that the absence of robust quality monitoring by the provider has been a contributory factor to the failure of the service to identify non-compliance, or any risk of non-compliance sooner.

We spoke with people who use the service but their feedback did not relate to this standard.

People were protected against the risks associated with medicines because the provider had improved arrangements in place to manage medicines.

Where people were unable to provide a verbal response or tell us verbally their experiences, for example as a result of their limited verbal communication or poor cognitive ability, we noted their non verbal cues and these indicated that the majority of people in the home were relaxed and comfortable and found their experience at the home to be positive.

Four people spoken with during our inspection told us that they were happy living at Catherine Miller House and they found the staff to be nice and caring. Positive comments included “Staff are lovely”, “The staff are very nice and they work very hard” and “They do their best.” People told us that they were treated well by care staff and that their privacy and dignity were respected.

One relative told us that they were always kept informed if their relative became unwell and/or required healthcare input. They confirmed that they found staff working at the home to be pleasant and polite.

A satisfaction survey was conducted by the owner in October 2011, so as to seek the views of people who use the service, their relatives, staff and visiting professionals about the quality of the service provided at Catherine Miller House. In general the comments were positive and these included “We can see a great improvement in the home since the new manager has been in place” and “The home is better than it was but still has a lot of room for improvement.”

Where negative comments were made these were of a similar theme and related to staff being slow to answer people’s call bells. Comments included “The home is run well. My only comment is sometimes the response times to residents ringing their alarms can be a little slow”, “There appears to be a long wait for staff to respond to a buzzer” and “My relatives do not get bathed or showered enough after we keep asking for this to be done. There is not enough activities in the home. Some carer’s are very stand offish which make our relatives upset.”

We spoke with four people who live at the home and asked them about their experience at Catherine Miller House. All were complimentary about the care and support provided to them. Comments included “It’s OK here, I have no complaints” and “I like it here at Catherine Miller House, the staff are very nice.”

People told us that the care and support provided was good and that staff were nice. Two visitors told us they were very happy with the level of care and support given to their member of family. One person said of their relative, “The care is excellent and I have no concerns.”

We received varied comments from people who use the service and relatives visiting the home.

Where people were unable to provide a verbal response or tell us verbally of their experiences, for example as a result of limited verbal communication or poor cognitive ability, we noted their non verbal cues and these indicated that people were relaxed and found their experience at Catherine Miller House to be positive.

Two relatives with whom we spoke confirmed they were very happy with their relative’s care and support. One relative told us “staff, are marvellous and very kind”. Another relative stated “staff are excellent, I can’t fault them; they are attentive, caring and nothing is too much trouble”.

One relative confirmed they had not been consulted about their relative’s care plan and had not been asked to contribute information, other than to provide background information relating to their personal history. They also confirmed that they had not seen or been provided with a copy of the service’s Statement of Purpose or Service User’s Guide.

Four people who use the service told us they like living at Catherine Miller House. Comments included “Yes, it’s very nice here”, “Oh I get good care” and “the staff are lovely”.

Three people who use the service told us they found the meals at Catherine Miller House to be of a good quality.

One relative told us that the meals provided for their member of family “are lovely” and appropriate, as their relative finds it difficult to chew and swallow.

One relative told us that the only negative comment they wished to make about the meals provided is that there appears to be a lack of fresh fruit and fresh vegetables made available. One person who uses the service confirmed this and told us they buy their own fruit. This does not concur with the Provider Compliance Assessment (PCA), which is a self assessment document we asked the provider to complete and send to us. This details that people are provided with and encouraged to eat fresh fruit in the afternoon. The owner told us that fresh fruit and vegetables are readily available. Fruit is given to people who use the service in place of the main dessert or during the day as they wish. Fresh vegetables are provided with the main meal and are used to make soup.

Two people who use the service told us they find the home environment to be clean and tidy.

One relative with whom we spoke told us that they believe there to be sufficient staff at the service but feel on occasions that the lunchtime period can be extremely busy and that staff are over stretched.