The inspection took place on 10 October 2018 and was unannounced. At our last inspection on 14 and 15 August 2017 we found breaches of three legal requirements relating to records, hydration and staffing levels. At this inspection we found there were no breaches in legal requirements and there had been improvements across the service to the quality of care and outcomes for people.

Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well-led to at least good. After the last inspection we added a positive condition to the providers registration asking for a monthly report to be sent to us so the service could share with us the improvements they were making and how they were managing risks. The service adhered to this positive condition and sent in reports as required.

Choice Care Home 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 accommodates up to 32 people in one adapted building. At the time of our inspection there were 24 people living in the home. Six of the rooms were allocated for people discharged from hospital who needed recuperation before moving home. The people in these rooms had specialist community health professionals from the integrated care team visiting them as well as care support from staff in the service.

Choice Care Home had 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.

There had been a marked improvement in the way risks were managed for people since our last inspection in August 2017. There was better oversight in ensuring people were hydrated and how this was recorded. The service had implemented a new electronic recording and support planning system which flagged up to care staff when people needed support and recorded when it was given.

People told us they were happy living in the service and staff were kind and caring. Some people said care staff could spend more time with them but we saw that people were having their needs met.

People were kept safe through robust safeguarding processes and staff were aware of what abuse might look like and how to report it. The service had shown how it learned from incidents such as falls and reduced the risk as a result. Risks around health concerns were managed well and health professionals told us they were pleased with the communication in the service.

Care plans were person centred and regularly updated. Care staff knew people’s needs and how they liked their personal care to be provided. People said they enjoyed the food and were offered different meal choices.

Complaints were recorded and fully investigated. People and relatives said they were happy to and knew how to complain. The quality assurance systems were thorough and the registered manager and deputy managers monitored the day to day running of the home.

Medicines were managed safely and staff who administered medicines were trained and competency tested. The home was clean, tidy and pleasantly decorated. Infection control procedures were followed and care staff wore appropriate personal protective clothing such as aprons and gloves where appropriate.

Choice Care Home is a care home without nursing registered to provide accommodation and care for up to 32 people. People living at the service are mostly older people, some of whom may be living with dementia or physical disability. Some people were living at the service for a short period of convalescence and intensive support between a period of ill health and returning home, known as intermediate care. Day to day care needs for these people were provided by the service, with intensive support coming in from community medical teams such as physiotherapists and occupational therapists.

Prior to this inspection we had received some information of concern about the service through recent safeguarding processes. The concerns related to people not receiving sufficient fluids, reports of people with unexplained bruising, concerns about staffing levels and people falling. Two safeguarding processes were ongoing at the time of the inspection.

At the last inspection on 3 July 2015 the service was rated as ‘Good’ with requires improvement in the key question of ‘Safe’. This had been because some information about one incident that occurred at the home had not been shared with the local authority safeguarding team at that time, which meant they had not been subject to external scrutiny and review. At this inspection in August 2017 we found the service had not sustained some areas of good practice. We also identified a number of concerns and breaches of legislation. The service has been rated as requires improvement overall.

The management of the service was reactive in that they had taken action to address concerns once identified by external agencies. However some of this action had not been sustained and had led to repeated poor outcomes for people. Management or governance systems were not always effective in making changes and improvements at the service, or identifying when systems were failing. This told us learning did not always take place and actions taken had not always been effective in reducing risks to people’s safety or poor health outcomes.

Risks to people’s health or well-being, particularly with regard to fluids or pressure ulcers were not always robustly addressed. We identified although risks to people had been identified, actions had not always been consistently taken or recorded. This meant it was not easy to see if actions had been successful in reducing risks or preventing additional risks. Poor recording meant records could not always be relied upon to highlight ongoing concerns. For example we found the systems for analysing risks did not assess the effectiveness of actions taken; fluid charts were not completed well or consistently and where poor fluid intakes were recorded concerns were not always immediately highlighted or actions taken.

There were not always sufficient staff on duty to meet people’s needs. We found there were times of the day when people did not receive sufficient supervision from staff which had left them at risk. We observed instances where people not being supported led to situations where their dignity was not respected. People using the service, visitors and staff told us there were not enough staff at times, particularly during the afternoon and evening.

Infection control practices for staff were effective but the laundry area and management systems needed attention to ensure infections could be managed safely. This was because this area was cluttered and there was limited effective separation between clean and dirty items. However a recent infection risk had been managed well. We have recommended the provider seeks and implements guidance on the provision and maintenance of a clean and low infection risk laundry management system.

Systems were in place for the management of complaints. When we looked at the systems we identified these did not cover all the concerns we were aware had been raised with the service. The registered manager told us they did not record minor concer

This inspection took place on 3 July 2015 and was unannounced.

At the previous inspection of this service on 1 July 2014 we identified concerns in relation to the records and systems for quality assurance at the home. Following the inspection the provider and registered manager sent us an action plan telling us what they were going to do to improve. On this inspection we checked to see that changes had been made. We saw that improvements had been made and sustained in these areas.

Choice is a care home, registered to provide accommodation for up to 24 people needing personal care. The people living at the home are older people, some of whom may be living with dementia.

The home has 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.

The home was not always safe for people. Some information about incidents that occurred at the home had not been shared with the local authority safeguarding team, which meant they had not been subject to external scrutiny and review. This could have left people at risk of abuse.

People were protected from risks associated with the premises and with their care. Systems were in place to analyse falls and other accidents to prevent a re-occurrence. Individual assessments were undertaken of risks to people with regard to choking, falls, poor nutrition, moving and handling and pressure ulcer prevention.

People were protected by the home's systems for the management of medicines. People received the correct medicines at the correct time. Staff had received training to help ensure the systems were safe and regular audits identified any areas for improvement or errors.

People were protected by the home's recruitment processes, and there were enough staff on duty to meet people’s. However, some people felt that there were not always enough staff, as staff were always very busy. Staff told us there were enough staff on days when everything was going smoothly. Staff received the training and support they needed to carry out their role.

People were monitored to ensure they received the food and fluids they needed to maintain their health. They had access to community healthcare services to meet their needs, including access to GPs, district nurses and hospital appointments.

People’s rights were protected and staff understood the Mental Capacity Act 2005, issues of capacity and consent to care. Applications had been made for authorisations under the Deprivation of Liberty Safeguards where this was needed.

Staff understood and were sensitive to people’s needs. They supported people’s well-being and had good supportive relationships with people who lived at the home and their relatives. People’s privacy and dignity were respected, and people had opportunities to be involved in making decisions about their care. People were also consulted about the operation of the home and how improvements could be made.

People spoke highly of the registered manager, who was positive and enthusiastic about the home.

Records and care plans had improved considerably since the last inspection. Each person who lived at the home had a care plan containing detailed guidance for staff on how their care was to be delivered. Improved quality assurance and audit systems were in place and learning took place from incidents to improve safety and quality.

We have made a recommendation in relation to the provision of activities.

We carried out this inspection as a part of our scheduled inspection programme. Choice Care Home (referred to throughout this report as Choice) was purchased by a new provider in March 2014, although it had previously been run under administration. This was the first inspection under the new provider.

The inspection was carried out by an adult social care inspector. During the inspection the inspector looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Choice is a care home without nursing, providing care and support for up to 24 older people, most of whom had some degree of dementia. We spoke with six people who lived at the home about their experiences there. We also spoke with a relative, four members of staff and the Registered Manager. We also reviewed records relating to the management of the home which included six care plans and observed the care and support people received in periods throughout the day.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

We saw staff engaging with people in positive ways. For example we saw one person had been given a cup of tea but they had fallen asleep and it had gone cold. We saw a staff member approach the person and gently touch their arm to wake them. They said “Your tea has gone cold – I’ll get you a hot one”.

One person we spoke with told us “The best thing about here is that we matter to them as people. They really care about us. Look at all the work they have carried out to make us comfortable.” Another person said “They’ve been as good as gold- when you don’t feel well it is so lovely to have them look after me”.

We saw staff working with people in a caring manner. As an example, we saw staff supporting a person with hoisting equipment. We saw they were competent and confident with the transfer. We saw that the person was consulted and informed about every action they were taking. This helped reassure the person during the activity. When the task was finished the staff members checked the person was comfortable and got them a cup of tea and something to eat. We saw the person was left smiling and enjoying some toast. This showed us that staff cared about the wellbeing of the person they were caring for.

Is the service responsive?

We saw the home was responding to changes in people's needs. We saw staff identifying and addressing people’s needs in a timely way. We saw people were given additional cold drinks for example as it was a hot day. People who went outside to sit had sunhats provided. This told us staff kept people’s needs under review.

We saw that the home responded well to changes in people’s needs. For example we saw evidence that the home responded quickly to seek medical or paramedic advice following falls or injuries to people. We saw that following two recent falls a person had been referred to the specialist falls team for a specialist assessment.

We saw that the provider had taken steps to gather the views of and consult with people about changes taking place at the home. We saw that concerns or complaints raised were investigated and addressed.

We saw that since our last inspection, under the previous provider, significant work had been undertaken both internally and externally. A shaft lift had been provided to help people access the first floor. We saw that an attractive and secure garden had been provided where people could spend time safely but independently of staff. A member of staff we spoke with about the changes said “I really think that they have done us proud.”

Is the service safe?

We found the provider had undertaken work to improve safety for people at the home.

We saw that the home had clear information available to support people’s healthcare needs. For example we saw staff at the home administered insulin to a person under the delegated authority of the district nurses. We saw the person’s condition was monitored regularly by the nurses who had trained three named staff to carry out the administration. We saw staff had clear protocols in place to manage changes to the person’s blood sugar levels. This told us safe practice was implemented.

However we also identified concerns about the records kept at the home. We saw that these were not always maintained in enough detail to enable staff to care for people consistently or safely.

We saw that there were enough staff on duty with the right level of skills needed. However we did not identify the staffing levels had been decided upon as the result of a formal assessment of skills or dependency level of the people who lived at the home.

We saw there were risk assessments undertaken of the environment, people’s needs and safe working practices. For example we saw there were nutritional risk assessments for people who lived at the home and pregnancy risk assessments had been undertaken for staff who were pregnant. However, we found some audits had lapsed and new quality assurance systems had not yet been implemented. This could leave people at risk if potential areas of risk had not been identified, for example infection control risks.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and report on our findings. No-one at the home was subject to an authorisation by the Court of Protection at the time of the inspection. The provider was however discussing the people at the home with the local authority and community psychiatric team to assess and prioritise applications due to a recent clarification of the law in this area. This told us that the provider understood the actions they needed to take to ensure that people’s rights were protected and that where people were being deprived of their liberty this was in accordance with legislation.

We identified that although the home was clean and substantially odour free, the laundry area was cluttered and therefore not easily cleanable. This could leave people at risk of potential cross infection.

Is the service effective?

Information was used and communicated effectively by staff. We saw staff taking part in a handover of information between shifts. Each person was discussed, along with any particular needs that had been identified and any changes to their care plans. For example staff discussed one person who was going to attend a family party and what they needed to pack to take with them that day. This showed us that staff were organised and tasks were delegated to meet people’s needs in a timely way.

People we spoke with told us their needs were met. We saw that staff knew people well and that people received their care in a timely way. We saw that staff were observant of people’s needs and intercepted requests. One person we spoke with told us “Of course we could do with more staff as they are so very busy. But we don’t go without and they always have a cheerful face for us even if they are busy”.

Is the service well led?

People who lived at the home told us the manager and staff were “Wonderful”. Staff we spoke with were clear about their roles and lines of authority at the home. They told us “I get a lot of support from the manager and deputy. I can go to them at any time for advice. There is a good atmosphere – all the relatives remark on it – and we all work really well together.”

We saw that the new provider had still to implement the major part of their quality assurance system and ensure effective governance of their policies and procedures since the change of ownership. This meant staff might not have access to policies that resulted from clearly understood or authorised management systems.