Chrissian Residential Home Limited 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 provides residential care in one adapted building for up to 22 older people, some of whom are living with dementia. There were 19 people living in the service when we inspected on 9 and 12 February 2018. This was an unannounced comprehensive inspection.

We last inspected this service on 9 January 2017 and rated the service as required improvement. During that inspection we found that the care plans did not always reflect people's current needs or risks associated with their care. This meant there was an increased risk of people receiving the wrong care or staff not taking correct actions to ensure people's needs were met.

This was a breach of Regulation 9 Person centred care, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found that the service was not adequately protecting people from risk associated with their care because records did not show adequate assessment, planning and evaluation of risk or actions staff should take to keep people safe. This was a breach of Regulation 12 Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe and Responsive to at least good.

During this inspection on 9 and 12 February 2018, we found that improvements had been made to meet the requirements to help ensure that people received a safe and responsive service.

Chrissian Residential Home Limited 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 people who lived in the service told us that they felt safe and well cared for. There were systems in place that provided guidance for staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe.

There were processes in place to ensure the safety of the people who used the service. These included risk assessments, which identified how risks to people were minimised. Some radiator covers had been removed in preparation of them being updated. However, this left people at risk of being burnt, as they were very hot to touch. The manager immediately arranged to get the radiator covers replaced and took action, after developing risk assessments, to keep people safe.

There were sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support safely, following best practice guidelines.

Both the manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The manager knew how to make a referral if required. 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 support this practice.

People were supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services.

There were arrangements in place to make sure the service was kept clean and hygienic. On our first day’s visit we found some minor examples of poor cleaning practices, but on

The inspection took place on the 9 January 2017 and was unannounced. The last inspection to this service was on the 22 February 2016 and was a responsive inspection as a result of information received from a whistle blower. During the responsive inspection in February 2016, we only looked at two lines of enquiry. Those being Safe and Well-led and found both areas required improvement. Prior to this the service had been rated as good overall in October 2015. At the time of our responsive inspection there was an acting manager in post. They have subsequently left before they could become registered with the CQC. At the time of our latest inspection there was an acting manager who has yet to be registered with the Care Quality Commission but they told us they have put in their application and were just waiting for it to be processed.

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 service can accommodate up to 22 people at any one time and provides residential care to older people. At the time of our inspection there were 21 people living at the service. .

At this inspection we found the new manager who was already familiar with the service was engaging well with people using the service and with staff. They had developed an action plan identifying what they needed to do in order to comply with the relevant standards. They told us that when they took over the management of the service, they had identified gaps and had not felt things were sufficiently robust. They were working towards bridging the gaps and ensuring records were up to date. Immediately following our inspection they sent us an action plan telling us how they would address the issues we raised which gave us some confidence in the ongoing management of the service.

We observed a caring, happy home in which staff appeared to get on well and were attentive to people’s needs. The home was relaxed and people were sufficiently engaged. The home was comfortably furnished and we found the home to be clean and smelling fresh. Prior to the inspection, we had concerns raised with us about poor infection control practices of staff. In addition we had identified some poor infection control practices at the last inspection but did not have any concerns at this inspection.

Staffing levels were adequate and people’s needs were reviewed to help establish if current staffing levels were adequate. However dependency assessment tools did not always identify changes in people’s needs. During the day there were catering staff employed to assist with breakfast and main meal at lunch time but in the evening care staff were expected to serve tea some of which might have been prepared earlier. This meant there was a reduction of staff at certain times of the day and this was likely to have an impact on the care and supervision provided. .

Risks to people’s safety were not always effectively managed. This is because we saw a number of incidents had occurred at the service and actions taken were not sufficiently robust and did not help ensure that an incident did not reoccur. For example falls risks assessments did not clearly show what actions had been considered and put in place before and, or following a fall. Records were not collated effectively and we found information difficult to follow in terms of actions.

We also found poor recording in relation to allegations of poor care which had not been referred to the safeguarding team and had not been fully investigated to show the outcomes and impact on people.

Medicines were managed effectively and people received their medicines as intended.

Staff received training and support for their role. Supervisions were being updated to ensure

The home is registered to provide residential and person care support for up to 22 people. On the day of our inspection the service was full.

There is a registered manager at the service but they have been on extended leave for about six months and no longer employed by the provider.

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.

During our inspection we were informed that the registered manager had put in their notice and the provider had recently appointed a new manager who had been in post for about three weeks. The provider was providing day to day management of the service. There were a number of senior staff, one allocated on each shift. Staffing on the day of our inspection appeared adequate but there were limited activities provided for people.

The provider did not have a dependency tool in use to determine how many staff they needed on each shift to ensure people’s needs were accurately met. However, through our observations staff worked well together and people’s physical care needs were met.

We did a detailed medication audit and looked at practices within the home. We were satisfied that there were adequate systems in place to ensure people received their medicines safely by staff who were trained to give medicines. However, we did identify a number of concerns which had not been identified by the providers own internal audits. These gave us concern that staff were not always following procedures and missed or changed medicines were not sufficiently recorded/reported which could put people at risk of not receiving their medicines as prescribed.

There were poor records and poor practices around staff recruitment which could and had resulted in staff appointments which were unsuccessful. This put people at risk of staff employed where the provider had not carried appropriate checks to ensure they were of good character.

Risks to people’s safety particularly in relation to falls and hydration/nutrition were documented and included actions staff should take to reduce the risks an ensure people’s needs were being met.

We identified some poor staff practice in relation to infection control which meant people were not adequately protected from the risk of cross infection.

Recent changes in the management of the service meant there were some gaps in service provision which had not been identified by the Director including some poor medication practices, poor recruitment practices and poor auditing of risks affecting people who use the service. We acknowledged that the provider had acted quickly to appoint a suitable manager and to address the concerns we had identified but this service has been in and out of compliance several times in the last couple of years which suggest the quality assurance management systems are not sufficiently robust.

We inspected this service on the 28 October 22015 and it was unannounced. The service was last inspected on the 12 June 2014 to follow up concerns identified at an earlier inspection on the 9 April 2014. Therefore not all the standards were looked at just the areas of concern and the service was compliant.

The home provides accommodation for up to 22 older people who may or may not have dementia.

There is 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 registered manager has been on extended leave and the home was being managed by an assistant manager, deputy manager and the provider. There had been a number of changes to the staffing team with a number of new appointments. Staff said there were enough staff but we observed staff to be busy through-out the morning and felt that people did not always receive enough mental stimulation. The staff were kind and caring and knew people well.

Medicines were given to people safely by staff who were trained to do so. Staff were appropriately supported through an induction and received on- going support, supervision and on the job training to help them develop the skills needed for their roles. Not all staff had received training around people’s specific health care needs/conditions such as dementia which might have helped staff support people more appropriately particularly where people were anxious. Care plans were centred on people’s needs and gave a good insight into people’s needs. Their needs were kept under review and we could see when someone’s needs had changed and the impact that had. However some people did not have life stories and there was a poor analysis of distressed reactions and how staff should support a person before they were acutely distressed.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider, manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The provider and staff understood the necessary legislation and worked within the legal framework.

Staff understood how to keep people safe and risks to people’s safety were documented. We saw staff encouraging people’s independence whilst being mindful of unnecessary risks.

People were supported with their nutritional needs and could make day to day choices. The home was a small homely environment where families were welcome and people had freedom in accordance to their wishes and abilities.

The provider consulted with people and was seen to have a good relationship. They carried out audits to identify where the service required improvement. They were responsive to people’s concerns but these were not formally recorded so we could not see recorded actions taken. We also found it difficult to see if all the records in relation to the running of the business and maintenance were up to date and records were not easily produced.    

We carried out this inspection to follow up on non-compliance found at our previous inspections 30 October 2013 and 9 April 2014 where we found concerns. These concerns related to the provider failing to protect the safety of people as they did not ensure that safe and robust systems were in place when recruiting new staff. As a result of our findings we issued the provider with a warning notice. We also set a compliance action following further concerns with regards to the transfer arrangements when moving a person from one service to another.

The purpose of this inspection was to follow up on the warning notice we issued and to see if improvements had been made.

We considered all the evidence we had gathered under the outcome we inspected. We used the information we had gathered 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?

Following the issue of a warning notice the provider had implemented a safe staff recruitment and selection system.

Is the service effective?

Following concerns identified at our previous inspection the provider had implemented changes to their admissions and discharge policy. This ensured guidance for staff which would ensure the welfare and safety of people was protected when transferring from one service to another.

Is the service caring?

The provider had implemented changes to their procedural guidance for staff when transferring people from one service to another. This meant that staff had guidance to ensure people would be cared for in a safe and supportive manner.

Is the service responsive?

The provider had taken steps to ensure compliance with a warning notice issued following our concerns about the unsafe recruitment of staff.

Is the service well-led?

There were sufficient staff to meet people’s needs.

We conducted our inspection to follow up on compliance actions made at our last inspection 30 October 2013 when we found concerns. These concerns related to the provider failing to notify the Care Quality Commission (CQC) of reportable incidents including deaths of people who used the service. Further concerns related to the lack of systems in place to reduce the risk and spread of infection and the lack of appropriate checks being carried out before staff began working at the service.

During our inspection on 9 April 2014 we found that some improvements had been made.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information we had gathered 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?

We noted that improvements had been made to the environment since our last inspection. The provider had taken steps to ensure that people were cared for in a clean environment and to ensure the risk of infection was reduced. We found the environment to be clean and there were records relating to infection control audits and cleaning schedules were in place. This ensured that each area of the service was regularly cleaned.

As a result of the ongoing improvements to the premises we identified some immediate hazards to people’s safety and sought assurances from the provider that these would be addressed. This included uncovered radiators, unrestricted windows and loose carpet tiles which the provider told us were being replaced with new carpeting. We have asked the provider to provide us with updated risk assessments with assurances that the ongoing building works would not compromise people’s safety. Once electric works have been completed we have asked the provider to send us the electrical wiring certificate.

We observed there to be enough staff on duty to meet people’s needs and we saw that people were regularly supervised for their safety.

Staff had recently attended training in understanding the Mental Capacity Acts (2005). The manager told us that there was no one currently living in the service who was subject to a Deprivation of Liberty Safeguard (DOLS).

Is the service effective?

People we spoke with told us their needs were met. We observed staff caring for people in an appropriate manner and offering them choices. The manager and staff spoken with and observed showed a good understanding of people’s needs and acted in accordance with people’s wishes. We looked at three care plans which told us about people’s needs and how staff should meet them. People’s needs were reviewed regularly. This supported staff in identifying and responding appropriately to the people's changing or unmet needs. Staff consulted with family members and other medical professionals when required and this was recorded.

Is the service caring?

Our observations indicated that people in the main were happy living at Chrissian Care Home. It was evident that the majority of people who used the service had a good relationship and rapport with the staff who supported them. Several people told us the staff were, ‘Very kind’ and, ‘Could not do enough for you.’

Is the service responsive?

People’s care records viewed showed us that their individual physical, mental and social care needs were assessed prior to admission to the service. Daily records evidenced that where concerns about the health and well-being of people had been identified appropriate action had been taken to ensure they were provided with the support they needed. This included access to health care professionals such as a doctor or district nurse.

We saw staff responding to people’s requests. One person told us, “The minute you press the alarm, staff respond.” We saw from a review of care plans that one person had requested that staff should not regularly monitor them throughout the night. This was recorded within the risk assessment and showed us that people’s individual needs were met. We saw records in the kitchen which told us that people’s dietary needs were known and people could have their meals at different times of the day and their individual dietary requests could be accommodated.

However, prior to our inspection we received information of concern which had been investigated by the local safeguarding authority. It was evident from the outcome of this investigation that a person assessed as physically frail and living with dementia had moved from Chrissian Care Home to another service without care staff support being provided. They had been left in the care of a taxi driver. We were therefore not satisfied that the provider had fulfilled their duty of care and taken steps to ensure people received safe coordinated care, treatment and support when transferring from one service to another.

Is the service well-led?

Following our last inspection we issued the provider with a fixed penalty notice for continued failure to provide a registered manager. The provider has since employed a manager who has been successful in their registration with the Care Quality Commission.

Our observation of records showed that following our last inspection the manager had implemented management quality monitoring systems. The records we viewed showed that the manager had regularly reviewed the cleanliness of the environment, care plans and monthly medication audits had been carried out.

We found that there were continued shortfalls in the management of staff recruitment. The provider continued not to protect the safety of people by failing to obtain satisfactory evidence of workers conduct in their most recent employment before they started working at the service. This meant that we could not be assured that only people suitable to work in a care setting were employed.

The purpose of this inspection was to check that improvements had been made following our last inspection of 9 August 2013, when we found that the provider was not meeting two essential standards. Following this inspection the provider sent us an action plan detailing actions they would be taking to ensure compliance. We found that there had been some improvements made.

We spent some time in a communal lounge and observed the interaction between staff and people who used the service. We were unable to hold meaningful conversations with the majority of people who lived in Chrissian Residential Care due to their limited mental capacity. However, we spoke with three people who used the service. We also spoke with a relative of a person who used the service. One person told us, “I have lived here a long time. I like it.” Another told us, “Staff are nice to me, they know me very well.”

As part of our inspection we looked around the service. We found shortfalls in that people were not protected against the risk of cross infection because the hygiene and cleanliness of the service and the equipment used had not been fully maintained.

During our inspection we spoke with six people who used the service about their experiences of the service they were provided with. People told us they were happy living at Chrissian. One person said, “It is lovely here you will not find a better place to live.” Another told us, “I have no complaints it is alright here.”

People told us that staff treated them with respect and kindness. One person said, “Most of the staff are kind, some are better than others.”

We saw that staff tok their time with people and were attentive to people’s needs and interacted with people in a caring, respectful manner. Care staff sought people’s agreement before providing any support or assistance.

We looked at the care records of three people who used the service. Care plans and daily contact records recorded the care, treatment and support provided to people. We saw that changing health care needs were monitored and specialist advice sought when required.

We spoke with a visiting district nurse who told us that the provider responded appropriately and sought advice when individuals at risk of pressure ulcers were identified.

We found appropriate checks were undertaken before new staff began work at the service. There was a structured recruitment and selection process in place and we saw that relevant checks were carried out when staff were employed such as two written references and criminal records checks. However, we found shortfalls in the training provided for staff to ensure that staff were properly supported to provide safe care and treatment to people who used the service.

The purpose of this inspection was to check that improvements had been made following our last inspection of 30 July 2012. During this inspection we found that improvements had been made. We had also received a concern from an anonymous source about the service provided. We made a safeguarding referral to the local authority about part of the information provided by the concerned party and looked into the other issues that were not safeguarding issues. It was found by us and the local authority that the concerns were unsubstantiated.

We spoke with three people who used the service who told us that they were happy living there. One person said, "Oh yes dear, I love living here." We chatted to two people about the cold weather and one person said, "We are nice and warm in here."

We looked at the care records of three people who used the service which showed that people experienced care, treatment and support that met their needs and protected their rights.

We spoke with seven people who used the service. They said that their choices were listened to and acted upon. They said that they were consulted about the care and support that they were provided with. We asked one person if they were consulted about their care and they said "Of course we are."

People told us that they felt that their needs were met. One person said "They look after us marvellously." Another person said "You won't find anything wrong here." Another person said "I only have to call the bell if I need anything, they (staff) come as soon as I ring."

People told us that they were provided with enough to eat and drink. They said that the quality of food was good and that they were always provided with a choice of meals. One person said that the menu was displayed daily on the white board in the dining room. They said "It is changed daily, you don't get the same old thing." Another person said "The food is usually good, I have no complaints."

During a visit to the home and discussion with some of the people who use the service they confirmed that there are frequent activities that includes bingo, dominoes, sitting dancing and they enjoy there time in the home, they feel that they are well looked after and treated like individuals. They confirmed that they can do what they want to do at any time, if they want to go to their room they can. One person stated that her family are involved with their care planning and they go out for trips with them.

Comments from the people who use the service include “ I am very happy here, it is all lovely and I am enjoying my morning walks”, “No complaints everything is fine I am relaxed and happy”, and ” really happy with the home ,they look after me well”.