We inspected Crescent House on 6 December 2016. We previously carried out a comprehensive inspection at Crescent House on 25 August 2015. We found areas of practice that required improvement. This was because we identified issues in respect to the provision of meaningful activities, quality monitoring and systems to obtain and act upon feedback received from people, systems to assess staffing levels and policies and procedures being up to date. The service received an overall rating of ‘requires improvement’ from the comprehensive inspection on 25 August 2015.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had made the required improvements. We found improvements had been made in the required areas and the overall rating for Crescent House has been revised to good.

Crescent House is registered to accommodate up to 17 people. It specialises in providing care and support for predomionatly older people. At the time of our inspection there were 16 people living in the service.

A registered manager was in 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 and associated Regulations about how the service is run.

People chose how to spend their day and they took part in activities in the service and the community. People told us they enjoyed the activities, which included singing, films, arts and crafts visits from external entertainers and themed events, such as reminiscence sessions and themed nights. One person told us, “Somehow the days slip past so quickly. There are no complaints about being bored”. People were also encouraged to stay in touch with their families and receive visitors.

The service asked people and other stakeholders to fill in surveys about the quality of the service and people’s feedback was included in plans for future improvements. There were effective systems in place for monitoring the quality and safety of the service. Where improvements were needed, these were addressed and followed up to ensure continuous improvement.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. One person told us, “Top marks here, I feel very safe”. Another said, “I have difficulty with my vision and the staff know this. When I want to move there is always someone around who will guide me and make sure I don’t bump in to anything”. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Policies and prcedures were up to date and provided staff with appropriate information and guidance.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, including the care of people with dementia and managing behaviour

We inspected Crescent House on the 25 August 2015. Crescent House is a residential care home providing care and support for up to 17 people. On the day of the inspection 16 people were living at the home. The age range of people living at the home varied between 60 – 100 years old. Care and support was provided to people living with dementia, diabetes, mental health needs, sensory impairment and long term healthcare needs.

Accommodation was provided over three floors with stairs connecting all floors and a stair lift in situ. The property is a detached Victorian building with gardens at the back for people to access. The home is centrally located in Hove with good public transport links to the city centre, which enabled people to go out and about independently. Many people living at the home have lived there for many years. The provider also has good retention of staff with some staff members having worked at the home for over 10 years. People spoke highly of the home. One person told us, “It’s a really good place where you can have a laugh.”

A registered manager was in 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 and associated Regulations about how the service is run.

Improvements were required around the opportunities for people to engage with meaningful activities. Activities were provided which included bingo, arts and crafts and quizzes; however, activities centred on the person and meaningful to them were not consistently in place. People also had mixed opinions about the opportunity for social engagement. One person told us, “I love it here, but one thing that could be better is more activities.” We have made a recommendation for improvement in this area.

Robust systems were not in place to analyse, monitor or review the quality of the service provided. Formal feedback was not obtained from people and their relatives. The provider was not completing formal audits and there were no mechanisms to assess the standards of care. Staffing levels were sufficient, but people felt additional staff at weekends may be beneficial. One person told us, “The weekends you really notice it, no one gets neglected, but they are really rushing around.” We have therefore identified the above as areas of practice that needs improvement.

Safe recruitment procedures were followed and appropriate pre-employment checks had been made including evidence of identity and satisfactory written references. Appropriate checks were also undertaken to ensure new staff were safe to work within the care sector.

People received care and support from dedicated staff who were appropriately trained, confident and highly motivated to meet their individual needs. They were able to access health, social and medical care, as required.

With compassion and pride, the management team and staff spoke about people, their likes, dislikes, personality and life history. It was clear staff had spent time getting to know people and delivering care in line with people’s needs. People looked at ease in the company of staff. Staff spent time chatting with people and laughter was heard throughout the inspection.

People’s needs were assessed and their care plans provided staff with clear guidance about how they wanted their individual needs met. Care plans were extremely person centred and contained appropriate risk assessments. They were regularly reviewed and amended as necessary to ensure they reflected people’s changing support needs.

There were systems in place to protect people from abuse and harm. Staff had a clear knowledge of how to protect people and understood their responsibilities for reporting any incidents, accidents or issues of concern.

People’s nutritional needs were assessed and records were accurately maintained to ensure people were protected from risks associated with eating and drinking. Where risks to people had been identified, these had been appropriately monitored and referrals made to relevant professionals, where necessary.

Medicines were managed safely in accordance with current regulations and guidance by staff who had received appropriate training to help ensure safe practice. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

There was a friendly, relaxed atmosphere at the home. There was an open and honest culture within the home. Staff had a clear understanding of the vision and philosophy of the home. Staff spoke passionately about how Crescent House was run as a family home with family values embedded into practice.

One adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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. The home could accommodate 17 people and, when we visited, there were 15 people living in the home and two vacant rooms. One person was completing a short stay in hospital. We spoke with five people who lived in the home and three relatives who were visiting. We also spoke with the manager and six members of staff.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found that the environment was safe, clean and hygienic. This was despite the fact that the house was old and difficult to manage. There was accommodation on the ground and first floors and an enclosed garden. There was a stair lift in two parts going up to the first floor, but people living on the first floor required some mobility in order to navigate the gap at the bend on the landing. People who were less mobile were accommodated on the ground floor. We saw that new permanent ramps had been installed to improve access to the garden for those people using mobility aids.

We spoke with the manager and staff about the challenges they faced in the old building and the on-going programme of work to maintain safety. When we visited there was scaffolding to the front of the building to repair the roof. In addition, on the advice of the environmental health officer, work was planned to replace the worktops in the kitchen as the existing surface had chipped. In the meantime, the areas that were chipped had been covered to avoid any risk of infection during food preparation.

We observed that the medication and other hazardous materials and were stored in locked cupboards, trolleys and fridges, as appropriate. We also saw the cleaning schedules and noted that a deep clean was scheduled to take place in the kitchen. One of the relatives who visited several times a week said that, “The home always smells fresh when you come in the door and they work hard to keep everything lovely and clean.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found that staff had received appropriate training to meet the needs of the people living at the home. This included mandatory training in areas such as manual handling, first aid and fire safety. In addition, there was additional training in areas such as dementia and two members of staff were studying for National Vocational Qualifications.

Staff were keen to use the most effective practices to treat pressure sores and to prevent falls, for example. We also found evidence of staff seeking advice, where appropriate, from the GP or district nurses.

We spoke with a senior member of staff about the audit work that had started at the beginning of the year on monitoring the number and pattern of falls within the home. This work had involved the staff working with the local authority ‘falls prevention team’ and had already been productive in reducing the number of falls.

Is the service caring?

One person we spoke with said, “They take good care of us here and some of us are quite hard work!” Another person said, “I feel like they are my new family.”

One relative we spoke with said, “I have been coming here for years and there is a homely feel”. This relative said, “I am able to visit at any time and I am always offered a cup of tea and made very welcome.”

We saw that the staff were kind and sensitive and took time not to rush, so that people were able to do things at their own pace. We observed high levels of respect and people were treated with consideration and dignity. People’s rooms were furnished with personal items and staff knocked before going in.

The manager visited each person every morning for a chat and to find out how they were. The manager also collected each person’s daily meal choices and any special requests. The people we spoke with about this really appreciated the personal approach and individualised attention from the manager.

Is the service responsive?

People’s needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed, at least bi-monthly. We saw that the staff monitored weight, nutrition and hydration and maintained body charts for any sores or skin damage.

Call bells were answered promptly and staff were alert to any changes in the behaviour or mood of people living in the home. The chef was responsive to different requests for meals and to any issues raised by people living in the home or their relatives. We saw that a book of concerns was maintained in the office. One relative said that her mother had been getting the wrong items of clothing back from the laundry and, when the issue was raised, the matter was resolved immediately and had not happened again.

People had access to activities within the home and, those who were able, could take trips out. They were able to choose dishes from the menu and the chefs were happy to provide for special diets and additional options as requested. People living in the home also engaged with the manager and staff at regular meetings where they could express their views about all aspects of life at the home. They told us that their feedback was acted upon by the manager.

Is the service well-led?

One member of staff said, “I love it here and I have never been happier at work. Everyone is friendly and approachable and the management team are fantastic. They have years of experience and I am learning from them.” Another member of staff said, “This is the best job I have ever had. It is hard work but we all know one another and are we are running a lovely home.”

We saw that the trustees undertook their own unannounced inspection of the home every month. We saw the reports of these inspections and they had separate sections on the ‘premises’ ‘the staff’ and ‘the residents’. Trustees used these inspections to follow up on issues and monitor progress. In April they reported, “Fire training had recently been held, attended by all staff, while in a week or so there will be a session on manual handling. The kitchen is soon to have a deep clean.” They also reported on a birthday party for a person living in the home who was 100 years old and which, “Was enjoyed by all and about 30 guests.”

During our inspection of Crescent House we spoke with seven people who used the service. We also spoke with five members of staff and the registered manager.

The people we spoke with told us they were happy with the care they had received and with the staff team. One person told us, “It’s lovely here, so comfortable and relaxing. Everyone’s so kind and helpful, I wouldn’t want to be anywhere else”. Another person told us, “I’m very happy here and have no complaints. The staff are all very kind and the food is good”. Care plans provided guidance for care workers, to ensure that the assessed current and on-going support needs of people using the service could be met consistently and safely.

We found that care workers had developed awareness and a sound understanding of people’s care and support needs. We observed people being spoken to patiently and clearly and helped to eat, mobilise or take part in activities, as necessary.

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The people who used the service were supported to have adequate nutrition and hydration. People were given choices of food and drink that met their diverse needs.

The provider had arrangements in place for the safe ordering, storage, administration and disposal of medicines at the service. Staff had a good understanding of their responsibilities in relation to the safe administration of medicines.

The service had appropriate systems in place to gather information and monitor the safety and quality of the service.

We talked with five of the people who used the service. They told us that they liked living there, that the care staff showed them respect, looked after them well and sought their consent whenever they offered support. One person told us that, “I was dreading coming here, but it has exceeded my expectations.” Another person told us, “I am treated like royalty.”

To enable us to be able to access people’s wellbeing we spent time sitting with them, observing the care they received and the level of staff interaction.

We observed that the staff were attentive to people’s needs. They interacted with people who used the service in a friendly, respectful and professional manner. We saw that staff sought their agreement before providing any support or assistance. The people we saw were relaxed, engaged with their surroundings and interacted well with each other.

We saw that staff were supported and supervised by the manager and received training essential for caring for older people. People told us that they felt safe living in the service. We also saw that complaints were taken seriously and handled effectively.

During our visit, we found that people living in the home were settled and well cared for. This was reinforced by positive comments received and also evident from direct observation of effective interaction and of individuals being supported in a professional, sensitive and respectful manner.

We were told that, in accordance with their identified wishes and individual support plans, people are encouraged and enabled, as far as practicable, to make choices about their daily lives.

Positive comments received from people living in the home and their relatives, indicated a high level of satisfaction with the home and the care provided:

‘I’m very happy here. The staff are always so kind and helpful’.

‘It’s marvellous here – you should get your name down on the waiting list!’