What life is like for people using this service:

Improvements had been made to the service following our previous inspection in November 2017 to address concerns and breaches of Regulation. The risks to the quality and safety of the service were identified and acted on. People's records clearly identified their preferences but daily records were not always completed and needed more detail. Information from audits, incidents and quality checks was used to drive continuous improvements to the service people received. People, their relatives and staff told us the provider and managers were approachable, they felt listened to when they had any concerns or ideas.

There was enough staff on duty to enable people to remain safe and receive care in a timely way. The environment was safe and people had access to appropriate equipment where needed. Staff had received appropriate training and support to enable them to carry out their role safely. People were supported to take their medicines in a safe way, their health was well managed and staff had positive links with professionals which promoted wellbeing for them. Staff provided effective care for people which met their needs through person-centred care planning. This enabled people to achieve positive outcomes and promoted a good quality of life. People enjoyed the activities that were provided, but some felt more should be provided and felt bored at times.

Staff were kind and caring and promoted people’s dignity. Staff understood the importance of treating people with respect and ensure they did this. People were observed to have good relationships with the staff team. Staff actively ensured people maintained links with their friends and family.

Staff were motivated and enjoyed strong team work. The provider had implemented a programme of improvements, including the appointment of a regional manager.

More information is in Detailed Findings below:

Rating at last inspection: Requires improvement (Published 24 November 2017), at this inspection we have changed our overall rating to Good.

About the service: Dorrington House (Dereham) is a residential care home that is registered to provide accommodation and personal or nursing care to a maximum of 45 people. At the time of our inspection, 43 people were living there.

Why we inspected: Why we inspected: This was a planned inspection based on the rating at the last inspection.

This inspection took place on 26 and 28 September 2017 was unannounced. Dorrington House (Dereham) provides accommodation and care for up to 45 people. The registered manager and provider told us that they specialised in dementia care. At the time of the inspection there were 41 people living in the home, 36 who were living with dementia.

The service had 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.

At our last inspection of this home in October 2015 we awarded it an overall rating of Good. At this inspection we found that not all aspects of the quality of care provided was good. Therefore, our judgement is that the overall rating for the home is now Requires Improvement. There were three breaches of regulations. These were in respect of regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some risks to people’s safety had not been adequately assessed or managed. Some prescribed creams were not secure within people’s rooms and it had not been assessed whether this was safe. Staff were not always vigilant to particular risks such as falls and therefore, did not take appropriate action to reduce the risk of harm to people.

Consent had not always been obtained in line with the Mental Capacity Act 2005. This Act states that certain steps need to be followed when a person is unable to consent to their care and treatment. There was a lack of evidence to show that all the required steps had been followed as are required.

Some of the systems the provider had in place to monitor the quality of care provided were not effective. This included ensuring people received their prescribed creams correctly and the management of some risks to the premises. Although staff had received training in a number of different subjects, the provider did not have an effective system in place to ensure staff understood this training and consistently used good practice.

People and relatives we spoke with were happy with the quality of care they received and were happy living in the home. There were enough staff working at the service to keep people safe. The provider had conducted the necessary checks about their character to make sure they were safe to work in the home, before they commenced their employment.

People received their oral medicines when they needed them. However, we were not assured that people had received their prescribed creams correctly.

Staff had a good knowledge about how to recognise abuse and were confident to report this. However, accurate and thorough information in relation to how the staff needed to support people when they became upset and/or distressed was not always in place. This meant staff had an inconsistent approach when this occurred.

People received enough to eat and drink to meet their individual needs. Where there was a concern about people not eating and drinking enough, this was monitored and acted upon. People were supported with their healthcare needs.

The environment required improving for people living with dementia so that it was more stimulating and helped them orientate themselves around it. The provider had identified this and was actively working with the local authority to make the necessary improvements.

People had access to a number of planned activities to stimulate them and improve their well-being. However, there were missed opportunities with staff not always actively engaging or distracting people which would improve this further.

People and/or relatives had been involved in making decisions about their/their family members care when they started using the service. Staff practice in respect of involving people in day to day de

We carried out an unannounced comprehensive inspection of this service on 22 and 24 April and 01 May 2015. Breaches of five legal requirements were found in how the service supported people with specific nutritional needs. The breaches we identified related to ensuring the safety of people with specific nutritional requirements, meeting their nutritional needs, application of the Mental Capacity Act 2005, how people’s specific nutritional requirements were planned for and management oversight of this area of care. After the comprehensive inspection the provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches we found.

A warning notice was issued on 29 May 2015 requiring the provider to provide care and treatment of people with specific nutritional requirements in a safe way by 24 June 2015.

We undertook this focused inspection on 14 July 2015 to check that the provider had met the legal requirements of the warning notice. This report only covers our findings in relation to this regulation. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dorrington House (Dereham) on our website at www.cqc.org.uk.

This July 2015 inspection found that significant improvements had been made and that the provider had ensured the safety of people with specific nutritional requirements.

People were receiving food in consistencies that were in accordance with the guidance provided by healthcare professionals. Staff were following the guidance by ensuring that people were positioned in a safe way during meal times. Specialised training had been provided and staff were positive about the changes that had been implemented. Staff were able to clearly describe what type of diets people required and what they needed to do to ensure people were safely assisted at mealtimes. The provider had taken the necessary action to mitigate the risks to people’s safety and welfare that we had identified at our previous inspection.

As a result of our April and May 2015 inspection this service was placed into ‘special measures’. A further comprehensive inspection will be carried out by November 2015 to ensure that the provider has met the legal requirements in relation to the remaining four breaches and to re-evaluate all ratings for this service.

Prior to our inspection the Care Quality Commission (CQC) had received concerns about the care provided at Dorrington House, Dereham. In particular there were concerns about how the home managed it cleanliness and hygiene and protected its residents from infections such as diarrhoea and vomiting. In addition there were concerns raised about whether equipment in the home was fit for purpose.

There was no registered manager at Dorrington House at the time of our inspection. However the provider was in the process of formalising the acting manager's position as registered manager.

The purpose of this inspection was to check that people who used the service were provided with safe and effective care that met their needs. We spoke with the manager and staff members who told us about recent improvements made in the service to meet people’s needs and expectations.

We conducted this inspection to establish the following about Dorrington House, Dereham:

• Was the service safe?

• Was the service effective?

• Was the service caring?

• Was the service responsive and

• Was the service well-led?

An adult social care inspector carried out this this inspection on 21 August 2014.

As part of this inspection we spoke with four people living at the home, three family members of people living at the home, the manager, and three members of care staff. We reviewed records relating to the management of the home which included four care plans two of which were kept in the residents’ rooms and the remainder in the treatment room. We also looked at staff training files.

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Was the service safe?

We found that there were not effective systems in place to reduce the risk and spread of infection. An infection control audit had taken place in July 2014. This showed some areas of potential risk which needed to be addressed. However during the inspection we identified other areas of potential risk which needed to be addressed in order to meet the Department of Health's code of practice on the prevention and control of infections.

People were able to indicate to us that they felt safe living at Dorrington House. We saw that the provider had satisfactory recruitment procedures in place. This ensured that only suitable people were employed to work with vulnerable adults.

The manager was able to tell us how they protected vulnerable adults. They told us how they responded to and reported safeguarding incidents to the relevant authorities. Staff we spoke with demonstrated knowledge of safeguarding adults and how to respond to and report safeguarding issues.

There was a system of assessing risks designed to keep people living in the home, and staff, safe from harm. Risk assessments were appropriate to people’s current and changing needs.

The provider had an effective system of recording person centred information. This meant that staff relayed important information to other staff relevant to the person's care. People were provided with their medication when they needed it.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to people living in care services. At the time of the inspection one person required these safeguards. Applications had been made to the appropriate authorities, although the provider had been told of a long delay in processing the submissions. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when DoLS should be implemented.

Staff understood their roles and responsibilities in making sure people were protected from the risk of abuse. The provider ensured that all staff were kept up to date with safeguarding training and accompanying reporting procedures.

There were emergency and contingency plans in place to secure and maintain the safety of people using the services and staff.

Was the service caring?

We observed that people received helpful, consistent and respectful support from care staff. One person told us, “It's lovely here, much better than the last place.” Care and support plans were up to date and reflected the support needs of people living in the home. People we spoke with understood their care plans. They told us who they would speak to if they had any concerns.

Was the service responsive?

People's care and social needs were assessed and reviewed on a monthly basis or as and when needed. GPs, district nurses, and chiropodists were noted to input to people's care when requested. Where changes to people's needs occurred such changes were documented and recorded.

An activities and events programme was in place to entertain and stimulate people. This included games and tournaments, music for health and sing-alongs. No one was pressured to take part in activities if they did not want to.

A family member of one person living in the home told us, "It's okay I suppose, but I'm not sure we are getting the best possible care for them. Still it's relatively early days yet, so we'll see."

Was the service effective?

People using the service that we spoke with said, or indicated to us, that the care and support provided was satisfactory. There was a pre admission assessment of people’s needs to ensure that the service could meet them and the provider took reasonable steps to ensure continuity of care throughout the person's stay.

People's care needs were monitored through a review system. This helped the home to meet people's expectations and needs.

One person living in the home told us that the food was, ‘…lovely, I enjoy it very much…’ Another said, “There is plenty of choice.” When asked if they were given enough to eat people replied, “Always."

Was the service well led?

The views of people using the service and, where possible, their families were sought by the service. Staff also had frequent opportunities to say what was going well, or not. Staff told us that they felt supported and had received sufficient training to carry out their role effectively. Staff training records reflected this. Staff added that if they felt they needed further or additional training or support, they were confident that this would be arranged by the provider. This told us that the provider took reasonable steps to keep the staff updated and trained to a high professional standard.

Quality monitoring systems were in place to ensure people received a good service and a programme of audits was scheduled.

People’s personal care records, and other records kept in the home, were kept safe and filed appropriately and securely.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they did.

We spoke with people about the care and support they received at Dorrington House. One person told us, “They know what I need before I do!” Another person said “It’s excellent here, I’ve no complaints."

Before people received any care they were asked for their consent. People told us how staff knocked on their doors and gave them time to answer before they went in. We heard staff asking people if they wanted any assistance with their meals or if they wanted some help when moving around the home. Where people were unable to consent decisions were made in people's best interests with mental capacity assessments made if necessary.

Communication books in people's rooms allowed staff and visitors to communicate with each other. These books included messages left by staff for relatives requesting further toiletries as well as messages of appreciation and queries left by relatives. This was a good system which enhanced relationships between the home and people's visitors.

The food was universally popular with people we spoke with living at Dorrington House. We observed a lunch time and found that the service was well paced. Those who needed support and encouragement received it.

We reviewed staff records and found that appropriate checking systems were in place to ensure that staff were suitable for their role upon recruitment.

Our last inspection in November 2012 identified heaters that presented a risk of scalding. These had all now been replaced or made safe.

Although the people in this home were not always able to verbally express what they wished to say we noted they were interacting well. Positive signs such as smiles, eye contact with people in the room and relaxed body language told us that people were content and involved in their day to day lives. People who were showing anxiety were reassured and spoken to in a calm manner.

The care plan folders containing the documents for each person were written clearly and were focussed on the individual with person centred details telling us the support the person required.

Although we found the home clean and tidy we expressed concerns regarding the uncovered heaters in the home that were too hot to touch. A risk was identified and action needs to take place to reduce/remove the risk. The home was not compliant for the safety and suitability of premises.

The staff in the home were suitably trained and supervised to ensure they could carry out their job safely and correctly.

We found that complaints were acted upon appropriately and that people and their relatives were listened to and that action was taken when concerns were mentioned.

People told us they were happy with the care they received at Dorrington House. We heard positive comments about the meals and people were happy with the activities that were on offer.

People told us that there were enough staff to help them. Everyone we spoke with said they liked the staff and more than one person described them as patient and kind. We were told that people felt safe in the home. None of the people we spoke with had any complaints but said they could speak to staff if they ever did.

This inspection took place on 14 and 21 October 2015 and was unannounced. Dorrington House (Dereham) provides accommodation and care for up to 45 people, some of whom may be living with dementia. There were 34 people living in the home.

The service had been without a registered manager for four months. 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.

Our inspection of April/May 2015 identified several serious issues about the care and support provided for people with swallowing difficulties which had placed them at a significant risk of harm. Consequently the provider had been in breach of five regulations under the Health and Social Care Act (Regulated Activities) Regulations 2014. These regulations related to meeting people’s nutritional needs, obtaining consent in accordance with the Mental Capacity Act 2015, the planning and delivery of person-centred care, good governance and providing safe care and treatment.

Following that inspection the overall rating had been determined as ‘Inadequate’. This meant that the service was placed into special measures. The purpose of special measures is to ensure that providers significantly improve with the assistance of other organisations if necessary. They are expected to make satisfactory progress within a six months period. Failure to do so could result in further action, which could include the cancellation of their registration to provide services.

Due to the serious nature of our concerns identified during our April/May 2015 inspection we issued a warning notice on 29 May 2015 in relation to the failure to provide safe care and treatment. On 14 July 2015 we inspected the service to see whether the service had improved sufficiently to meet the requirements of the warning notice. We found that significant progress had been made and judged that the provider had met the requirements of the warning notice and was providing people with safe care and treatment in relation to their nutritional needs.

This October inspection was carried out to determine whether significant progress had been made overall and to provide an updated rating for the service. We found that significant progress had been made across all areas of concern and we were satisfied that people with special nutritional requirements were safely supported by the staff at Dorrington House (Dereham) and that their needs were met. The service was no longer in breach of any regulations under the Health and Social Care Act (Regulated Activities) Regulations 2014. Consequently, the service is no longer in special measures.

People felt safe living in the service and were supported by staff who knew how to keep them safe. Risks to their welfare, which included the risk of choking, were identified and mitigated as far as was possible by the actions taken by staff. There were enough trained and experienced staff to ensure people’s needs were met in a timely manner. People received their medicines when they needed them. People’s medicine arrangements were well organised and managed in a safe manner.

Staff received enough training to be able to support people effectively. All staff had received training from professionals about how to support people with eating and drinking. The provider had a comprehensive training programme in place, which included training on mental capacity.

Staff had developed good relationships with the people they supported. They understood them and knew how best to encourage them when necessary to support their wellbeing. Staff were patient, friendly and always willing to assist people when they asked for help.

People received care that was planned specially for them and designed to meet their needs, whilst taking into account their preferences. Staff sought people’s input when assessing and planning their care and involved relatives when appropriate.

The provider had commenced recruitment for a new manager. In the meantime, the supporting arrangements in place were working well. The providers had the confidence of their staff who felt well supported during this interim period. Communication was good and meetings held monthly with staff and residents and relatives ensured everyone was kept up to date and had a chance to make their views known.