This inspection took place on the 16 July 2018 and was unannounced. At the previous inspection in July 2017 the overall rating was requires improvement. At that inspection we found a Breach of Regulation 12. This was because the provider had failed to provide safe care and treatment of people because the management of falls was not consistently safe and robust risk assessments and guidelines were not always in place. We also found improvements were required to the provider’s quality assurance framework.

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, responsive and well led to at least good. This inspection found improvements had been made and the breaches of regulation met. However, the quality assurance systems whilst improved still needed to be developed to provide clear actions and outcomes.

Dunsfold is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. It is registered to provide support to a maximum of 18 people and 12 people were using the service at the time of our inspection.

Dunsfold is a residential care home that supports older people living with dementia and disabilities associated with old age such as limited mobility, physical frailty or health problems such as diabetes. Accommodation was arranged over two floors with stairs and a stair lift connecting each level.

The service had a registered manager in place. 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.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan as stated in their provider information return (PIR), and confirm that the service now met legal requirements. We found improvements had been made in the required areas. The overall rating for Dunsfold has been changed to good. We will review the overall rating of good at the next comprehensive inspection, where we will look at all aspects of the service to ensure the improvements have been sustained.

Improvements had been made to the provider’s quality assurance framework; however, these improvements were not yet embedded or sustained. The registered manager and provider were not always proactive in identifying how ongoing improvements could be sustained. Shortfalls in the provision of training had not always been identified by the provider’s quality assurance framework. We have identified this as an area of practice that needs improvement.

Whilst risk assessments were undertaken they were not in a format that identified all risk factors considered, evaluation of action taken or the review of the actions taken.

We have recommended that the provider accesses the Health and Safety Executive (HSE) website in respect of the five steps of risk assessment or the seven steps to patient safety (NPSA 2004.)

Regular fire alarm checks had been recorded, and staff knew what action to take in the event of a fire. However, there was some confusion over the need for staff to undertake practical practice fire evacuations. At this time staff had received fire training but not regular fire drills.

We have recommended that the provider seeks advice from the fire service in respect of fire training..

People were relaxed and comfortable with staff. They said they felt safe and there were sufficient staff to support them. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to

We inspected Dunsfold on the 6 July 2017 and the inspection was unannounced. Dunsfold provides accommodation for up to 18 older people living with dementia. On the day of the inspection, there were 15 people living at the service. Dunsfold is a residential care home that support older people living with dementia and disabilities associated with old age such as limited mobility, physical frailty or health problems such as diabetes. Accommodation was arranged over two floors with stairs and a stair lift connecting each level.

There was a registered manager 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 2008 and associated Regulations about how the service is run.

At the last inspection undertaken on the 12 January 2017, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to the principles of the Mental Capacity Act 2005 not being adhered to. Risks associated with the environment and premises had not been mitigated or addressed. Staffing levels were insufficient and accurate records had not been maintained. The provision of meaningful activities was poor and the risk of social isolation had not been mitigated. The provider’s quality assurance framework was not robust and they had failed to display their rating and notify the Care Quality Commission of significant incidences. Recommendations were also made in relation to the environment, care plans and following best practice guidelines. The provider sent us an action plan stating they would have addressed all of these concerns by February 2017. At this inspection we found the provider had made improvements to staffing levels, the environment and care plans. The provider was now displaying their rating and was notifying the Care Quality Commission of significant incidences. However, improvements were not yet fully embedded and the provider continued to breach the regulations relating to the other areas.

People, staff and relatives spoke highly of the registered manager and their leadership style. However, despite people's praise, we found areas of care which were not consistently safe or well-led. The management of falls was not consistently safe and robust risk assessments and guidelines were not always in place.

Improvements had been made to the provider’s quality assurance framework; however, these improvements were not yet embedded or sustained. The registered manager and provider were also not proactive in identifying how ongoing improvements could be sustained. Shortfalls in the provision and delivery of care had not always been identified by the provider’s quality assurance framework. We have identified this as an area of practice that needs improvement.

People told us they felt safe living at Dunsfold. Staffing levels had improved since the last inspection and action had been taken to improve fire safety at night. Staff worked in accordance with people's wishes and people were treated with respect. It was apparent that staff knew people's needs and

preferences well. Positive relationships had developed amongst people living at the service as well as with staff.

Systems were in place to ensure people were supported to receive their medicines on time by qualified and competent staff. Medicines were ordered and disposed of safely. People were supported to access health services and their health care needs were being met. People were safe and staff knew what actions to take to protect them from abuse. The provider had robust recruitment procedures in place to ensure that staff were suitable to work with people.

Staff knew the people they were caring for very well. They were able to communicate effectively with people and involved them in making decisions about their care and support. Laug

We inspected Dunsfold on the 12 January 2017 and the inspection was unannounced. Dunsfold provides accommodation for up to 18 older people living with dementia. On the day of the inspection, there were 13 people living at the service. Dunsfold is a residential care home that support older people living with dementia and disabilities associated with old age such as limited mobility, physical frailty or health problems such as diabetes. Accommodation was arranged over two floors with stairs and a stair lift connecting each level.

There was a registered manager 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 2008 and associated Regulations about how the service is run.

Although people and staff spoke positively of the service, we found the service was not well led. The provider’s internal quality assurance system was not robust and failed to identify shortfalls we observed during the inspection. Accurate and complete records had not been maintained and policies and procedures had not been reviewed or updated to reflect best practice guidelines.

Staffing levels were not based on people’s assessed needs. The deployment of staff was insufficient and healthcare professionals raised concerns over the visibility of staff within the service. The principles of the Mental Capacity Act 2005 (MCA) were not embedded into practice and conditions attached to Deprivation of Liberty Safeguards (DoLS) had not been acted on. The provider had failed to display their performance rating on their website and had not consistently notified the Care Quality Commission of significant events.

The provider and registered manager were unable to demonstrate how they followed and embedded best practice guidelines on the delivery of dementia care. Consideration had been given to making the environment dementia friendly, but further work was required. We have identified this as an area of practice that needs improvement and made a recommendation for improvement.

People did not have regular access to call bells. Risks associated with the environment and premises had not been mitigated or risk assessed. Radiator guards were loose and people’s bedrooms were not consistently personalised. One person’s bed had been made with a soiled quilt cover. We have identified these as areas of practice that need improvement and made recommendations for improvement.

Care plans were in place and person centred. However, guidance on the management of catheter care and supporting people who may not be oriented to time and place was not sufficient and lacked detail. We have identified this as an area of practice that needs improvement and made a recommendation for improvement.

The risk of social isolation had not been mitigated and people did not have regular access to activities that were meaningful. Healthcare professionals also raised concerns over the lack of stimulation and interaction for people.

The management of medicines was safe. People received their medicines on time and staff told us how they minimised the use of medicines to manage behaviours. A programme of essential training was in place and staff told us that they felt supported and valued as employees. One staff member told us, “I really enjoy working here.”

People spoke highly of the food provided. One person told us, “The food is very nice.” Dietary requirements were catered for and people were maintaining a stable and healthy weight. People had regular access to healthcare professionals and the GP either visited the service weekly or conducted weekly telephone consultations.

Staff spoke highly of the people they supported and it was clear that staff had spent time building rapports with people. People’s privacy was respected and staff demonstrated a caring approach

We inspected Dunsfold on the 15 December 2014. Dunsfold is registered to provide personal care and support to people living with dementia. The service can accommodate up to 18 people. There were nine people living at Dunsfold during our inspection.

An interim manager was in post, and they had submitted their application to the CQC to be the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider. The home has been without a registered manager for four months.

At the last inspection in April 2014, we asked the provider to make improvements in respect to cleanliness and infection control, supporting workers and quality assurance. An action plan was received from the provider and we found that improvements had been completed. The provider now carried out regular audit and monitoring activity to assess the quality of the service and make improvements. Areas for improvement had been identified and action plans put in to place. Such as training and supervision of staff.

People spoke positively of the service and commented they felt safe. Our own observations and the records we looked at reflected the comments people had made.

People were safe. Care plans and risk assessments whilst basic reflected people’s assessed level of care needs, action for staff to follow and an outcome to be achieved. People’s medicines were stored safely and in line with legal regulations and people received their medication on time and from an appropriately trained care staff member. The home was clean and staff had received infection control training.

Staff received training on the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and they had a sound basic understanding of the legal requirements of the Act. They were aware of restrictions posed on some people in the home and why they were in place.

Care plans contained information on people’s likes, dislikes and individual choice. Information was readily available on people’s life history and there was evidence that people and families had been involved were regularly involved in their care planning.

Everyone we spoke with was happy with the food provided and people were supported to eat and drink enough to meet their nutrition and hydration needs. A communal dining experience was made available to people, and people ate their lunch where they wanted to.

Staff felt supported by management, said they were well trained and understood what was expected of them. There was sufficient day to day management cover to supervise care staff and care delivery. The current management staffing structure at the service provided consistent leadership and direction for staff.

People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapports with people and people responded well to staff.

Feedback was regularly sought from people, relatives and staff. Residents’ and staff meetings were held on a regular basis which provided a forum for people to raise concerns and discuss ideas. Incidents and accidents were recorded and acted upon.

We carried out this inspection to look at the care and treatment that people who used the service received.

This inspection was carried out by one person.

As part of our inspection we spoke with the manager, and care staff available during the inspection. We also looked at four care plans and other documentation within the home.

Not everyone living in Dunsfold was able to tell us about their experiences living there. We were able to meet all the people who used the service. We spoke with three people, who told us “I am much better now than when I first came here.” We were also told, “I am quite an independent person, it is lovely here, the food is good.”

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?

Is the service safe?

People were treated with respect and dignity by the staff. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. Systems were in place to make sure that the manager and staff learn from events such as accidents and incidents and investigations. Some staff had received training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). The home had appropriately made a referral to DoLS in the past. This meant that people would be safeguarded as required.

Staffing levels have been increased to meet the needs of the people who used the service.

The people who used the service were not protected from the risk of cross infection as there were no cleaning schedules in place to monitor the standard of cleanliness and we found areas of concern during our inspection.

Staff were not supported to deliver care and treatment safely and to an appropriate standard. Two new members of staff had commenced working without an induction programme and appropriate in –house training in emergency procedures. There were gaps in staff training, supervision and appraisals.

Is the service effective?

We found during our inspection that the service was effective. Staff we spoke with were able to tell us about people who lived in the home, and their individual needs. People were supported to maintain independence when possible. We saw that people were supported to care for their pets with support from staff.

Is the service caring?

We found during our inspection that the service was caring. We saw staff interacting in a positive manner, speaking to people in a calm respectful manner at all times. We saw that people were encouraged to participate in activities and responded to warmly and with affection by staff throughout the day.

Is the service responsive?

We found during our inspection that the service to be responsive. We saw evidence that when people’s needs had increased, the manager had made appropriate referrals to outside agencies. One G.P service told us, "The staff will ring for advice if they need to."

Is the service well-led?

People who used the service and their relatives were encouraged to make their views known and raise any concerns if they arose. One visitor told us, "The manager is quite approachable and seems caring." People who lived at Dunsfold told us that staff were kind and the food was good. One visitor told us, “Good staff, but the home is not always clean.”

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Not all staff that we spoke with told us they felt supported and listened to. Some also told us that they had not received appropriate training to care for the people who used the service.

We used a number of different methods to help us understand the experiences of people who used the service, because some people who used the service had complex needs which meant they were not able to tell us their experiences. One person told us, "I like it here." We observed staff interacting positively with people.

We examined six care plans and saw evidence that staff had taken steps to involve people in developing their care plans and choosing a way of life that they wanted.

Care plans identified people’s needs and provided guidance for staff to follow.

Records we examined showed that there were appropriate checks made to ensure the home recruited suitable staff. Staff we spoke with felt well supported and enjoyed working at the home.

We looked at the staffing levels and found that the staffing levels were not sufficient in number to meet the current needs of the people who used the service.

We saw that the provider had an effective complaints system.

Not everyone who lived in the home was able to tell us their experiences as this was a home specifically for people who have a dementia type illness. We used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people who used the service.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us

During the day we spoke with six of the 14 people living there. People that could tell us, said that staff were good and that they were nice. We were told, ”My room is nice," and another said “I like it here". One visitor said “The staff are kind and I am welcomed when I visit."

The staff we spoke with were knowledgeable about people’s needs and what support they required.

We saw the service ensured that staff were able to deliver care and treatment safely due to the training and audits in place. The service had assurance systems in place to monitor the quality of the service provided and to gain the views of the people who lived there.

This inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector and joined by an Expert by Experience (people who have experience of using services and who can provide that perspective).

Not everyone who lived in the home was able to tell us their experiences as this was a home specifically for people who have a dementia type illness. We used a number of different methods such as observation of care, and reviewing of records to help us understand the experiences of people who used the service.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us

During the day we spoke with four of the 14 people living there. People said that staff were nice and that they were friendly and caring. We were told food was good and there were lots of drinks. We were told, ”my cat came with me,” and another said “I know it is my home.” One person said the food is “good”, another person said “I eat everything.”