We undertook a comprehensive inspection on 7 and 8 August 2018. The inspection was unannounced.

Five Bells Residential Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide accommodation for up to 28 older people or people living with a dementia type illness or a physical disability. There were 23 people living in the service during our inspection. Two people were living in the service under a tenancy agreement and did not receive personal care from the provider. We have not referred to these people in our inspection report. Eleven people lived in the main house; an adapted three storey property and a further 12 people lived in adjacent apartments and mews houses.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are registered persons. Registered persons have the 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 Five Bells Residential Care Home in April 2017 we found a breach of the regulations and the service was rated 'Requires Improvement’. This was because the registered provider failed to ensure that people were kept safe from the risk of harm. At this inspection we found that some improvements had been made and the service was now rated ‘Good.'

Staffing levels had improved for some staff groups and staff had security checks prior to starting work to ensure that they were appropriate to care for people. Medicines were administered by competent staff. All areas of the service were clean and ongoing improvements were being made to the environment.

People received care and support from staff who understood their care needs. The delivery of care was coordinated and person-centred. People were provided with their choice of food and drink. Staff referred people in a timely manner to other healthcare professionals when their condition changed. Staff followed the guidance in the Mental Capacity Act 2005 and people were lawfully deprived of their liberty.

People were enabled to be involved in planning their care. Staff focused their care on the individual person. People were treated with kindness and compassion. However, some staff did not consider an individual person's dignity.

People received care that was responsive to their individual needs and preferences. Systems were in place to enable people to make a complaint if they wished to do so. Staff respected a person’s end of life care needs and wishes.

Quality monitoring systems were in place.

People spoke highly of the care they received and the attitude of staff. Staff enjoyed working at the service and were proud of their achievements

People who lived in the service and staff had a voice and were supported to give their feedback on the service. The registered manager was proactive and had made significant improvements to the standards of care in the service.

This was an unannounced inspection carried out on 19 April 2017.

We competed a comprehensive inspection of this service on 14 September 2016. We completed the present inspection because we had received concerning information that people were not receiving safe care.

Five Bells Residential Care Home can provide accommodation and personal care for 28 older people, people who live with dementia and people who have a physical disability. There were 20 people living the service at the time of our inspection. The accommodation consists of an adapted three storey property in the grounds of which there are a number of cottages and apartments.

The service was run by a company who was the registered provider. 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. In this report when we speak both about the company and the registered manager we refer to them as being, ‘the registered persons’.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the registered persons had not suitably protected people from the risk of avoidable accidents. You can see what action we told the registered persons to take in relation to this breach of the regulations at the back of the full version of this report.

We also found that parts of the accommodation were not clean and that full background checks had not always been completed before new staff were employed. Medicines were managed safely and there were enough care staff on duty. Care staff knew how to respond to any concerns that might arise so that people were kept safe from abuse.

Some care staff had not received all of the training the registered persons considered to be necessary and did not have all of the knowledge and skills they needed. The arrangements used to support people to eat and drink enough were not robust, but care staff ensured that people received all of the healthcare they needed.

The registered persons had ensured that whenever possible people were helped to make decisions for themselves. When people lacked mental capacity the registered persons had ensured that decisions were taken in people’s best interests.

The Care Quality Commission is required by law to monitor how registered persons apply the Deprivation of Liberty Safeguards under the Mental Capacity Act 2005 and to report on what we find. These safeguards protect people when they are not able to make decisions for themselves and it is necessary to deprive them of their liberty in order to keep them safe. In relation to this, the registered persons had ensured that people only received lawful care.

Care staff were kind and compassionate. People’s right to privacy was promoted and confidential information was kept private.

Although people received a lot of practical assistance, care staff had not always followed the correct procedures to ensure that this level of support was maintained. People were not suitably supported to pursue their hobbies and interests. However, care staff promoted positive outcomes for people who lived with dementia and there were arrangements to quickly and fairy resolve complaints.

Quality checks had not always effectively resolved problems in the running of the service and people had not been fully consulted about the development of their home. Most care staff considered that the service was run in an open and inclusive way so that they were able to speak out if they had any concerns.

The inspection took place on 14 September 2016 and was unannounced.

We previously inspected the home on 21 December 2015. At that inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not have enough staff to meet people's needs, infection control processes were inadequate, the environment was not adequately maintained and the provider was not identifying risks to the quality of care people received.

The service is located in an old building in the centre of the village of Folkingham, Lincolnshire. Accommodation is provided within the main building, in apartments in the garden and in flats adjacent to the home. The home is registered to provide personal care for a maximum of 28 older people or people living with a dementia. There were 19 people living at the home when we inspected.

At the time of our inspection 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 home is run.

At this inspection we found that the provider, registered manager and deputy manager had made significant improvements to the care people received. The care was meeting the requirements of the legislation. However we found that more improvements were needed before people could be certain of receiving good quality care.

Care plans did not fully record the care that people needed. Changes in their care and information about their daily lives was recorded in a way that would not always be accessible for staff and healthcare professionals when they reviewed people’s needs. In addition, risk assessments did not contain all the information staff needed to ensure that the care they provided protected people from harm. Risk monitoring forms did not always support staff to recognise issues.

We also saw that mental capacity assessments had not been completed when decisions had been for people who were unable to make choices for themselves and that while decision had been taken in people’s best interests it was not clear why the decision had been made and who had been involved in making the decision.

While there had been some improvement in the systems to monitor the quality of service people, we saw that more work was needed to ensure that the systems were fully embedded into the management of the home. This meant that while some issues were identified and rectified we could not be confident that this was always the case. People were not always sure on how to raise complaints and verbal complaints had not been recorded. Furthermore the provider had not taken any action to gather the views of people living at the home about the quality of care they received.

The staffing levels had improved and that there were now enough staff to meet people’s needs. In addition, staff had received appropriate training and support to enable them to care for people safely and to raise concerns with the management team if they were worried about the standard of care people were receiving.

Staff spoke with people in a kind and caring manner and responded appropriately to verbal and non-verbal requests for support. Staff respected people’s privacy and dignity by speaking to them quietly when discussing personal care and by protecting people’s dignity when they were unable to do so for themselves. People’s end of life wishes were known and recorded.

Staff monitored people to ensure that they were happy and made sure that people were always able to access hot and cold drinks. People were happy with the meals provided and were able to personalise them to their individual tastes. People received their medicines in a timely manner and staff supported people to understand what med

This inspection took place on 21 December 2015 and was unannounced.

The service is located in an old building in the centre of the village of Folkingham, Lincolnshire. Accommodation is provided within the main building, in apartments in the garden or in flats adjacent to the home. The home is registered to provide personal care for a maximum of 28 older people or people living with a dementia. There were 22 people living at the home when we inspected.

At the time of our inspection 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.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider did not have enough care workers to meet people’s needs, infection control processes were inadequate, the environment was not adequately maintained and the provider was not identifying risks to the quality of care people received. You can see what action we told the registered persons to take at the back of the full version of this report.

The provider had completed a staffing tool to identify the staffing levels needed to support people. However, we saw that staff were not always available when needed and at times people had to wait for care. Staff had received training and support to provide safe care to people, however, training was not always implemented into day to day care.

The provider had failed to maintain the building and furniture and equipment to an adequate standard to keep people safe and support their well-being. The infection control processes in the home did not keep people safe from the risk of infection. In addition management audits did not identify where improvements were needed.

Medicines were safely administered; however, records did not always support staff to know what medicines were needed. Staff were kind and caring but at times they focused on the tasks and did not consider the impact on person centred care.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect themselves. The registered manager had not fully understood their responsibilities under the MCA and DOLS. Therefore people were not protected from inappropriate care when they could not make decisions for themselves. Where people could make decisions their choices were respected.

The provider had systems in place to keep people safe from harm and to take appropriate action if a person was at risk of harm. Staff knew how to raise concerns and the registered manager responded appropriately when concerns were raised.

People were involved in planning their care to meet their individual needs. However, care plans did not fully record these details. There was a lack of support for people to maintain hobbies and interest and people spent a lot of time watching the television.

Staff told us they were supported by the registered manager and people and their relatives told us the registered manager involved them in the development of the service. However, the registered manager and the provider had failed to identify the concerns we found during our inspection and audits to assess quality were ineffective.

We used a number of different methods to help us reach a judgement on the quality of the service provided at Five Bells. These included talking with five people who used the service, three carers, the cook and the registered manager.

We looked at records. These included care plans and information about how the service was managed. We conducted a tour of the building and observed the interactions between the care staff and people residing at the home.

The records we looked at showed that people’s needs had been assessed and appropriate support provided to care for their needs.

We found that people were provided with a choice of suitable and nutritious food and drink in sufficient quantities to meet their individual needs and preferences. One person who lived at the home told us, “Some of us were cooks. So the food had better be good.”

We saw the building had undergone some changes to better meet the needs of people living at the home and were informed that more improvements were planned.

There were sufficient numbers of suitably qualified and skilled staff to meet people’s needs.

The provider had in place systems to regularly monitor and assess the quality of the service provided.

We found that people were cared for in a safe and caring environment and the service was well led and managed.

We carried out an inspection of Five Bells to follow up an area of non-compliance identified in a previous inspection. We reviewed the evidence that demonstrated the provider's compliance in this area.

We reviewed all the information that the provider had sent us, visited the premises and talked with the registered manager.

We saw that the provider had taken the appropriate measures to meet the essential standards of care for people who used the service provided at Five Bells.

Due to the complex needs of some of the people who used the service we used a number of different methods to help us understand their experiences when we undertook our visit.

Prior to our visit we reviewed all the information we had received about the service. During the visit we spoke with three people who used the service. We also spoke with two visiting health care professionals, three members of the staff team and the registered manager. We also looked at records. These included care plans, records of meetings and information about how the service operated. We also looked at information from surveys undertaken by the provider to assess the quality of service.

The people we spoke with said they were happy with the care and support they received and felt it was delivered in a safe way. They told us that staff offered them choice and respected their opinions while encouraging them to be as independent as possible.

One person told us about various community resources they used and their involvement in local community groups.

People also said they felt confident taking any suggestions or concerns to the manager or any of the staff team. They were satisfied with the support they received and the service provided. One person living at the home told us, “The staff are reliable and trustworthy.”

We identified concerns regarding limited access to and from the first floor of the building for people who had difficulty in mobilising.

All the people we spoke with were satisfied with the service they receive.

One person told us "I'm very satisfied with everything, I have no complaints."

Another person told us "I'm very happy here, the staff are very kind to us. The food is good, we had a lovely Christmas dinner."

Another said "The manager is great. We get care when we need it."

One of the people living at the home told us that staff were very friendly and the manager was easy to speak to.

One person we spoke with told us that the staff were lovely people and there were enough staff at all times. However, the family of a person living at the home expressed their concern that there were not always enough staff on duty to cover both the needs of highly dependent people in the flatlets as well as people living in the main house.

Another person living at the home said the manager was very flexible and that staff had adjusted to her routine very well.

The family of a person living at the home said that the staff were really caring and pleasant but always busy and they felt there were not enough of them on duty all the time.

One person told us that staff always came when they rang their bell for assistance but said that sometimes it took longer for staff to come because they were so busy.

Another person told us that staff always came when called if only to say they were in the middle of helping someone else and would return. However, sometimes it took a long time for them to return.