This was a comprehensive inspection carried out on 6 and 7 November 2018. The inspection was unannounced on the first day and announced on the second.

Fornham House is a 'care home'. People in care homes receive accommodation and personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection. The service is registered to accommodate up to 73 people who require personal care. At the time of the inspection 60 people were living at the home.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At our last inspection on 12 October 2016, we rated the service good overall and good in the questions of Effective, Caring, Responsive and Well-Led. We rated the service required improvement in the key question of Safe.

At this inspection we found the evidence continued to support the overall rating of good and the service had improved to good regarding the question of Safe. The other key questions continued to be good.

At our last inspection we were concerned regarding how the service staff cared for people needing support with pressure area care, The management of medicines when people were away from the service on trips and the time it took to answer call bells.

At this inspection we found action had been taken to improve the safety of the service on all three of the above issues. We saw risk assessments which identified how to support people with their skin integrity. Medicines were carefully managed including recording medicines that were booked into and out of the service. The registered manager monitored call bell response times and investigated if any call were not answered within a set time frame. We found there were justifiable reasons for the few calls that were not answered within the set parameters.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the home. 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.

Staff continued to understand safeguarding procedures and said they would not hesitate to report any concerns. Risks assessments about people’s well-being were carried out and updated regularly.

There was a robust recruitment procedure in place and staff were employed in sufficient numbers to meet people’s needs. The staff team had received training to care for people at the service and were further supported through supervision and appraisals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People continued to enjoy a choice of food and were supported to maintain a healthy diet and fluid intake. People had access to health professionals as needed to promote their health and well-being. Health professionals expressed their confidence in the staff team’s ability to recognise people’s

People were treated in a kind and caring way by the staff team. Their privacy and dignity was respected. Staff interacted with people in a caring, respectful and professional manner. Staff had developed good relationships with people and were attentive to their needs. Health care professionals expressed their confidence in the staff team’s ability to care for people.

People’s care plans identify what support they required and how they would like this to be provided. People had opportunities to take part in activities which they enjoyed and which met their abilities a

The inspection took place on 12 and 13 October 2016 and was unannounced on 12 October. The provider was aware of our return visit on 13 October.

The service provides accommodation for up to 73 older people some of whom may be living with dementia. At the time of our inspection 55 people were living at 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 2008 and associated Regulations about how the service is run.

When we carried out our last inspection on 21 December 2015 we found that a number of improvements were required to ensure that the service provided safe and effective care. The main concern was a lack of adequate staffing levels which impacted negatively on the people who used the service and meant that standards of care were poor in several areas of the service, notably the management of people’s drinking and eating and medicines management. At that inspection we also found that there was a lack of oversight by the manager and systems to make improvements were not in place. At this inspection we found that the service had improved in all areas. The new manager had shown a level of commitment to the people who used the service and the staff and the staff team had brought about significant changes.

Although staffing levels had been increased and all staff and most residents and relatives were very positive about the additional staffing we found that some responses to call bells were not prompt.

Staff were trained in keeping people safe from abuse and understood their responsibilities should they suspect abuse had occurred. Staff were able to outline how they would report any concerns they had.

Risks to people’s health and wellbeing were assessed and reduced in most cases but risks related to pressure area care required further review. Medicines were mostly well managed but some improvement was needed with regard to how the service manages medicines for people who go out for the day.

Staff received a structured induction and training was provided to equip them to carry out their roles. Experienced staff demonstrated a good knowledge of the people they were supporting and caring for and knew people’s particular preferences and wishes with regard to their care..

We saw that most staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Staff demonstrated an understanding of MCA and DoLS and ensured people consented to their care and treatment

People who used the service were very positive about the food and were able to exercise choice about their meals. Mealtimes were seen to be very sociable occasions which people greatly enjoyed. People identified as being at risk of not eating enough were referred to appropriate healthcare professionals and monitored. Records relating to people’s eating and drinking were clear and were monitored by senior staff.

People were supported to access healthcare professionals promptly when they needed them and the staff involved relevant professionals when a person’s health declined.

Staff were caring and committed and we saw that people were treated respectfully and their dignity was maintained. The atmosphere was of a friendly place and the good relationships between staff, the people they were supporting and visiting relatives were observed throughout the service.

People were involved in ass

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

The service provides accommodation for up to 73 older people some of whom may be living with dementia. At the time of our inspection 61 people were living at the service. We last inspected the service on 31 March and 14 April 2015 and found there was a breach of regulation 9 of the Health and Social Care Act 2008 Regulated Activities Regulations (2014) which relates to person centred care.

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 2008 and associated Regulations about how the service is run.

People who used the service and their relatives commended the professional and caring nature of the staff. However this was compromised by the lack of adequate staffing which nearly everyone we spoke with commented on. There were not always enough staff on duty and people were not confident their needs would be met promptly. The geography of the building was a further consideration as staff were not a visible presence.

Staff were trained in keeping people safe from abuse and understood their responsibilities should they suspect abuse had occurred. Staff were able to outline how they would report any concerns they had.

Risks to people’s health and wellbeing were assessed and reduced in most cases but risk assessments were not always promptly updated following a change in need. Medicines were mostly well managed but some errors were identified.

Staff received a structured induction and training was provided to equip them to carry out their roles. Some staff had not received all the training they felt they needed. Experienced staff demonstrated a good knowledge of the people they were supporting and caring for and knew people’s particular preferences and wishes with regard to their care. Some newer staff and agency staff did not know people’s needs well which meant we were not assured they could meet their needs effectively.

We saw that most staff had not received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Staff lacked an understanding of MCA and particularly of DoLS.

People who used the service were very positive about the food and were able to exercise choice about their meals. Meals had improved greatly in recent weeks. Mealtimes were seen to be very sociable occasions which people greatly enjoyed. People identified as being at risk of not eating enough were referred to appropriate healthcare professionals and monitored. However records relating to people’s eating and drinking did not clearly show that people were always drinking enough for their needs or how this was effectively managed.

People were supported to access healthcare professionals when they needed them and the staff involved relevant professionals when a person’s health declined.

Staff were caring and committed and we saw that people were mostly treated respectfully and their dignity was maintained. We did observe some poor practice with regard to respectful language and maintaining dignity. The atmosphere was of a friendly and happy place and the good relationships between staff, the people they were supporting and visiting relatives were observed throughout the service.

People were involved in assessing and planning their care. People’s care was regularly reviewed but care plans were not always updated to reflect the

We inspected the service on the 5 August 2014. This was a scheduled inspection. We had received some concerns before the inspection took place relating to several people's care and welfare. This was clarified during the inspection and the manager was taking appropriate action. As part of this inspection we spoke with seventeen people using the service, three relatives, and eleven staff and observed the care and support being provided to people. We looked at six care plans and other records relating to the management of the business. 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? And is the service well-led?

This is what we found:

Is the service safe?

During our inspection we saw that people had call bells in reach and these were answered promptly by staff. We saw a number of people had pendants round their neck and sensor pads and bedrails which helped to protect people from falls. The care documentation and risk assessments viewed showed us the service took adequate steps to protect people from unnecessary risk particularly in relation to the prevention of falls, the prevention of unplanned weight loss, dehydration and the prevention of pressures sores.

We saw that the service responded appropriately to complaints raised and reported safeguarding concerns as required but we could not always see what learning had taken place as a result of an incident.

Mental capacity assessments were being completed but we could not see from the current records how staff always acted in people’s best interest.

Is the service effective?

People’s needs were assessed and care plans were in place for people’s needs which told staff how they should be met. Records were adequate but we found not all to be up to date and some information which had not been cross referenced was conflicting and could result in the wrong care being given.

Is the service caring?

Staff were observed speaking kindly to people and providing assistance to people when they required it. Some people told us the quality of staff varied. We noted that direct observations of staff practice took place by members of the quality team to enable them to comment on staff practice and promote best practice.

Is the service responsive?

We saw staff responding to people’s needs but observed staff being pushed for time which meant that people had to wait, all be it for a very short time of five minutes or less. Some people told us they did not get the staff attention they needed. We observed a robust activity programme which tried to accommodate the different needs of people using the service.

Is the service well managed?

The service appeared well organised with staff having clear responsibility for particular areas of the service. Senior staff were on hand to support staff and the manager and deputy manager were largely supernumerary which gave them time to manage and audit the service. We saw that the service had systems in place to identify how well they were performing and where they needed to improve. However people spoken with raised concerns about the service and we could not always see how their experiences were taken into account. People were given the opportunity to partake in resident meetings and there was a robust quality assurance system in place but this did not tell us how some of the concerns raised with us were being managed. Staff said they did not always feel well supported by senior staff but felt able to raise concerns. Staff supervision was not as frequent as we would expect. The manager said they did three formal supervisions a year but we did not see evidence of this so could not be assured all staff received adequate support.

We inspected this service on the 7 November 2012 and found them non compliant with five standards which we judged was having a minor or moderate impact on people using the service. During this inspection we identified Improvements had been made in respect of, involving and consulting people who used services, health and welfare, staffing levels, records and notifying the commission of events affecting the wellbeing and, or safety of people using the service. There was a new manager in post who received regular support from the operational manager and members of the quality assurance team.

We spoke with 15 people at the service. One person told us, “I have a large airy room with a nice view which I am pleased with. I choose to spend a lot of time there because I find it difficult to make conversation with, or get to know other residents, as all the chairs are in rows and so you almost crick your neck when you turn to talk to them.” One person told us “I have a room downstairs and sometimes find it difficult to negotiate around the furniture.” We asked people about the staff at the service and they told us, “Very kind. They can’t do enough for you excellent.” People told us about the service, “So pleased I chose here. “ “Can’t fault it,” “wouldn’t want to go anywhere else.” Some people told us that staff did not always have time to stop and chat and they were grateful to the volunteers and the mobile library staff who interacted with them frequently.

We spoke with ten people using the service and two relatives. One person told us, “They do keep an eye out. I feel respected and treated with dignity. I feel safe here.” Another person said “Staff treat me well. I can have a bath as often as I like. Food is ok. I haven’t had cause to complain.” Another person said, “I would be happy to complain if I needed to, but I tend to sort my own problems out. I feel safe.” We spoke with the activities coordinator for the service. They told us how they met people's social needs. Activities included, bingo, crafts, games, open communion, themed parties, drinks, hairdressing, exercises, quiz with family members, word games, flower arranging, film nights, summer fete, and art classes.

We spoke with staff and looked at their records. The service had robust recruitment processes and new staff were supported through an induction and training programme. Staff had the necessary skills to meet people's needs.

We inspected six care plans. These were not person centred and had been poorly evaluated so we could not be assured people's needs were fully met.

We observed lunch and this was provided in a timely, dignified way.

We looked at records relating to the management of the business and the care provided. They did not always identify what actions had been taken to improve the service.

You can see our judgements on the front page of this report.

We inspected this service on the 31 March 2015 and the 14 April 2015. The inspection was unannounced on the first day but we arranged with the provider to go back on a second day.

There were a number of breaches at the previous inspection carried out on the 5 August 2014. These related to how the provider did not always involve people in the planning of their care and also in relation to poor record keeping. During the inspection in March/April 2015 we found that not all the required improvements had been made since the last inspection For example we found that staff were still recording in people’s daily care notes once a day, which was alright in some instances but where people’s needs were changing rapidly we could not see how staff were meeting their increased needs. Not all care plans were up to date and therefore did not reflect people’s changed needs and staff did not always show through record keeping that people received the care they needed.

The service is registered for up to 73 older people who require residential care. There is 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.

The home has had a number of issues with its staffing levels but were proactive in recruiting enough staff to meet people’s needs. There were systems in place to raise awareness amongst the staff so they knew how to raise concerns and would recognise when a person was at risk from potential harm and or abuse. Staff were aware of their responsibilities and knew who to report concerns to.

Risks to people’s safety were reduced as far as reasonably possible and people were adequately supervised which helped keep people safe. We noted people were encouraged to mobilise and keep active.

People received their medicines as prescribed and systems were in place to help staff administer medicines safely. Staff received medicine training and their practices were assessed to ensure they could competently give people their medicines. Audits helped to identify any shortcomings with medicine administration, storage or stock issues. This enabled staff to take appropriate actions.

Staff were competent and they were supported through an initial induction and received training required for their roles. They were supported by their manager through annual appraisal, observations of practice, one to one and group support.

People were supported to eat and drink enough for their needs and were provided with a healthy balanced diet. Gaps in recording meant we could not always see if people were protected fully from the risks of dehydration.

Staff had received training in how to support people and give them choices in terms of their health care needs and day to day living. Staff understood that most people have capacity to make decisions about their care and welfare but where they lacked capacity staff knew how to best support them and who should be involved in making best interest decisions.

People health care needs were met and staff had the skills and knowledge to meet people needs or refer to the appropriate health care professional as and when required.

Staff cared for people and respected their privacy, dignity and independence. People were asked about their care needs and staff took into account people’s personal preferences when delivering care to people.

During our first inspection we were unable to see how staff kept people's records up to date to reflect a change in need or risk. This meant we were unable to see from the records alone how everyone's needs were being met and if the care being provided was always appropriate. However on our second day of inspection we saw that records had been updated and accurately reflected people's needs.

There was a robust activity programme which was designed to meet people’s individual needs and help people maintain their independence and provide enough mental stimulation for people.

People were confident that the service was well led and the manager was responsive to their concerns. There were systems in place to assess the quality of care and ask people how they found the service. This enabled the manager to improve the service when required and run it in the interest of the people using it. The manager was not always proactive in reporting events to the local Authority or properly investigating events affecting people’s well-being.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of this report.