About the service: Fosse House Nursing Home is a care home. It provides accommodation and personal care for up to 37 older people. At the time of the inspection there were 33 people living at the service.

People’s experience of using this service: The service has on two previous occasions been rated as requires improvement. Some improvements were made in ensuring people who were not able to make a choice were assessed and treated in their best interest. Medicine management had also improved.

• People were supported by a consistent staff team who were kind and caring. Staff had good relationships with people and knew them well. People were encouraged and supported to maintain their independence.

• People received their medicines safely and as prescribed except for prescribed creams which required more direction for staff to follow. Medicine management practices were safe. However, medicine policies did not effectively cover the administration of concealed covert medicines and PRN protocols were not always in place. Handwritten medicine administration records had not been signed by two staff.

• Care plans and risk assessments did not always contain accurate and complete information, particularly in relations to people’s specific health conditions. There was a lack of guidance in how risks should be managed safely.

• Recruitment procedures ensured all relevant checks were completed before new staff began work.

• Audits had not always identified shortfalls we identified.

• An activities time-table was provided to all. An activities coordinator was in post and people were engaged if they wished.

• People spoke positively about the food provided at the service.

• Relationships were supported both within and outside the service. Visitors were welcomed. The service was clean and tidy.

• Feedback was sought from people through direct contact with people and their relatives and staff through meetings and questionnaires. Relatives said the service communicated well with them. People felt comfortable in raising any concerns or issues.

For more details, please see the full report which is on CQC website at www.cqc.org.uk

Rating at last inspection: Requires Improvement (19 December 2017 and 9 January 2018). This service has been rated as requires improvement at the previous two inspections (November 2016 and March 2018).

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

Enforcement: We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we made one recommendation into guidance for specific health conditions. Please see the ‘action we have told the provider to take’ section towards the end of the report

Follow up: We will review the report on actions the provider intends to take following the inspection. We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

We undertook an unannounced inspection of Fosse House Nursing Home on 19 December 2017 and 9 January 2018. When the service was last inspected in October 2016 no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified.

Fosse House Nursing Home provides accommodation and nursing care for up to 37 people. The home is over two floors with lounge and dining areas on each floor. The home provides care to older people. At the time of our inspection there were 27 people living in the home.

Fosse House Nursing Home is a “care home”. People living 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.

There was a registered manager in post at the time of this inspection. 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.’

There was a lack of a robust arrangements to ensure people's rights were protected where decisions were made on people's behalf specifically where actions were taken which could be viewed as restrictive practice such as the use of bed rails.

There were mixed views from people about the staffing arrangements in the home. Some were satisfied but others said there was not enough to respond in a timely way to care needs. There was no formal system to decide on the numbers of staff required to meet people needs safely and effectively. We have made a recommendation about the provider reviewing how decisions are made in relation to staffing arrangements in the home.

Whilst there were arrangements for the reviewing of people's care needs this was not always undertaken with the person and/or their representative.

We have recommended the provider review how decisions are made about staffing arrangements in the home.

People told us activities could be improved with one person telling us "There is nothing to do-not enough going on." This was an area recognised as requiring improvement because for some people group activities were not an option either because of their frailty or as matter of choice.

Efforts had been made to improve mealtimes for people in making them a more relaxed and a social occasion. However, this remained an area for improvement specifically to ensure there were enough staff available to support people when it was required.

There was a pathway for end of life care however, this had not been consistently followed for people who were deemed as requiring this care.

The arrangements for supporting people with their medicines were good and people received their prescribed medicines at the times required and people's health and welfare were protected.

People told us they felt safe and staff recognised and were confident about reporting any concerns about the safety and welfare of people.

The service was responsive to people's changing care needs and had good arrangements for getting support from outside professionals such as tissue viability nurses and dieticians.

People told us how they felt they received the personal care they needed. Care was provided in a person centred way with staff having a good understanding of the, at times, complex needs of people.

People were confident of having their views and concerns listened to by the registered manager. One person told us, "The manager is very good you see her around the home and can talk to her about any worries we have."

We have identified a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014: Safeguarding service users from abuse and improper treatment. You can see what action we told the provider to

This inspection was unannounced and took place on 11 October 2016.

Fosse House Nursing Home is registered to provide accommodation and nursing care to up to 37 people. The home specialises in the care of older people. At the time of this inspection 31 people were living at the home.

The last inspection of the home was carried out in May 2013. At that inspection we did not identify any concerns with the care provided to people.

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.

We found that people received care and support which met their physical needs but did not always effectively address their social needs. We found that meals were not always a pleasant and sociable occasion for people and there was a lack of social engagement for people who were not able to occupy themselves. We have recommended that staff look at research and guidance about the best ways to engage with people who are not always able to fully to express themselves.

We also found that some areas of the environment would benefit from redecoration to make sure people lived in a pleasant and homely environment.

The registered manager told us in the Provider Information Return (PIR) that their plans for the future included improving activities and the décor in the home. An additional activity worker had been employed at the time of this inspection. This demonstrated their audits and observations were effective in identifying shortfalls.

People told us staff were always kind and patient and responded quickly to them when they requested help. People felt safe at the home and with the staff who supported them. One person told us “I definitely feel safe here. The staff are always kind to you.”

The provider had a robust recruitment process which minimised the risks of abuse to people. All staff knew how to recognise and report any concerns. People said they would be comfortable to talk with the registered manager or a member of staff if there was any aspect of their care they were unhappy with. Records showed complaints were always investigated.

People’s healthcare needs were monitored by trained nurses and referrals were made to other professionals in accordance with people’s specific needs. Where advice was given by professionals, staff followed the advice to make sure people received appropriate care and treatment. People received their medicines safely from trained nurses or senior staff who had received specific training to carry out the task.

People’s privacy was respected and people were able to spend time in their rooms or the communal areas of the home. Visitors were always made welcome.

We carried out this inspection as part of our routine schedule of inspections. We spoke with seven people who lived in the home and one person who was visiting.

People spoken with told us they were happy with the care they received. One person told us, "It is really good, I think it has improved in the last few months. Staff smile and are happy to chat. It’s a tough job but nobody complains”.

We observed staff had a close and friendly rapport with people, one group of people we spoke with told us, “They take the time to show they are interested that means a lot”. We saw people were encouraged to make their own decisions about taking part in daily activities.

We saw care planning was person centred and agreed with the individual when possible or a relative. We found that people consented to their care and treatment, both in writing and verbally on a daily one to one basis.

We found the receipt, storage and administration of medication was managed safely within the Royal Pharmaceutical Society guidelines.

Staff spoken with confirmed they were given the opportunity to build on their skills and received appropriate support from the acting manager.

The provider had quality assurance systems in place that ensured people were safe and changes could be made to improve the service provided.

We spoke with four people who lived in the home and the relatives of one person. Everyone we spoke with said that the staff were respectful and treated them properly. People told us, “I think the staff are really wonderful” and “Staff are perfectly kind and respectful”. We observed people in the dining room at lunchtime. Staff treated people respectfully and introduced themselves whenever they engaged with people or offered to assist them with their meals. People told us, “They come around and ask you what you would like”.

People we spoke with said they were happy with the care provided. We were told “We are all looked after properly” and “Staff come quickly when I need them”. One person said, “The staff are very pleasant people. I feel perfectly safe here”. A relative told us, “I’ve seen nothing but kindness here, I can’t speak highly enough about the staff” and “The staff have bent over backwards to make sure my relative is comfortable”. One person told us that in their opinion staff at night were very busy. We observed that staff in the dining room were also busy over the lunchtime period

People told us they were able to express their views and were involved in making decisions about their care and daily living. We were told, “I’ve got no grumbles, if I ask for anything it will be sorted”

People told us that the manager was very visible and continually checked that people were received an appropriate standard of service. We observed this. We were told,”The manager is always around and into everything. You name it and she is there” and “I’m happy I’ve come to this home. I’ve had no second thoughts”. People’s relatives were able to visit at any time and could stay for as long as they wished. Relatives told us that they were made to feel very welcome. We were told, “Staff are good at communicating and will let us know about any issues” and “I would recommend this home to everyone”.

We observed that the care plans contained sufficient detail of the care needs of the people at the home.

Staff told us that they felt well supported and that they had received all necessary training. We looked at the training records and saw that some people had not attended all necessary training.

Prior to the inspection we received concerns from one person about the care and support provided at the service. These concerns are currently being reviewed in conjunction with the local authority who have the primary responsibility for safeguarding.

This visit was part of our routine schedule of planned inspections.

We spoke with six people who lived at Fosse House. Some people spoken with were able to tell us about their experiences others were either unable to comment or preferred not to. We also spoke with visitors and staff that worked in the home.

People spoken with said staff members that worked in the home were caring and polite; one person said “They are really nice; there is nothing I can complain about. I like to stay in my room with my book so I don’t really join in things like bingo. Staff do pop in and talk during the day so I get to know what is going on”.

Another person said, “I can’t complain about the care, it is excellent and the staff are really caring. However I do not like some of the activities. There is plenty for people to do if you like the things offered but I would like to do something that makes my brain work a bit harder.” We saw that people who lived in the home took part in a coffee morning and enjoyed the company of people from the village. One person said they enjoyed catching up with “local gossip”.

One person told us that they enjoyed the meals provided in the home, they said, “there is always plenty to eat and the cook is really good at making a very tasty meal, they certainly know what I like and don’t like”.