About the service: Four Seasons is a residential care home in Gloucestershire that provides personal care for up to 21 older people, some of whom are living with dementia. At the time of our inspection 16 people were using the service.

People's experience of using this service:

•The provider had a clear vision for the service. There were systems in place to monitor the quality and risks in the service, ensure staff kept up to date with good practice and to seek people's views.

• Staff morale was low. Staff told us they did not always feel confident to challenge more senior staff regarding concerns they might have as they did not feel their views were always listened to and respected. They also told us they had limited opportunities to feed back to the provider as staff meetings had not taken place regularly and staff surveys were not completed. The provider assured us they would take action to improve the staff morale.

• Despite staff’s concerns with the service’s leadership we found staff to be hard working, caring and committed and people had consistently received safe and personalised care.

• People felt safe and were protected from avoidable harm by staff who understood how to keep them safe.

• Staff supported people to take their medicines safely and understood how to prevent the spread of infection.

• People were empowered to decide how and when their care was provided. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice.

• People were supported to maintain relationships with people important to them, including others living in the home.

• People’s needs were assessed to ensure they could be met by the service. Staff had a good knowledge of how to support people.

• Staff were recruited safely, and there were enough staff to meet people’s assessed needs.

• People, relatives and health professionals told us the care provided was effective and people experienced positive outcomes.

• Staff respected people’s rights to privacy and dignity and promoted their independence.

• Systems were in place to manage and respond to any complaints or concerns raised.

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

Rating at last inspection: At our last comprehensive inspection of this service in February 2016, we rated the service as 'Good'. At this inspection the service was rated as ‘Requires Improvement’ in Well Led and remains ‘Good’ in all other areas and therefore ‘Good’ overall.

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

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner. We will ask the provider to keep us updated on the progress made to improve the rating of the key question ‘Is the service Well-led?’ to at least Good.

We carried out an unannounced comprehensive inspection of this service on 29 February 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection on 18 October 2017 to check that they had followed their plan and to confirm that they now met legal requirements in relation to a breach of Regulation 15, premises and equipment. The inspection was also prompted in part by the notification of a moving and handling incident. This incident did not result in injury. However, the information shared with CQC about the incident indicated potential concerns about the management of risk in relation to people's use of hoisting equipment. This inspection examined those risks. This report only covers our findings in relation to these two issues. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Four Seasons on our website at www.cqc.org.uk

Although we found improvements had been made, our findings at this inspection have not changed the current rating of 'requires improvement' for the key question safe. We did not change this rating because we did not review all of the key areas of this question. We will review all of the key questions at our next comprehensive inspection.

There was a registered manager in place. A registered manager is a person who has registered with the CQC 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 unannounced comprehensive inspection of this service on 29 February 2016 a breach of legal requirements was found. After this comprehensive inspection, we asked the provider to take action to make improvements to the cleanliness of the environment and infection control procedures. We found these improvements had been made. The provider had met the requirements of the regulation.

People were protected against the risk of infection. Systems for the prevention and control of infections had been improved. Domestic staff were employed to provide a seven day service and a bathroom had been refurbished. Cleaning schedules were being followed and monitored to make sure the cleanliness of the environment and equipment had been maintained.

People were protected against the risk of harm through accidents and incidents. Their moving and handling needs were risk assessed and staff had been provided with training to make sure they knew how to use any equipment provided for moving and assisting people as safely as possible.

At the last inspection, the service was rated overall as Good. The rating was clearly displayed in the home.

This inspection was carried out on 23, 24 and 29 February 2016 and was unannounced.

Four Seasons provides accommodation and care to a maximum of 21 elderly people. At the time of the inspection there were 15 people living in the home. Services were provided across two floors with a passenger lift for access the second floor. Prior to admission a person’s needs had to be particularly assessed in relation to the environment as some areas had space limitations. This meant for example, some areas of the home were not suitable if people required a lot of moving and handling equipment such as a wheelchair and a hoist. Some bedrooms had private toilet and washing facilities. Bedrooms which did not have these facilities had wash hand basins. Communal bathing facilities had been adapted to make bathing easier and safer for the frail older person. A large lounge with a television and music system was enjoyed by several people. A separate dining room provided people with an area to eat and take drinks in. A summer room could be enjoyed in the warmer weather only as this room did not have heating. The garden was well tended with a summer house which people liked to use, also in the warmer weather.

The registered manager had managed the home since 2014. 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 did not live in an environment which had been kept suitably clean enough to protect them from potential avoidable infections. This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.’ We also recommended that the provider seek suitable advice and guidance in relation to the cleaning of particular items of equipment.

Arrangements were in place to protect people from other risks. Risks were generally well identified, managed and monitored. This included risks against abuse. The registered manager ensured there were enough staff with the appropriate knowledge and qualifications on duty to meet people’s needs. Good recruitment processes and a commitment to address poor practice also helped to ensure people were kept safe.

People’s care was tailored to their needs and delivered by staff who were well trained and supported to do this. People’s care was delivered after they provided consent. Where a lack of mental capacity prevented people from being able to do this they were protected under the Mental Capacity Act 2005. This was because the staff understood the principles behind the Act and made sure it was adhered to. People were therefore supported to make decisions about their care and treatment if they were able to do this. These decisions and people’s preferences and wishes were very well considered when planning their care. Where people were unable to be part of this process their family or representatives were encouraged to represent them and speak for them. Staff were particularly caring and compassionate. This was recognised by visiting health care professionals and appreciated by those receiving care and their relatives.

A close working relationship with community health care professionals ensured people’s health needs were reviewed regularly and met. Community health care professionals also helped the staff deliver people’s end of life care. People’s medicines were well managed. Risks related to poor nutrition and loss of weight were monitored and addressed. People received very good support to eat a nutritious diet in order to maintain their well-being. When people required specialised equipment to help retain their independence or keep them safe appropriate actions were taken to ensure this was pr

On 9 August 2013 we found people who used the service were not protected against the risk of unsafe or inappropriate care and treatment arising from a lack of information about their care needs. Care plans and risk assessments did not always reflect people's needs or risks. Where care/support had been altered to meet people's needs or risks, their care records did not record this. Where other professionals had been involved in meeting people's health needs, such as a community nurse or doctor, this had not always been recorded. This meant people's care records did not contain up to date information about how people's needs were to be met or how, in some cases, they had been met. The provider wrote to us and told us how they would address these issues by 30 November 2013.

On 18 December 2013 we returned to the service to check on their progress. We found that improvements had been made to people's care records but they were not always reflecting people's needs or risks. Some care and treatment had still not been recorded. Following this inspection the provider wrote to us and told us how they would complete the improvements they had started to make by 3 March 2014.

An adult social care inspector carried out this inspection. We inspected two people's care files and the completed audits of three further care files. We spoke with the member of staff who had taken the lead on improving care records and we spoke with another member of staff about their new involvement with the care records. We also spoke with a representative of Four Seasons Mickleton Ltd. They told us how they ensured that the improvements made were being maintained.

When carrying out inspections five key questions are asked: is the service safe, effective, caring, responsive and well led?

As this inspection was following up non-compliance in one area, the question asked was is the service safe?

Below is a summary of what we found. The summary describes what staff told us, what we observed and what the records told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People's care needs had been assessed and this was recorded. Care plans had been reviewed since our last visit in December 2013 and some had been re-written to reflect people's abilities, choices and needs. Reviews of care records, such as care plans and assessments of risk, which assess risks such as falls and weight loss, had been completed monthly or as people's needs had altered. Where people's needs had altered and a change in care/support had been required, this had been clearly recorded in the content of the review. This meant staff had up to date guidance on what care people required and how to deliver this.

We found that where health care professionals from other agencies had been involved in reducing risk or monitoring people's changing health needs this had been clearly recorded. This meant staff had accurate information about what advice had been given, what adjustments they needed to make to their care delivery and how people were to be kept safe.

The service had accomplished improvement in how records about people's care were written and maintained. Systems were also in place to continue to identify shortfalls and discuss how record keeping could improve further. Support to staff remained in place so they continued to improve their skills in record keeping and care planning.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Consideration of Deprivation of Liberty principles was reflected in people’s care plans. Relevant staff had been trained to understand when an application should be made and how to submit one.

We did not speak to people who used the service during this follow up inspection. Instead we re-visited the care records of people who used the service, spoke to staff about the new management arrangements and met the new management team.

We found that people's needs had been met and senior staff were more proactive in communicating with and accessing support from external health care professionals when needed. Risks to people were being appropriately managed and the potential impact on the person reduced.

Arrangements for controlling the spread of infection were more robust and the cleanliness of the environment had improved.

Due to a re-organisation in how staff were deployed staff were more able to be available to meet people's needs. Staff were being provided with training and support. Some staff had left since our last inspection on 9 August 2013 and new staff had been employed.

New and robust systems had been adopted by the management team to monitor the care and services being provided to people who used the service. Record keeping had improved but some care records had not been maintained accurately and in these cases, people had been at potential risk of receiving inappropriate or unsafe care because of this.

This inspection was carried out after we received information of concern which related to how some people's needs had been assessed and met and how the service was staffed and how it was being managed.

We spoke to six people who used the service. One person said "It's very nice here", another person said "I wish I could go for a walk more often". Where people were unable to express a view we gathered evidence about their experiences by observation, inspecting care records and speaking with staff. We found that people's needs were generally being met. In some cases however, through a lack of leadership and direction, people's needs had not been identified as immediately as they could have been. One relative was happy with the care being delivered to their family member, but sometimes was not always confident that things were followed up by senior staff.

We found general disorganisation in the way the service was being managed. This was reflected in a lack of sufficient cleaning hours being worked and action taken to sort this out. Care staff were having to perform other tasks, such as kitchen tasks, rather than being able to concentrate on people's care delivery. There were systems to monitor areas of service provision and practice, however this was not effective as it was not resulting in action being taken to resolve the shortfalls. Some staff lacked appropriate training. Records, such as duty rosters and some care records were not being accurately maintained.

When we visited the service 18 people were accommodated. We spoke to ten people living in the home, one relative, the registered manager, three care staff and a domestic cleaner. People were generally pleased with the service and told us, "the staff are very kind", "I like the food", "I can do what I like", and "the staff always ask me before they begin bathing me". A relative told us, "the staff could come and talk to people more in the afternoons". People's concerns and complaints had been recorded and taken seriously. Additional staff had been recruited to address a recent concern.

We found well recorded care plans and healthcare records and people had support from healthcare professionals. People's consent had been recorded when required and they were also asked about their care.

The home was well maintained and clean throughout and there were regular safety checks to help ensure people were safe in accessible surroundings that promoted their wellbeing.

Recruitment records were complete and staff had an informative induction programme.

People are treated with dignity and respect and they told us, “the staff are fine they treat me with respect” and "I can do what I like here and there are lots of activities to join in with".

We were also told that on the whole the care was very good. One person felt that the staff did not always have enough time to talk to them.

People told us they felt safe and knew how to raise concerns as they had the complaints procedure and safeguarding information in their own copy of the service user guide.

People told us the staff were very good and generally we observed people receiving the correct support and encouragement.

Regular surveys are completed by people living in the home to help ensure that the quality of the care is monitored and people have a say in how the home is run.