This inspection took place on 24 October 2018 and was unannounced. This meant the provider and staff did not know we would be attending.

Four Seasons is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Four Seasons accommodates up to 72 people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of our inspection 66 people were using the service.

The last comprehensive inspection of Four Seasons took place in July 2017, when the service was rated requires improvement. This was due to maintenance and cleanliness issues on the unit for people living with a dementia.

After that inspection we received concerns about an incident involving a person using the service that had allegedly been shared on social media. As a result, we undertook a focused inspection in March 2018 to look into those concerns. We saw that improvements had been made to maintenance and cleanliness of the unit for people living with a dementia, and the rating of the service was changed to good.

There was a registered manager in place, who had been registered since March 2017. 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 premises and equipment were not always clean or well-maintained. Medicine records were not always accurately completed. Staff had not always received training deemed mandatory by the provider, and training records were incomplete. The provider’s governance systems were ineffective at ensuring mental capacity assessment and best interest decisions were made and recorded effectively. People were supported with food and nutrition but records relating to this had not always been consistently or effectively completed. The provider’s governance processes had not identified or resolved the issues we saw during the inspection.

Risks to people were assessed and plans put in place to reduce the chances of them occurring. Plans were in place to support people in emergency situations. People were safeguarded from abuse. Staffing levels were monitored to ensure enough staff were deployed to support people safely. The provider’s recruitment processes minimised the risk of unsuitable staff being employed.

Staff were supported with regular supervisions and appraisals. People's health and social needs were assessed before they moved into the service to ensure the correct support was made available to them.

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. The service worked with other external professionals to ensure people received the healthcare they needed. The premises had been adapted for the comfort and convenience of people living there.

People spoke positively about the support they received from staff. People were treated with dignity and respect. Staff worked to promote people’s independence by encouraging them to do what they could safely for themselves. Throughout the inspection we saw numerous examples of staff delivering kind and caring support. Policies and procedures were in place to support people to access advocacy services.

People received person-centred support based on their assessed needs and preferences. People were supported to access activities they enjoyed. Policies were in place to investigate and respond to complaints. At the time of our inspecti

This inspection took place on 29 March 2018 and was unannounced.

We carried out an unannounced comprehensive inspection of this service on 26 July 2017. After that inspection we received concerns about an incident involving a person using the service. As a result we undertook a focused inspection to ensure that people were safe and to see if the service was well-led. This report only covers our findings in relation to those topics. We did not investigate the specific concerns but did check to see how the provider had investigated them and acted to keep people safe. 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.

Four Seasons 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. Four Seasons accommodates up to 72 people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of our inspection 58 people were using the service.

There was 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. The registered manager was also one of the owners and registered providers of the service.

At our last inspection in July 2017 we found people who lived at Four Seasons were not always safe because the provider did not ensure the premises were properly maintained and was not effectively monitoring the level of cleanliness in the home. The provider’s quality assurance processes had not identified this. We took action by rating the safe and well-led domains as requires improvement. When we returned for this latest inspection we found that improvements had been made to the premises, furniture and quality assurance audits.

Risks to people were assessed and plans put in place to reduce the chances of them occurring. Plans were in place to support people in emergency situations. Measures were in place to ensure appropriate standards of infection control. Policies and procedures were in place to safeguard people from abuse. Medicines were managed safely. There were enough staff deployed to support people safely. The provider’s recruitment procedures minimised the risk of unsuitable staff being employed.

Staff spoke positively about the culture and values of the service and said they felt supported in their roles by the registered manager. The registered manager had worked to create and maintain a number of community links to help enhance people’s quality of life. The registered manager had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken.

This inspection took place on 26 July 2017 and was unannounced. This meant the staff and the provider did not know we would be visiting.

Four Seasons was last inspected by CQC on 3, 12 and 19 June 2015 and was rated Good overall. At this inspection we found the service was not meeting all the fundamental standards we inspected against and we rated the service Requires Improvement overall.

The home had a registered manager in place. A registered manager is a person who has registered with 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.

Four Seasons is a care home which provides accommodation with personal care and nursing for up to 72 older people and people with a dementia type illness. At the time of the inspection 65 people used the service. The home is divided into 3 separate buildings, with one providing nursing care (Autumn – 27 people) and two providing residential care (Spring – 16 people, and Summer – 22 people).

The home comprised of 72 bedrooms, the majority of which were en-suite. Facilities included several lounges and dining rooms, communal bathrooms, shower rooms and toilets, a hairdressing room, sensory room and several communal gardens. The layout of the building provided adequate space for people with walking aids or wheelchairs to mobilise safely around the home and was suitably designed for people with dementia type conditions.

The home continued to provide a wide variety of activities for people and had been successful in winning a number of awards which they were proud of. The range of activities and meaningful engagement people experienced was extensive and tailored to each person’s needs. This gave people a sense that they were valued and continuing to contribute to the local community life.

We saw that entry to the premises was controlled by key-pad entry and all visitors were required to sign in. This meant the provider had appropriate security measures in place to ensure the safety of the people who used the service.

The provider did not ensure the premises were properly maintained and was not effectively monitoring the level of cleanliness in the home.

The provider had audits in place to measure the quality of the service however the audits were not used effectively and had failed to identify the deficits we found in the service.

People who used the service and their relatives were complimentary about the standard of care at Four Seasons. We saw staff supporting and helping to maintain people’s independence. People were encouraged to care for themselves where possible. Staff treated people with dignity and respect.

The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff. There were sufficient numbers of staff on duty in order to meet the needs of people using the service.

Training records were up to date and staff received supervisions and appraisals, which meant that staff were properly supported to provide care to people who used the service.

The service was working within the principles of the Mental Capacity Act 2005 and any conditions on authorisations to deprive a person of their liberty were being met.

All the care records we looked at contained evidence of consent.

People were protected against the risks associated with the unsafe use and management of medicines.

People had access to food and drink throughout the day and we saw staff supporting people at meal times when required.

All the care records we looked at showed people’s needs were assessed. Care plans and risk assessments were in place when required and daily records were up to date. Care plans were written in a person-centred way and were reviewed regularly.

We saw staff used a range of assessment tools and kept clear

The inspection team who carried out this inspection consisted of two inspectors. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

We used a number of different methods to help us understand the experiences of people using the service, because many of the people using the service had complex needs which meant they were not able to tell us their experiences. During our visit the team spent time on each unit, observing the care and support people received, talking with people who used the service, their relatives, staff, a visiting health care professional, and looking at records.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

Safe systems for the storage, administration and management of medicines were in place. Nursing staff administered medication on the nursing unit, with trained care staff administered medication on the residential units. Where people had specialist needs relating to medication, information about these was recorded in their care records. For example, information about medication prescribed on an ‘as required’ basis and the arrangements that had been put in place for covert medication administration.

People were now being cared for in an environment that was safe and had been reasonably maintained. Some redecoration and refurbishment had taken place and further work was planned to address the areas of the home that still looked “tired.” New maintenance staff had been employed and records showed that routine checks were being carried out to ensure that the premises were safe and maintained to a reasonable standard.

There had been changes made to the staff team working at Four Seasons and the numbers of staff on duty. We found that there were enough staff on duty to meet the needs of the people living at the home. However, some relatives still felt that staff could be very busy at times.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Four DoLS authorisations were in place and two were in the process of being assessed at the time of our visit. The manager understood when an application should be made, and how to submit one. Information was available to staff about the Mental Capacity Act and DoLS, MCA awareness sessions had been provided and further training was planned for staff.

Is the service effective?

Feedback from people who used the service and their relatives was mainly positive. People told us that people received the general care they needed. However, two relatives raised similar issues, saying that although basic care was generally satisfactory, sometimes the details could be better. For example, sometimes their relative’s nails could be cleaner, hair could be tidier or clothes could be changed sooner if they became dirty from spilled food or drink. The relatives we spoke with felt that this could be due to the availability of staff when they were busy, with one commenting “Maybe down to there not being enough staff to see to those details that make all the difference.”

Is the service caring?

We saw people being supported by staff in kind and caring ways. For example, we saw staff explaining what was happening, taking their time and talking with people while carrying out care tasks. Relatives were generally complementary about individual staff, but we did receive comments about some staff being better than others. For example, comments made about staff included; “Really good”, “Really attentive”, “Some go out of their way” and “Others you know when you hear their name that you are not going to get anywhere.”

Is the service responsive?

People’s needs had been assessed and plans put in place for their care needs. Records included information about people’s preferences and individual needs. Systems were in place to assess risks and monitor people’s needs, so that care needs could be identified and responded to. A visiting health care professional told us that in their experience the service had followed things through and listened to their advice. The relatives we spoke with told us that they were kept informed about their loved one’s care. For example, one person commented “They are pretty good at that” and another said “Sometimes you have to ask for things, but staff are helpful when asked.”

Is the service well-led?

The service had a new manager, but they had not yet registered with us as manager of the home. The manager was able to show us the changes and improvements they had made since starting work at the home. They were enthusiastic about their role and keen to make improvements. Staff told us that the manager was approachable and effective. Comments included “It’s got a lot better with this manager here”, “He’s a manager you see and he puts you at ease straight away” and “The communication has got loads better, the staff all get on better, it’s a much nicer place to work”.

Overall we found that effective systems to assess and monitor the quality of the service had been put in place. However, many of these systems were still in the early stages of implementation and will need to be sustained and developed over time.

Following our inspection in February we found that several incidents had occurred, which should have been raised as safeguarding alerts but staff had not done so. We asked the acting deputy manager to raise them retrospectively and to complete appropriate notification forms and send these to CQC, which she did the following week. Whilst reviewing the submission of notifications since the manager had been on extended leave we noted that CQC had not been appropriately notified of other incidents such as the problems with the water. It is a direct breach of the regulations not to submit notifications to CQC and we are taking action away from this process to address the matter.

In light of these omissions we had concerns and completed this inspection to review how the provider oversaw the operation of the service provided at the home. The new manager had found that effective monitoring systems had stopped during the previous manager’s extended leave. He had re-introduced these and taken adequate steps to ensure the quality assurance system was effective.

Whilst at the home we spoke with five staff and observed care offered to people. Staff reported that the home was improving under the direction of the new manager. We saw that staff were attentive to people’s care needs and heard about the activity coordinator’s plan to for people from the home to attempt to break the World Record for the largest picnic on a knitted blanket they had all made.

We visited the home because we received information suggesting that too many people lived in the nursing unit, which meant not everyone had a room. We were also informed that staff on the nursing unit were not rapidly identifying when people’s needs changed and were not therefore seeking assistance from other healthcare professionals in a timely manner.

We talked in-depth with the deputy manager and head of residential care who were on duty. We found that the home was full but not exceeding the stated number of available places. We noted that the lift in the nursing unit had broken and this had led to staff temporarily moving people to more accessible rooms if they could not manage the stairs. The home had also alerted us to this issue and taken steps to ensure the lift was repaired in a timely manner. When we visited a lift engineer was on site repairing the lift.

We spoke with three people who used the service. People said: “I’m happy here” and “The staff are lovely”.

Information we received suggested a person had not received appropriate care. We found from a review of their records that when the individuals had become unwell, staff had contacted the GP and they had been seen by a clinician from the GP surgery on the same day. We found that staff had taken appropriate action to meet their needs and regularly monitored the person.

We completed this follow-up inspection to check whether action had been taken to deal with the issues raised at the last inspection. At that inspection we found the staff needed to apply the Mental Capacity Act 2005 requirements appropriately. The provider needed to ensure the quality assurance measures used to monitor practice within the home were effective. Also action needed to be taken to improve the records used within the home.

We found that the new manager had ensured all the staff completed additional training around working with people who may lack capacity to make decisions; when they could restrict people’s lifestyles; and when to apply for Deprivation of Liberty Safeguards. We talked with five staff who were on duty. We found that these staff were now aware of how to apply the requirements of the Mental Capacity Act 2005. We saw that staff were less risk averse and now supported people who used the service to lead more independent lives. People were no longer prevented from following everyday lifestyles, such as going for a walk in the grounds.

We spoke with six people who used the service and two relatives. People told us they were happy with the service. They said: “I like the staff and find that they are always helpful” and “It is lovely here”.

We also found that the new manager had ensured an effective quality assurance system was re-introduced and made sure all of the records had been improved.

We spoke with four people who used the service and two relatives. People told us that they found the staff were kind, friendly and they knew how to assist them. They said “It is nice here, they are a good bunch”, “We get on really well and they are always giving me a hand” and “I’m asked what I want to do and that”. The relatives we spoke with thought the staff appropriately supported the individuals.

The activities coordinator told us about the entertainment she arranged. The crafts people had made were displayed throughout the three units. We were told that 20 people who used the service had completed the NAPA Challenge ‘Dance with me’ and they had won first prize.

Many of the people who lived at the home found it difficult to think about recent events or at times, to have a conversation. During the visit we used a specific way of observing care to help to understand their experience of the service. We found that the nursing and care staff were adept at working in ways that supported the people who used the service.

The nine staff we spoke with told us that the teams in each of three units were working well. Staff who had recently commenced work at the home told us that they had received a comprehensive induction and were supervised for at least the first week. We talked with six staff who were on duty about people’s ability to make decisions. We found that staff were unaware of positive risk taking practices or requirements of the Mental Capacity Act 2005.

We did not gain feedback from people living at the home during this visit as the inspection was a follow up visit which focused on staff training and supervision.

The visit took place because we were following up concerns raised at the last two

inspections in August and November 2011. Following the November inspection a warning notice was issued in respect of ensuring care records assisted staff to met people's care needs. A warning notice regarding the safe handling of medication had also been issued. We have checked the warning notice in respect of care records and found this had been met. At this inspection we looked at staff practice when storing and administering medication. We were unable to speak to anyone about their medicines at this visit.

The visit took place because we were following up concerns raised at the last two inspections in August and November 2011. At the last inspection a warning notice was issued in respect of ensuring care records assisted staff to meet people's care needs. We also found that the requirements of the warning issued in relation to safe handling of medication had not be met. The Care Quality Commission (CQC) pharmacist inspector is checking whether this matter was resolved. Therefore, in this inspection we concentrated on those specific areas raised about care records, the quality assurance system and staff training. When talking to people we concentrated on those specific matters.

We spoke to nine people who used the service and three relatives. People said the staff understood how to meet their care needs and were very attentive. Relatives said the staff, ''were a good set'', ''I find that they are always there and really know how to help my relative'' and ''The staff have hearts of gold and are always very helpful''. People told us that ''The girls are kind'', ''I like it here'' and ''They put my mind at rest''. A significant proportion of the people living at the home had marked problems with their memory and found it difficult to think about recent events or at times to hold a conversation. Therefore we also observed they way staff delivered the care. From our observation we found staff effectively supported the people; made sure individuals could follow what had been said; included people in conversations; and approached people in a gentle and caring manner. If people were experiencing distress staff quickly went to the person and offered comfort. Staff had still not received the planned training in dementia care, but we found that a number of staff on duty had previously attended this type of course and the way they did interact with people suggested their learning had been used to develop their practices.

The visit took place because we were following up concerns raised at the last inspection in August 2011. Therefore we concentrated on those specific areas raised in the last inspection when talking with people. We spoke to twelve people who used the service, two visiting clergy and three relatives. People said the staff were easy to get on with and they had found when they raised issues these were acted upon. One person told us of an issue that they had raised with the local authority and how the staff had worked through their concerns and put actions in place to deal with it.

People said the staff were ''were a good bunch'', ‘'lovely'' and ''I have always found the staff to be very helpful''. People told us that the meal times had improved and now they no longer needed to sit around in the dining room for a lengthy period of time. We were looking at medication practices, but people did not make specific references to how staff looked after their medication. People did tell us that if they became unwell the staff quickly got in touch with the doctor.

A proportion of the people living at the home had marked problems with their memory and found it difficult to think about recent events or at times to hold a conversation. Therefore we used a specific way of observing care to help to understand the experience of people who could not talk with us. This involved spending a substantial part of the visit observing a group of people to see how they occupied their time, appeared to feel and how staff engaged with them.

From our observation staff were constantly working in ways that supported the people and they made sure individuals could follow what was being said; included people in conversations; and approached people in a gentle and caring manner. If people were experiencing distress staff quickly went to the person and offered comfort. Staff have not recently received training in dementia care, but did interact with people in a very caring and respectful manner.

We spoke to approximately fifteen of the people using the service and all said the staff were easy to get on with. People said the staff were 'smashing', 'lovely' and 'there is not a bad one amongst them'.

People told us that there was always plenty of food and that if they did not want what was on the menu the cooks would make something else. However people on one of the residential units felt they were expected to sit around in the dining room for an intolerable amount of time. One person told us that they sit for 2 hours each mealtime waiting for the food and then waiting to be allowed to leave the dining room.

One of the relatives we spoke to said that sometime ago there had been some problems but these were now resolved. They said all the concerns they had raised were dealt with in a timely manner and to their satisfaction. They said the manager was always very approachable and went out of her way to ensure people were looked after properly.

Comments from people using the service included, 'It’s a lovely home',' I really like it', 'I am happy living here and I wish I had come here before'. ' I can do the things I want', 'I can sleep in until dinner time', I watch telly'. 'The staff are wonderful', 'they are very kind and caring', 'they listen to me'. 'The food is great', 'it’s like a restaurant', 'it’s better now'. 'There is always something going on', 'I enjoy painting', 'we bake cakes', we go out to places' and 'I feel safe, they look after me', 'I don’t worry about anything'.

We inspected Four Seasons on 3, 12 and 19 June 2015. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting.

Four Seasons is a care home which provides care for up to 72 people. It is divided into 3 separate buildings, with one providing nursing care and two providing residential care. The home provides care for people with dementia. At the time of the inspection 69 people used the service.

The home had a manager in place and they were in the process of applying to become the registered manager. 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 a range of stimulating and engaging activities were provided at the home. The two activities coordinators had linked into a wide range of local resources, which included clubs and societies as well as people who used the service who volunteered for a garden preservation society. People routinely went to these clubs. The registered provider had developed the garden and this was now fully accessible and people who used the service had vegetable patches as well as chickens. The activities coordinators had organised a choir, which people who used the service sang in and this group made a yearly demo record.

Each year people who used the service were supported to enter competitions such as the National Activities Programme Award and had won several national prizes. They had come third last year in the picnic competition; people who used the service and staff knitting a huge blanket and all joining in a large picnic. People and staff, on several occasions, had attempted to become Guinness Book of World Records holders. The activities coordinators and people who used the service used their skills and expertise to fund raise and had collected over £36000 this year. The people who used the service and relatives had determined how this was to be spent and decided that some would be allocated to renting transport whilst the remaining monies would be used to enrich the lives of the people who were unable to get out and about.

People told us that staff worked with them and supported them to continue to lead fulfilling lifestyles. Staff outlined how they supported people to continue to lead independent lives. For those people who lived with a dementia, we saw that staff matched their behaviour to people’s lived histories (the time of the person’s life they best recall) and this enabled individuals to retain skills and work to their full potential.

We found that people were encouraged and supported to take responsible risks and positive risk-taking practices were followed. Those people, who were able to, were encouraged and supported to go out independently and others routinely went out with staff.

People we spoke with told us they felt safe in the home and the staff made sure they were kept safe. We saw there were systems and processes in place to protect people from the risk of harm.

People who used the service and the staff we spoke with told us that there were enough staff on duty to meet people’s needs. A nurse, two heads of care, two senior care staff and ten care staff were on duty during the day and a nurse, two senior care and eight staff on duty overnight. However, we noted that staff could be deployed more effectively across the three units to ensure support was readily available during the early morning and at mealtimes. The manager undertook to provide a floating twilight and dawn staff member as well as review mealtime practices.

We reviewed the systems for the management of medicines and found that people received their medicines safely.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. We found that all relevant infection control procedures were followed by the staff at the home and saw that audits of infection control practices were completed.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as dementia care. We found that the manager not only ensured staff received refresher training on all training on an annual basis but had introduced checks to make sure staff understood how to put this training into practice. Each month the manager questioned staff about different aspects of the courses and when staff struggled to find the correct answer they ensured staff received additional training.

Staff had a greater understanding of the requirements of the Mental Capacity Act 2005 and had appropriately requested Deprivation of Liberty Safeguard (DoLS) authorisations. Staff had been working hard to ensure capacity assessments were completed in line with the Mental Capacity Act 2005 code of practice. They and the manager recognised that they were still developing the skills needed to always complete these accurately and they needed more space on the sections relating to people’s ability to take on board information to write their analysis.

People told us that they made their own choices and decisions, which were respected by staff but they found staff provided really helpful advice. We observed that staff had developed very positive relationships with the people who used the service. The interactions between people and staff were jovial and supportive. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity. Staff also sensitively supported people to deal with their personal care needs.

Where people had difficulty making decisions we saw that staff gently worked with them to work out what they felt was best. We saw that when people lacked the capacity to make decisions staff routinely used the ‘Best Interests’ framework to ensure the support they provided was appropriate. We found that staff had also obtained information to confirm whether relatives had been appointed to the role of lasting power of attorney care and welfare and that these powers had been enacted or confirmed as in place.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight and nutritional needs.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People’s needs were assessed; care and support was planned and delivered in line with their individual care needs. The care plans contained comprehensive and detailed information about how each person should be supported. We found that risk assessments were very detailed. They contained person specific actions to reduce or prevent the highlighted risk.

We saw that the registered provider had a system in place for dealing with people’s concerns and complaints. The manager had ensured people were supported to access independent advocates when needed. People we spoke with told us that they knew how to complain and felt confident that staff would respond and take action to support them. People we spoke with did not raise any complaints or concerns about the service.

The registered provider had a range of systems to monitor and improve the quality of the service provided. We saw that the manager had implemented these and used them to critically review the service. This had led to the systems being extremely effective and the service being well-led.