We undertook an unannounced focused inspection of Friston House on 24 July 2018. The team inspected the service against two of the five questions we ask about services: is the service well led, is the service safe?

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Friston House 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.

Friston House provides accommodation, residential and nursing care for up to 81 older people. The home comprises of three units. The main building has two floors and accommodates people with residential needs with early onset dementia on the ground floor; and people with nursing needs on the first floor. There is a separate 'Memory Lane Unit' for people who live with dementia and nursing care needs.

On the day of our inspection there were 78 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility, pressures ulcers and some people received care in bed.

The service had a 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. The registered manager became registered on the day before we inspected the service. They had previously been in post as the peripatetic general manager.

At the last inspection on 03 and 06 October 2017 the service was rated Good overall and Requires improvement in Responsive. We had made a recommendation in the Responsive domain that registered person's reviewed activities following good practice guidance to ensure people have access to activities and hobbies to meet their needs.

There were enough staff deployed to meet people’s needs. The provider continued to operate a safe and robust recruitment and selection procedure to make sure staff were suitable and safe to work with people. One recruitment record and some maintenance records were not always clear or complete.

Risks were appropriately assessed and mitigated to ensure people were safe. People’s pressure areas had been appropriately recorded and treated. Equipment was in place to meet people’s needs. Medicines were managed safely. Records evidenced that people had received their medicines as prescribed.

Effective systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service. Accidents and incident were monitored and lessons were learned when things went wrong to reduce the risk of it happening again.

People and their relatives were actively involved in improving the service, they completed feedback surveys and had meetings.

The service was clean and tidy. Staff used personal protective equipment to keep themselves and people safe from the risks of infection. The service had been appropriately maintained.

Staff knew what they should do to identify and raise safeguarding concerns. The registered manager knew their responsibilities in relation to keeping people safe from harm.

Staff were positive about the support they received from the management team. They felt they could raise concerns and they would be listened to.

The management team had built strong links with other local registered managers and providers who they gained support and advice from. The management t

The inspection was carried out on 03 and 06 October 2017. The first day of our inspection was unannounced.

Friston House provides accommodation, residential and nursing care for up to 81 older people. The home comprises of three units. The main building has two floors and accommodates people with residential needs with early onset dementia on the ground floor; and people with nursing needs on the first floor. There is a separate ‘Memory Lane Unit’ for people who live with dementia and nursing care needs. The home has a garden and courtyard areas available for all of the people.

On the day of our inspection there were 80 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility, pressures ulcers and some people received care in bed.

The service had a 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. The registered manager had been off work for some time. The deputy manager had been managing the home until August 2017, which is when the provider had put in place a peripatetic general manager.

At the last inspection on 25 August 2015 the service was rated Good overall and Requires improvement in Safe. We had made a recommendation in the Safe domain that prescribed thickening powders were kept locked away to prevent accidental ingestion.

At this inspection we found that that there had been improvements to the storage of thickening powders. However, activities to meet people’s individual needs to help keep people active and stimulated had deteriorated. We made a recommendation about this.

Most staff had undertaken training relevant to their roles. Some staff required updates and training relevant to meet people’s health needs. We made a recommendation about this.

Some people experienced care which was task led. We made a recommendation about this.

Medicines were well managed. Medicines were stored and administered appropriately. Some medicines were prescribed on a ‘when required’ basis. There was guidance in place for each person’s when required medicine.

Staff had a good understanding of what their roles and responsibilities were in preventing abuse. The safeguarding policy gave staff all of the information they needed to report safeguarding concerns to external agencies.

The provider followed safe recruitment practice. Essential documentation was in place for all staff employed. Gaps in employment history had been explored to check staff suitability for their role. There were suitable numbers of staff deployed on shift to meet people’s assessed needs. Some people told us about delays to calls bells being answered. We made a recommendation about this.

The premises were well maintained, clean and tidy. The home smelled fresh. Areas of the home had been decorated to help people orientate in their environment. More improvements were planned.

Staff were supported to gain qualifications and were supported in their roles. They had received regular supervision meetings.

Meals and mealtimes promoted people’s wellbeing, meal times were relaxed and people were given choices.

Staff had a good understanding of the Mental Capacity Act 2005 and supported people to make choices. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority by the management team.

People received medical assistance from healthcare professionals when they needed it. Staff knew people well and recognised when people were not acting in their usual manner. Feedback from healthcare professionals was positive.

People were supported to maintain their relationships with people who mattered to

The inspection was carried out on 25 August 2015. Our inspection was unannounced.

Friston House provides accommodation, residential and nursing care for up to 81 older people. The home comprises of three units. The main building has two floors and accommodates people with residential needs with early onset dementia on the ground floor; and people with nursing needs on the first floor. There is a separate ‘Memory Lane Unit’ for people who live with dementia and nursing care needs. The home has a garden and courtyard areas available for all of the people. On the day of our inspection there were 78 people living at the home. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Some people had limited mobility, pressures ulcers and some people received care in bed.

The service had a 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.

People gave us positive feedback about the home. People felt safe and well supported. They told us that staff were good at communicating and the food was good.

Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse.

We found some unattended prescribed thickener. This powder which is added to fluid to enable people to swallow had been left out of a locked cupboard. This put people at risk because if ingested without following the guidelines, it could lead to people choking if ingested. We made a recommendation about this.

People’s safety had been appropriately assessed and monitored. Each person’s care plan contained individual risk assessments in which risks to their safety were identified, such as falls, mobility and skin integrity.

The home was suitably decorated, adequately heated and was clean. There was a relaxed atmosphere.

There were enough staff on duty to meet people’s needs. Recruitment policies were in place. Safe recruitment practices had been followed before staff started working at the service. Staff had undertaken training relevant to their roles and said that they received good levels of hands on support from the management team.

There were procedures in place and guidance was clear in relation to Mental Capacity Act 2005 (MCA) that included steps that staff should take to comply with legal requirements. Staff had a good understanding of the MCA 2005 to enable them to protect people’s rights.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood when an application should be made and how to submit one when required.

People had choices of food at each meal time. People were offered more food if they wanted it and people who did not want to eat what had been cooked were offered alternatives.

People’s information was treated confidentially. Personal records were stored securely. Staff were careful to protect people’s privacy and dignity and people told us they were treated with dignity and respect, for example staff made sure that doors were closed when personal care was given.

People and their relatives described a service that was welcoming and friendly. Staff provided friendly compassionate care and support. People were encouraged to get involved in how their care was planned and delivered.

Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected. People’s care was responsive and recorded.

People were engaged with activities when they wanted to be. The activities plan for the home showed that activities took place every day of the week.

If people complained they were listened to and the registered manager made changes or suggested solutions that people were happy with. People told us that the registered manager and staff were approachable and listened to their views.

There were effective quality assurance systems and the registered manager carried out regular checks on the home to make sure people received a good service.

This inspection was carried out by one adult social care inspector following up on a previous compliance action. During the inspection, the inspector considered five key questions; is the service safe, effective, caring, responsive and well-led?

The inspector spoke with the manager, four members of staff and three people who used the service. The inspector reviewed daily care records, care plans and risk assessments and other records in relation to the management of the home. The inspector also made observations around the home.

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.

Is the service safe?

We looked at the records relating to people who used the service and their care. We saw that records were accurate and up to date. Care records included information about people’s needs and there was monitoring in place for people such as food and fluid intake and positioning charts. These monitoring forms allowed staff to monitor people’s health and welfare on a daily basis and over a period of time.

Is the service effective?

People we spoke with told us that they thought that staff were very caring and they were well looked after. People said that staff asked them for their views in relation to their care needs and they felt able to tell them if they were feeling unwell. We saw in care records that when people had told staff that they were unwell, the service had sought further medical advice by making GP appointments or referrals to other care professionals, such as dieticians.

Is the service caring?

We observed staff supporting people throughout the inspection and saw that staff were patient and kind and explained to people how they were supporting them. People we spoke with confirmed that staff were caring and knew their needs well. We observed staff being asked whether they would like to attend the entertainment that afternoon and that people’s choices were respected.

Is the service responsive?

We looked at records relating to people’s care and welfare. Each person had a set of risk assessments in place which identified their care and support needs. We saw that where the risk assessments highlighted that people required specific care and support, plans had been put into place to support them. We saw that risk assessments had been completed when changes to people’s health occurred and that when people’s health deteriorated, staff made referrals to other healthcare specialists for advice.

Is the service well-led?

We saw that the manager carried out checks of people’s care record files to ensure that staff had completed records appropriately. The manager also completed random spot checks of the home at different times of the day and night and part of the spot checks included looking at record keeping. We saw that where the manager had identified that there had been errors or omissions in the records, that appropriate action had been taken and documented.

The inspection was carried out one Inspector over ten hours. During this time we viewed all areas of the home; talked with people living in the home, visitors to the home and talked with the manager as well as other staff.

We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that the home was well presented and clean in all areas and there were reliable procedures in place for the ongoing cleanliness of the premises and equipment. Each bedroom in the home was personalised and each room looked bright and cheerful.

We found that the home was appropriately staffed in each of the three units.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

Records were not kept up to date. We found fluid and food monitoring charts that had not been completed accurately. We also saw other charts with missing information. For example, supplementary feeds charts, blood sugar monitoring charts and repositioning charts.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to maintaining accurate records.

Is the service effective?

People’s health and care needs had been assessed and care plans were in place. There was some evidence of people being involved in assessments of their needs and planning their care, we also found evidence to show that relatives had been involved, particularly when people lacked capacity to give consent.

We saw that some best interests meetings had taken place for some people who lived in the home. We found that the home had made Deprivation of Liberty Safeguard (DOLS) applications to the local authority which showed that they had a good understanding of the Mental Capacity Act and DOLS.

Is the service caring?

Staff supported people to take part in planned activities. We saw that staff offered encouragement for people to join in with activities. We observed that people were given space to interact with their peers by staff.

People who use the service said that the staff provided “Help to make choices” and that the staff “Listen to what they have to say”

Staff told us that the management team "Walked round the home daily” and that the managers conduct “stand up meetings daily”.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s needs and likes.

Is the service responsive?

People’s views were listened to and taken into account in the ongoing management and monitoring of the home’s progress. The provider sought the views of people who lived in the home, relatives and other stakeholders.

We looked at the likes and dislikes detailed in care plans for people that used the service. We saw that these were clear.

Is the service well-led?

The provider had effective systems to identify, assess and manage risks to people's health, safety and welfare.

We did saw that the provider met with people who used the service to gain feedback. We also saw that the provider met with relatives and all staff to gain feedback. We saw meeting minutes that showed meetings were held regularly and we saw action plans to demonstrate what action had been taken in response to comments and feedback.

We found that a range of audits had been undertaken by the service. These included medication audits, provider audits, infection control and housekeeping audits, general quality audits and ad hoc checks of units within the home.

There were three units in the home. One of which cared for people with dementia which meant that we were not able to ask them about their experiences. We spoke with people who lived on the other units and observed the care provided on the dementia 'Memory Lane' unit.

There was a calm relaxed atmosphere on the residential and first floor nursing unit. People we spoke with were complimentary of staff and thought they were kind and caring.

Our observations, discussions with staff, visitors and people who used the service demonstrated that staff were very busy. We saw that this impacted on the care they provided particularly on the Memory Lane unit.

Not everyone who lived in the home received consistency of care and support that met their needs as not all staff read the care plans. Communication at handover between shifts did not always give the staff the information they needed to ensure they were aware of peoples changing needs.

People were provided with a choice of nutritious meals and snacks. The chef understood the importance of fortifying meals. We saw that staff on the Memory Lane unit, however lacked understanding in this area.

We saw that there was sufficient equipment to meet people’s needs.

Staff received training and support appropriate to their role.

There was an effective system to regularly assess and monitor the quality of service that people received.

The inspection visit was carried out by one Inspector and lasted for seven and a half hours. During this time we talked with nine people living in the home who were able to converse clearly with us, and met and chatted with other people with dementia. Because of cognitive difficulties they were not all able to express themselves clearly. We observed that people were smiling and laughing throughout the day and appeared relaxed with the staff. We carried out a “Short Observational Framework Inspection” (SOFI) for half an hour in the Memory Lane Unit.

We talked with four relatives, another visitor and 14 staff.

People spoke positively about the home with comments such as:

“We are looked after very well”.

“It is all lovely here. The staff are all very caring and supportive.”

“I am very happy here. You cannot fault the staff.”

A relative said “It is always nice and clean here; and the manager is always accessible to people if you want to talk to her.”

Another relative said "I have a good relationship with the staff. They enable me to see the GP when he visits, and they contact me if they have any concerns. There is always someone to talk to, and I can talk with the manager at any time."

People were generally happy with the way that staff assisted the people who live in the home, with their personal care and healthcare needs. One person said, "Staff treat people here well".

People said that although staff were generally available when they needed them, people could not always summon help, because they could not always reach their call alarms.

People told us that there were a lot of choices at meal times and that that although the meals had always been good, they had got even better by including more food that people in the home liked.

People told us that they could receive care and treatment from other professionals when they needed it.

People said that the home was clean. One person said that one of the reasons that they had chosen Friston House was because it was clean. They also said that it had been decorated to a good standard.

People said that although there was a lot of specialist equipment in the home, there was not enough specialist chairs for all the people who needed them.

People told us that they have been asked their views about the quality of the food in the home.

People said that when they have had any concerns about the home that they have spoken to staff about it and their concern and it has been resolved for them.

We spoke to some of the people who lived in the home. We were unable to speak to people who lived in the Memory Lane unit, due to their complex dementia needs.

People we spoke to all told us that they were happy in the home and felt well cared for. They told us that staff supported them with their needs. They said "Staff are very good" and "They are always very kind".

People also informed us that they were given choices and comments included "They always ask me what I want to wear" and "I am asked if I want to join in activities and if I want to spend time in my room they respect that".

People told us that they enjoyed the meals and that they could choose what they wanted to eat.

We spoke to families and they all told us that they were happy with the care provided at the home.