About the service: Gorsefield is a residential care home providing personal and nursing care for up to 17 people. At the time of the inspection there were 15 people using the service some of whom were living with dementia.

People’s experience of using this service:

People were not consistently supported by enough staff. People were not consistently receiving responsive care and support.

The systems in place to monitor the quality of care were not always effective and actions were not consistently driving improvements.

People felt safe and they were protected from the risk of abuse. Peoples risk assessments were followed and risks associated to the environment had been mitigated. Staff were safely recruited. Staff were trained and able to support people’s needs.

People were treated with kindness by staff who knew them well. People’s privacy and dignity was respected and their independence was encouraged. People could choose for themselves.

People were listened to and had their views sought about the care they received. There was a positive culture and learning and partnership working were encouraged.

The service met the characteristics of Requires Improvement in most areas.

We identified a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 governance. Details of action we have asked the provider to take can be found at the end of this report.

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

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published 7 February 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. The location has previously been rated as Requires Improvement. At this inspection the provider had made improvements to those areas, but other areas were found to require improvement. We may consider enforcement action if there is a continued lack of improvement at our next inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

The inspection took place on 6 December 2017 and was unannounced.

The service was last inspected on 4 April 2016, when it was given an overall rating of Requires Improvement. At our last inspection, we found there was not always sufficient numbers of staff deployed to meet people's needs. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found the provider was now meeting the requirements of Regulation 18, although there was a need for a more systematic approach to the assessment and adaptation of staffing arrangements in line with people’s changing needs.

Gorsefield Residential Home 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.

Gorsefield Residential Home accommodates for up to 16 older people some of whom are living with dementia in one adapted building. At the time of the inspection, nine people were living at the home.

The service is required to have a registered manager and there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager and provider did not work in partnership to assess, monitor and improve the quality and safety of the service provided. As a result, the provider’s quality assurance was not as effective as it needed to be.

Staff did not always follow good practice when handling and administering people’s medicines. Further measures needed to be taken to protect people, staff and visitors from the risk of infection. Staff had received training in, and understood, how to recognise and report abuse. The risks associated with people’s care and support had been assessed, recorded and plans were in place to manage these. The safety and accessibility of the home’s back garden needed to be improved.

People’s rights under the Mental Capacity Act 2005 were not always fully promoted. People had enough to eat and drink and any risks or specific needs associated with their nutrition or hydration were assessed, recorded and managed. The provider needed to do more to make the care home environment more dementia-friendly. Staff received induction, training and ongoing support from management to help them fulfil their job roles. Staff monitored people’s general health and supported them in accessing healthcare services as required.

We have made a recommendation about adapting the care home environment to meet the needs of people living with dementia.

The provider needed to do more to protect people’s confidential information. Staff knew people well and treated them with kindness and compassion. People were supported to express their views and be involved in decision-making that affected them.

People did not receive consistent support to take part in activities they found enjoyable and stimulating. People and their relatives were involved in care planning and reviews. Care plans were individual to people and included information about what was important to people. People and their relatives understood how to raise complaints or concerns about the service, and felt comfortable doing so.

The registered understood the responsibilities associated with their post. People, their relatives and staff spoke positively about the overall management of the home. Staff were clear what was expected of them and felt able to seek any additional support required from a registered manager who was approachable. Staff understood how to raise any serious concerns about the way the home was being run.

You can see what ac

The service provides personal care for up to 17 older people who may have dementia. There were 13 people living at the home on the day of our inspection.

There was 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 inspected this service on 18 November 2014. The inspection was unannounced.

At our inspection in April 2014 compliance actions were made as the provider was breaching legal requirements. These breaches related to the improvements needed regarding; risk assessments, staffing levels, mental capacity assessments, timely medical referrals, the quality of recording and quality monitoring systems not being effective and inconsistencies in records. Following this inspection we asked the provider to complete an action plan detailing when improvements would be made. The provider did not complete an action plan. We returned to the service in June 2014 and found some improvements had been made in respect of the recording of care. At this inspection we found that although some improvements were seen further improvements were still required.

People who were living at the service told us they felt safe. People’s risk of harm was being assessed and there was guidance in place to manage people’s risks.

The recruitment processes provided assurance that sufficient checks had been completed to ensure staff were suitable to work within a caring environment.

Staff received training which was linked to people’s needs. Staff told us they received supervision and they felt supported to fulfil their roles.

We observed people being given day to day choices about food and bedtime preferences. People we spoke with told us they had not been asked to agree their care plans although some relatives told us they had been involved.

Some people were not provided with a suitable table to eat from. People at risk from weight loss were not being monitored in line with their care plans.

We observed that people were relaxed being with and talking to staff.

People we spoke with told us staff knew what they liked and how they wanted their care provided.

There were no regular arrangements in place to involve people in hobbies, pastimes and outings which interested them.

People and their relatives told us they would feel comfortable raising complaints or concerns with staff or the registered manager and felt they would be listened to.

The provider had asked people to complete a satisfaction questionnaire earlier in the year but there was no evidence that actions had been taken to address people’s comments. There were no residents or relatives meetings in place for people to share their views of the service on a regular basis.

There were no systems in place to assess the quality of their service. Information from incidents was not used to identify trends which could affect or influence people’s care. We identified some concerns with the way medicine stock was recorded. The provider did not have protocols in place to guide staff administering medicines prescribed on an ‘as and when’ basis to protect people from receiving medicine inappropriately.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which correspond to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 . You can see what actions we told the provider to take at the back of the full version of this report.

This was a follow up inspection carried out by an inspector for adult social care.

At a previous inspection completed on 9 April 2014 we identified non compliance with the regulations we inspect against. We issued a warning notice in respect of the care and welfare of people who used the service. We issue warning notices when we want to see rapid improvements in the way care is provided. We carried out this inspection to check that the provider had taken action to ensure the safety of the people who used the service, was protected. A further inspection will be undertaken to monitor the progress in the other areas of non compliance.

During this inspection we asked the questions we always ask; is the service safe, effective, caring, responsive and well-led.

Is the service safe?

The provider had taken action to address the safety concerns we identified at our last inspection.

People’s risks had been assessed and actions taken, where necessary, to reduce the impact the risk might present.

The process for information sharing between staff had been improved and formalised by the introduction of a signature sheet.

Is the service effective?

The people who used the service had detailed care plans, which provided staff with the information they required to care for people. People’s individual preferences on care were recorded.

The equipment used to monitor people’s weight had been replaced with appropriate and accurate medical scales.

Is the service caring?

We observed that people experienced kind and dignified care from the staff. A relative told us, “The staff look after my X (the person who used the service) really well. The staff really do care. X is better than she has been for years”.

Is the service responsive?

The registered manager had responded to specific concerns we raised at our last inspection about a person’s vulnerability to financial abuse and the legality of preventing a person from leaving the home.

Is the service well-led?

The registered manager had implemented improvements to the way care was delivered, recorded and monitored.

This was an unannounced scheduled inspection. As part of this inspection we also looked at the progress the home had made in meeting the concerns we had raised at our previous inspection.

During this inspection we spoke with people who used the service, relatives, care staff, a visiting health care professional and the registered manager.

We considered our inspection findings to answer the questions we always ask.

Is the service safe?

Some people who used the service had not had their needs or risks fully assessed to ensure they received the most appropriate care which protected their health and well-being.

Staffing levels were not sufficient to meet people’s care needs and identified risks. We saw people who required the support from two staff left without assistance.

We identified some people who were vulnerable to abuse but appropriate referrals had not been made to ensure they were suitably protected.

Is the service effective?

A person who used the service told us, “We’re well fed and well kept”.

There was no evidence to support the care plans were effective or had been reviewed regularly. There was a stable workforce who knew people well however when people’s needs changed there was no effective process in place to update staff.

Is the service caring?

A person who used the service told us, “I find it alright. They always treat me alright”.

We saw good interactions between people and staff. Staff treated people with kindness and protected their dignity when providing personal care. Staff entries in the care plans were sometimes written in an unprofessional manner which did not support people’s dignity.

Is the service responsive?

We saw examples where the staff had not responded to changes in people’s physical health or taken action to ensure the care provided to them was appropriate.

The home had a complaints procedure. People who used the service and their relatives told us they knew how to complain if necessary.The views of people had not been sought through meetings or satisfaction surveys.

Is the service well led?

There were no systems in place to regularly audit the environment or the quality of the service provided.

Staff told us they were well supported by the registered manager and had regular appraisal and supervision sessions. The registered manager did not receive an appraisal, supervision or management review meetings.

We spoke with four people living at the home. They told us that they felt safe living at the home and had no concerns about how staff treated them. One person told us that, “I love being here and feel part of a big family.” People told us that the staff at the home were caring and made sure they were looked after. One person told us, “The girls are marvellous, they keep me going.”

We found that relatives remained involved in people’s care and day to day life at the home. We spoke with four relatives, who were all complimentary about the staff. One relative told us, “The staff know my mum better than me.”

The home had a small but stable workforce, with no recent changes in care staff. There was an ongoing training programme provided for all staff. We spoke to two members of care staff. They were both positive about working at the home. One care staff told us, “I couldn’t work anywhere better.” Another member of staff told us, “I would come to work every day, I love my job and working here.” The staff we spoke with had a good understanding of people’s current needs.

We looked at the care records for five people to check how well their needs were assessed and planned for. Everyone had an assessment of their care, which included information about their needs. There were also risk assessments in place. We found that changes in people’s needs were not always reflected in their care plans and risk assessments.

The home was a clean and comfortable place to live. Everywhere smelled fresh. One person told us, “Everywhere is always so clean. They work hard at it.” People were happy living at the home. One person told us,, “I am fed up with this getting old business but the girls only do what I can’t and let me do what I can. And I would tell them if I wasn’t happy with anything.”

Care was provided that met people's needs and kept them safe. Care staff were skilled and experienced in meeting people's needs. The manager and care staff had a good understanding of when concerns with people’s safety and welfare needed to be reported.

There were effective recruitment and selection processes in place. It was not clear how the number and skill mix of care staff had been assessed and kept under review to ensure that staffing levels continued to meet people’s needs and keep them safe.

At our previous inspection, we identified that the provider was not meeting the expected standards in some of the outcome areas. We set compliance actions, requiring the provider to make the improvements required to ensure the quality and safety of care. The quality and accuracy of records about people’s care still needed to improve. Everyone had a record of their individual care and health needs but there was no written plan, setting out how these care needs should be met.