This inspection took place on 17 and 18 July 2018. The first day of the inspection was carried out by one adult social care inspector, a Pharmacy inspector, a specialist nurse advisor and an expert by experience and was unannounced. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day was carried out by one adult social care inspector and a specialist nurse advisor and was announced.

Gracewell of Frome is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service has a dual registration which means there are two registered providers jointly managing the regulated activities at this single location. They are: Gracewell Healthcare Limited and Gracewell Healthcare 3 Limited. This means the service is subject to one inspection visit however the report is published on our website twice, under each provider.

This was the first inspection since the location was registered with the new dual provider Gracewell Healthcare 3 Limited. No concerns were identified during the registration process.

People told us they felt safe living in the home. One person said, “Yes I feel very safe, because there is always someone here to look after me.”

There were systems and processes in place to minimise risks to people. These included a robust recruitment process and making sure staff knew how to recognise and report abuse. All staff spoken with were confident action would be taken by the registered manager and provider to address any issues they may raise.

There were sufficient staff to meet the needs of people in the home and a recruitment programme meant they no longer needed to rely on support from agency staff. However, some staff and relatives felt there could be more staff on duty at busy times. The management team had listened to people’s comments and a twilight shift had been introduced.

The administration of medicines was managed safely however it was noted that a there was some excess stocks of medicines in the home and some people had missed medicines due to stock not being replaced. The deputy manager said they were currently looking into these shortfalls and discussing with their suppliers.

People received effective care from staff who were well trained and understood their needs, likes and dislikes. However, we recommended the provider looked at ways of using the knowledge and expertise of local healthcare professionals to support training for qualified staff.

People told us the dining experience was outstanding we observed most people were supported to eat and drink with dignity and respect. The home chef had developed sensory meals for people which involved them using all their senses to enjoy a meal using reminiscence of smells and sounds. Meals for people who required pureed diets were well presented with the food still resembling its original shape through moulding and sculpting. The chef told us about the smoothie’s recipes they had adapted for people in the home. This meant they could liaise with GP’s when fortified foods were required so that people could have fortified smoothies of their choice rather than prescribed fortified drinks.

People said they received care and support from caring and kind staff. Comments included, “They [the staff] are all really nice and they care about me.” And, “They [the staff] are all lovely. They have a tough job and always do it with a smile.”

People told us they could talk with staff and the manager if they wished to raise a concern. One person said, “He [the manager] is always visible and takes the time to listen. If I felt the need to complain, which I don’t. I think he would listen to me.”

People received care that was responsive to their needs and personalised to their wishes because regular

This inspection took place on the 29 June & 04 July 2017.

Gracewell of Frome provides accommodation and personal care for up to 70 older people. Part of the home is known as Marketplace where people living with dementia are cared for. There are further parts of the home where nursing care is provided and a floor where people with personal care needs are cared for.

There is a registered manager for this service. 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 arrangements for supporting people with their medicines were good with people receiving their prescribed medicines at the times required and people's health and welfare were protected.

People felt safe living in the home and one person telling us "I feel much safer here than home because there are always staff around." However, there were some differing views from people about the staffing arrangements. We noted changes had been made in the staffing of the home and observed staff responded in a timely way to requests for assistance and support. Staff told us other than when staff were redeployed to another part of the home when there was sickness and no replacement staff available they felt the staffing arrangements were good.

People were supported by caring and kind staff. One person said, "All the staff are so caring they really care for me." Another said, "Staff are all very good, there when you need them and always so thoughtful and kind. Definitively makes me glad I came here to live."

The service was responsive to people's changing care needs and had good arrangements for getting support from outside professionals such as tissue ability nurses, dieticians and mental health nurses. There were regular reviews of people care needs and people or their representatives had an opportunity to discuss their care needs so care plans accurately reflected their health and social care needs.

People spoke positively of the activities available in the home. One person telling us how they always felt there was something for them to do if they wished and another person "I enjoy the art and sometimes just having a chat." There was a wide and interesting range of activities available for people with a weekly programme of events.

Mealtimes were calm and relaxing occasions with people being offered meal choices and supported to have their meal. People spoke of good quality meals. One person told us "The food is excellent just what I like." The chef had recently been a regional winner and finalist in a nationwide competition which was about quality of meals in care homes.

There was a welcoming environment where people were able to maintain their relationships with family and friends. People and relatives told us there were no restrictions on visiting.

People felt able to voice their views or concerns about the service. There were regular meetings where people living in the home could give feedback about the quality of care provided in the home.

There was a culture in the home which promoted openness and active engagement with people and staff.

There was a focus to have strong links with the local community so making the home part of the community.

This unannounced inspection took place on 09, 10 and 15 February 2016.

The last inspection of the Gracewell Of Frome (formally Rossetti House Care Home) was carried out in March 2016. We found areas for improvement related to people receiving enough fluids to enable them to maintain hydration and protecting people’s rights with regard to the Mental Capacity Act. There were also concerns about the management of the service. We looked at these areas as part of this inspection.

Gracewell of Frome is registered to provide personal care with nursing for up to 70 older people. Part of the home known as Marketplace provides care and support to people living with dementia.

There is a registered manager in post and they were present throughout the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 09, 10 and 15 February 2016 and was unannounced. It was carried out by three adult social care inspectors.

The arrangements for the administering and management of medicines were not always safe. Records of time specific medicines did not show when these had been administered so their administration could be monitored. This would ensure these medicines were being given at the required time. Where medicines were prescribed as “as required” there was no information available to provide staff with guidance and information as to their use to ensure when being administered it was being done safely and effectively.

There were inconsistencies in the recording of care and treatment needs and how these were to be met. Some people did not have their assessments and treatment arrangements recorded to ensure they received the care they needed.

Improvements had been made since the previous inspection in ensuring people were not at risk of dehydration.

Care plans did not always reflect the individual in terms of providing specific information about the person in order for care to be provided in a person centred way.

Whilst there were extensive quality monitoring arrangements and actions taken to make improvements these had not identified the failures in records, care planning and medicines outlined in this report.

Communication was not always effective in making sure care staff felt fully informed about people’s care needs. They lacked an opportunity to meet as teams to share information and knowledge specifically about the care people needed. Care staff told us they would welcome such an opportunity.

Since the previous inspection improvements had been made to the environment of The Marketplace which had resulted in people’s quality of life and independence being improved. Further changes were needed to the environment so people could live in an environment which was homely and less clinical. People’s accommodation and communal areas provided a good standard of décor and furnishings.

Whilst staffing arrangements had improved since the previous inspection there were varying comments about the availability of staff. Specifically not everyone was being supported to get up at a time of their choosing.

Staff had a good understanding of how to identify possible abuse and their responsibility to report any concerns. People told us they felt safe in the home. One person said “I feel safe her. The staff are excellent and very caring.” A relative told us “I am confident about the care (name) receives I don’t worry about them when I leave knowing they are being well looked after.”

A health care professional spoke of the service supporting people with complex needs “Brilliantly” with a pro-active approach to meeting people’s health needs.

People and relatives all spoke of staff as being “Caring and kind,” “Carers are wel

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

The service was safe because there were sufficient numbers of qualified nurses and care staff to meet the needs of the people who lived at the home.

We observed staff were competent and professional in their interactions with people who lived at the home. During our inspection we observed people were relaxed and appeared very content with the care and support provided.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

The service was effective. We saw staff recorded information about each person on a daily basis. Information included how people had spent their day and how they had responded to activities of daily living. This meant the effectiveness of people's care plans could be fully reviewed.

Is the service caring?

Staff interacted with people in a gentle and kind manner. The people and visitors we spoke with were positive about the staff who worked at the home. They made the following comments “the carers are excellent, as too are the nurses” and “all the staff are lovely and so very kind. I don’t have a bad word to say about them.”

The visitors we spoke with did not raise any concerns about the care their relatives received. They told us “We visit most days and are very happy with the care and attention X receives” and “there is lots of love and care here. They genuinely care about my X and me. The personal care is very good. Everyone has been marvellous.”

Is the service responsive?

We found the service was responsive. The staff we spoke with were knowledgeable about the needs and preferences of the people they supported. They knew about the things which were important to people.

The people we spoke with were positive about the care they received. They made the following comments “I am very happy here and have no complaints” and “yes, I feel very well cared for. I couldn’t ask for more really.”

Information about people's health needs and contact with health and social care professionals had been recorded and responded to.

There was a good staff presence throughout our visit and we saw staff responded to any requests for assistance in a timely manner.

Is the service well led?

Since our last inspection a manager had been employed and it was their intention to submit an application to us to be registered manager.

At this inspection we found the manager had been proactive in addressing the non-compliance found at our previous inspection on 9 May 2014. This related to the supervision of staff.

The staff we spoke with told us they felt “well supported” and had regular supervisions with senior staff. We were shown a matrix which detailed staff supervisions which had taken place and were due to take place. This showed that all staff had received a supervision session since our last inspection. It also provided dates for the next planned supervision.

We read recent supervisions for five members of staff. Supervision records showed their skills and competencies had been reviewed and that they had been able to discuss any training needs. This meant that systems were in place to monitor the skills, competencies and performance of the staff who worked at the home.

There were clear lines of accountability which meant staff in all roles received appropriate levels of support. In addition to the registered nurses, senior carers were available to support care staff and we saw a good mix of staff skills and experience.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found :

Is the service caring?

We found from our observations and talking with people the service was caring. We observed staff treated each individual with dignity and respect. Where people were living with dementia we observed staff responded to what could be viewed as challenging behaviour in a professional and sensitive manner. One person repeatedly placed themselves on the floor each time staff responded in an appropriate and patient way without questioning or challenging what the individual had done. People told us how friendly staff were and how they felt staff listened to what they wanted. One person told us "You cannot fault the staff here they are all lovely and kind". A relative told us "staff are very caring, friendly and have lots of affection for people".

Is the service responsive?

The service was responsive to people's needs. People told us how staff responded promptly to their requests for assistance. There was evidence people had been seen regularly by community based services such as optician and podiatrists. One person told us if they needed to see a doctor this was arranged for the next day. Another person told us "if there is anything wrong with me they get the doctor in straight away". Where people had specialist or complex care needs they were referred to their G.P. for this advice or be seen by a dietician or nutritionist.

We looked at the staffing arrangements for the home. People told us there were adequate staffing though this could be improved. We noted the service did not have any system to help in making an informed judgement about the level of staffing required to meet people's needs effectively. Where people were at risk of skin breakdown skin integrity care plans had been completed. We saw people who were nursed in bed and required re-positioning had received this care and staff were able to tell us the level of care people needed to maintain healthy skin and reduce the risk of skin breakdown.

Care plans we looked at included comprehensive assessments of need and outlined how needs should be met. The assessments were regularly reviewed to ensure they accurately reflected people's up to date needs.

Staff told us they were confident in raising any concerns about people's care needs. There were daily handovers and they felt informed about people's care needs and changes in those needs.

Is the service safe?

We found from what people told us and how the service responded to identified risks associated with people's care needs the service was safe. People we spoke with told us they felt safe in the home. One person told us they had always been treated with respect and never seen or heard anything of concern in relation to how people were being treated by staff. A relative told us they were confident when they left the home their relative was well cared for and safe. They told us " staff do their level best for xxxx at all times".

Staff we spoke with were very clear about their responsibilities to report any concerns about possible abuse. They told us they would always report any such concerns and were also aware of how they could report concerns to an outside agency. The service had policies and procedures in place to respond to any allegation of abuse.

We found recruitment practices of the service were safe in undertaking the necessary checks when recruiting perspective employees. Checks were made in relation to professionally qualified staff that they were registered with their professional body.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

We found the service to be effective because people's care, treatment and support met their needs and achieved good outcomes. People were supported to maintain their health and wellbeing where they had complex care needs in relation to their nutritional needs and skin integrity. There was evidence we saw of significant improvement for one person who had come to the home with a pressure wound. Another person had suffered a broken arm and staff had supported them with daily exercises and continued support from a therapist.

Is the service well led?

Currently this service has no manager in post. Recruitment of a new manager has taken place and they are due to commence employment in June 2014. The service is being managed by the deputy manager with the regular support of the regional manager. The new manager will have to undertake a registered manager interview to establish their fitness to act as manager of the service and be registered with the Care Quality Commission.

People told us they felt able to give their view about the care they received and these views would be listened to. People were aware of their right to make a formal compliant if they wished. One person told us "I know I can always speak to one of the staff or the manager if I am not happy about something. They will listen and do something about it". Another person told us "I can always make a complaint if I want but have never needed to".

We found staff were confident in reporting concerns and the management had an approachable, listening culture. Staff had an opportunity to express their views through staff meeting and talking with seniors, nurses and the management. However we found there were significant gaps in the provision of regular individual formal supervision.

We found there were satisfactory arrangements for the training of staff in core skills. However staff felt they had not been given the opportunity to undertake more specialist or professional training.

There were comprehensive arrangements in place for the monitoring of the quality of the service. Action plans had been implemented where shortfalls had been identified. The service had learnt from incidents and improved procedures in relation to the administering and management of medicines.

At the last inspection in May 2013, not all care plans demonstrated the intervention required to meet people’s needs. The lack of information within documentation particularly applied to managing behaviours such as agitation and aggression. This impacted upon the ability of staff to support people in a consistent manner.

We issued a compliance action to ensure the provider addressed the shortfalls. The provider sent us a clear action plan which demonstrated how they would make improvements.

During this inspection, we found improvements had been made.

The care plans we looked at were well written, informative and person centred. The information identified how people’s needs were to be met. There was clear information about diffusing challenging situations and how past experiences could impact upon people’s daily lives. The plans were up to date and had been regularly reviewed.

Staff spoke to people in a caring and friendly manner. Some people required staff assistance to eat. This was undertaken attentively at the person’s own pace.

People and their visitors were happy with the service they received. One person said “they’ve given me my life back. They care with love and compassion.” People looked well supported and said their rights to independence, choice, privacy and dignity were maintained. A range of social activity provision, including regular trips out, was organised to enhance people’s quality of life.

Rossetti House Care Home provides accommodation for up to 70 older people who need personal or nursing care. The home also provides care for older people who are living with dementia. The home is a large, purpose built property. Accommodation is arranged over three floors.

This was an unannounced inspection, carried out over three days on 2 March, 3 March and 6 March 2015.

The last registered manager ceased working at the home in 2014. The current manager had worked at the home since June 2014 and had recently applied to register with us. 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 and associated Regulations about how the service is run.

People felt safe and they were able to take risks as part of their day to day lives. There were clear risk assessments which meant care was provided in a way that minimised risks. The provider checked staff were suitable to care for vulnerable people before they commenced employment.

People told us their healthcare support was good but we found some people were not being encouraged to drink enough. The records of what people had to drink were poor. People’s decisions were not always being respected and at least two people were being deprived of their liberty by having their visitors restricted.

People’s dignity was respected. People spoke very highly about the care provided at the home. One person said “All of the staff try to please us. The whole ethos is it’s our home. It’s so refreshing the attitude of staff. They are so very good to me.”

People could not be assured that confidentiality would be maintained. There was a significant issue with the inappropriate use of social media by both current and ex-members of staff.

People were supported to keep in touch with their friends and relations. Most relatives and visitors we spoke with were very happy with the care provided by staff. A small number of relatives did not think the care was as good as it used to be; they were particularly concerned that some older, experienced staff had left the home.

Care was generally well planned, although there were no clear plans in place or specific staff training for when people became anxious, confused or aggressive. People’s views were usually listened to but there was no system in place to record or learn from informal concerns or complaints.

People chose how to spend their day. There were a variety of planned activities. One person said “We have fantastic facilities here. We have different events and meet up. I go out to an art group and we have a creative writing group that meets here.” A small number of relatives felt that some frailer people could become isolated as they either could not or did not wish to take part in communal activities or trips out. There was therefore a clear plan to extend the scope and range of activities on offer.

Staff training, support and morale were good. Staff felt listened to and changes they had suggested to improve care for people had been acted upon. One staff member said “A lot of the changes are positive changes. Lots of staff have said to me they have more confidence now. I wasn’t well supported before. It’s much better now.”

There had been significant changes within the service in recent months. The scope and number of changes had clearly been difficult, but not always well managed. Most people spoken with during our inspection felt the service had improved; they respected the manager and had confidence in them; some relatives felt differently. One relative said “I don’t feel that staff listen to concerns about (my relative’s) care needs.”

The systems in place designed to monitor the quality of the service, compliance with the law and best practice and to plan ongoing improvements were not fully effective. Some relatives thought there needed to be much more emphasis on honest and open communication, to ensure they felt listened to, respected and involved with the care being delivered.

We found breaches 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 this report.