This inspection took place on 21 and 23 February 2017. It was an unannounced visit to the service. This meant the service did not know we were coming.

Greene house is a care home which provides accommodation and personal care for up to fourteen people with epilepsy and other associated conditions. At the time of our inspection there were eleven people living in the home.

Greene house is a listed building. People’s bedrooms and communal areas are on the ground floor. The registered manager and administration offices are situated on the first floor.

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 home was previously inspected in January 2016. At that inspection it received an overall “Requires Improvement” rating and recommendations were made to improve some areas of practice.

At this inspection we found the recommendations made at the previous inspection had been actioned and the service was safe, effective, caring, responsive and well-led. People and their relatives were happy with the care provided. A relative told us the home offered a personalised service. They commented “The keyworker knows how to motivate, encourage but also knows how to avoid behaviours that challenge”. People and their relatives described staff as kind, caring, friendly and tolerant. People were unhappy with the regular use of bank and agency staff but recognised that was necessary to maintain the required staffing levels.

Systems were in place to safeguard people. Risks to people were identified and managed which promoted people’s independence. People had care plans in place which provided clear guidance to staff on the support individuals required. Care plans were updated and reviewed as people’s needs changed.

Medicines were safely managed and people’s health and nutritional needs were met. People had access to activities of their choice.

People’s privacy and dignity was promoted. We observed staff were kind, caring and had a good knowledge of the people they were supporting. Staff were aware of people’s needs, risks and the support required to promote their safety.

Staff were suitably recruited, inducted, trained, supervised and supported. They were able to relate their training to their practice to support people effectively. The home had a number of staff on maternity leave and had staff vacancies. Staff worked well together as a team in an attempt to provide consistent care to people.

People and their relatives knew who to contact to raise a concern or complaint. Systems were in place to get feedback on the service. Resident meetings took place and annual surveys were sent to people who used the service, relatives, staff and professionals involved with the service. Actions were taken

The registered manager was new in role. They had worked with their senior team in implementing changes. They had introduced person centred reviews and was keen for those to be carried out for all people living at the home. They had a visible presence in the home, assisted on shift and supported staff in their day to day work.

People who used the service, relatives, staff and professionals were happy with the way the home was managed. They described the registered manager as kind, pleasant, focused, accessible and approachable.

Systems were in place to audit aspects of care and practice. The provider carried out quarterly monitoring visits of the service to satisfy themselves the service was being effectively managed and monitored.

People’s records and other records relating to health and safety and the running of the home were organised, accessible and well maintained which made access to the required infor

Greene House is a care home which provides accommodation and personal care for up to fourteen people with epilepsy and other associated conditions. It is a listed building. People who used the service lived on the ground floor. The registered manager’s office and the administration office was situated on the first floor.

At the time of our inspection there were thirteen people living in the home. 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 inspection took place on the 6, 7 and 8 January 2016 and was carried out as part of our schedule of comprehensive inspections.

Risks to people were generally identified and managed. However in two files viewed risk assessments did not identify all risks and one risk assessment was not up date to reflect change in practice. We have made a recommendation to address this. There was also good practice in this area, one person with capacity to make choices and decisions made choices which potentially placed them at risk. The relevant professionals were involved and provided advice and guidance to support staff to minimise the risks.

Systems were in place to promote safe administration of medicines. Some staff practice was not in line with guidance which was addressed by the registered manager on the day.

People told us they felt safe. Relatives were confident people were safe. Staff were trained in how to recognise potential abuse and keep people safe. Policies and procedures were in place to support safe practice to safeguard people.

People were happy with their care. Staff were generally kind and caring. We observed some practices that did not promote people’s dignity and we have made a recommendation for the registered manager to address this. Staff offered people choices and engaged with them. However we saw aids such as objects of reference and pictures were not used to communicate with people who had limited communication. We have made a recommendation to address this.

The minimum staffing levels were maintained to meet people’s needs. This was under review to meet people’s changing needs. Staff were suitably recruited. They completed induction and training. We have made a recommendation to improve induction and training. This is to ensure all staff receive the same level of induction and that the training meets their needs to give them the required knowledge and skills to do their job. Staff felt supported and supervision took place although not in line with the organisations policy on supervision which the registered manager was addressing.

Systems were in place to promote good communication within the team. We have made a recommendation to look at ways of improving communication to ensure key information on people is handed over to staff. People had access to a range of health professionals. Their health and nutritional needs were identified and met. People had mixed views on the meals that were provided. Some people liked them but others told us they would prefer proper home cooking. The provider agreed to look into what options were available to enable that to happen.

People had care plans in place which provided guidance for staff on how to support people. Staff were knowledgeable about people’s needs. People had a programme of activities in place. The registered manager was reviewing this, in line with staffing levels to see how they could provide more community based and person centred activities for people.

The home was clean, maintained and systems were in place to ensure it was suitably maintained and fit for purpose. Equipment was cleaned and regularly serviced.

People, staff and relatives told us the home was well manag

The inspection visit was carried out by one inspector. We spoke with three people who lived at Greene house. We spoke with the manager, team leader and two care staff. We observed the interactions between staff and people who lived at Greene house. We also carried out a SOFI observation over lunch to observe staff interactions and engagement with people who were unable to communicate verbally with us. This was to assess the quality of care those people received. We walked around the home to review the environment. We looked at some records, including people's care plan files, rotas and quality monitoring checks records.

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

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

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

Is the service safe?

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS). The manager told us at the time of our inspection there was no person with a DOLS application in place, but they understood when it would be required.

Staff were trained in the Mental Capacity Act 2005 and DOLS and demonstrated a good understanding of those legislations.

Two of the three care plans viewed were detailed, specific and provided clear guidance for staff as to how they supported those individuals with their needs.

Peoples care plans included risk assessments which addressed and managed potential risks.

Risk relating to the health, welfare and safety of others had been identified and managed.

Aspects of the home had been refurbished and redecorated. It was clean, homely and safe. Fire procedures had improved and fire drills had taken place. A contingency plan had been developed and was in place which outlined actions to take in the event of a disaster at the home.

We saw the required staffing levels were maintained and staff were suitably inducted and trained in their roles. Regular supervision of staff had commenced and appraisals were planned. This meant people were supported by staff who were suitably inducted, trained and supervised to meet their needs.

These findings demonstrated to us the service was safe.

Is the service effective?

People's health care needs were identified and met. People had a detailed and comprehensive health passport which contained key information on their health needs. This document went with them to hospital which ensured other health professionals were aware of key information on people.

Care plans had been developed in a new format and provided specific details for staff on how they supported people.

These findings demonstrated to us the service was effective.

Is the service caring?

We spoke with three people who use the service. They told us they were happy with their care. They told us staff were available when required and staff were kind, caring and treated them well. We observed positive interactions between staff and people who use the service. Staff provided assistance where required whilst enabling and encouraging people to be independent. We saw one person became distressed and staff were quick to respond to this and provided the person with reassurance and support which de-escalated the situation.

These findings demonstrated to us the service was caring.

Is the service responsive?

People were asked for their views on the service through annual questionnaires and regular house meetings. This feedback was taken into account and action taken to address failings where they were identified.

The provider had taken action and had made good progress in addressing the non-compliance with regulations identified at the previous inspection. However some records were not completely up to date and accurate which had the potential to mean they were not always responsive to people's needs.

These findings demonstrated to us the service was not always responsive.

Is the service well led?

The organisation had appointed a management company to assist them in achieving compliance and in supporting the manager to put systems in place to enable them to manage the home effectively. Staff told us the manager was approachable, accessible, listened to and acted on concerns raised. They said the management company supporting the home were experienced, knowledgeable and had enabled them to improve working practices in the home.

We saw policies and procedures had been reviewed and updated. Protocols had been put in place to support staff in their practice.

Quality monitoring systems had been introduced which included daily, weekly and monthly auditing of practices. A home improvement plan was in place which included actions from all audits. This was monitored to ensure actions were completed within an agreed timescale. The provider may find it helpful to note the daily monitoring and audits of fluid charts did not always pick up if people had the required fluid intake. This meant this aspect of auditing was not effective.

These findings demonstrated to us the service was well-led.

The inspection visit was carried out by one inspector. We spoke with three people who lived in Greene house. We spoke with the manager, acting team leader and three care staff. We observed the interactions between staff and people who lived at Greene house. We also carried out a SOFI observation over lunch to observe staff interactions and engagement with people who were unable to communicate verbally with us. This was to assess the quality of care those people received. We walked around the home to review the environment. We looked at some records, including people's care plans files, rotas and quality monitoring checks.

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

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

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

Is the service safe?

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS). The manager told us at the time of our inspection there was no person with a DOLS application in place, but they understood when it would be required.

Staff had a good understanding of the Mental Capacity Act 2005 and DOLS. They were able to give examples of how it related to the people they supported. However we saw in one person's care plan that they had capacity to make decisions but the care plan outlined they may need support in making decisions. This was contradictory and did not safeguard the person to ensure that decisions around their care and treatment were made within a legal framework.

We looked at care plans and spoke with staff. We found there were risk assessments in place to identify and manage risks to people's health, safety and welfare. However we found two out of the three care plans viewed were not detailed and specific as to how staff supported people with their identified needs. This had the potential for care to be inconsistent and for people's needs to not be met.

We saw the home was not adequately maintained and areas of the home were damp and in need of redecoration and updating. Fire drills were not happening as frequently as outlined on the provider's fire procedure and there was no contingency plan in place to promote people's safety in the event of a disaster at the home.

We saw the required staffing levels were not maintained and there was a delay in staff support being provided to people when it was required.

We saw risks relating to the health, welfare and safety of others had not been identified and managed. This had the potential to put people and others at risk.

These findings demonstrated to us the service was not safe.

Is the service effective?

People's health and medical needs were identified and met. Protocols were in place for the management of epilepsy.

Staff completed induction training and were provided with regular updates in training. This ensured they were suitably skilled to meet people's needs.

These findings demonstrated to us that the service was effective.

Is the service caring?

We spoke with three people who lived at the home. They told us they were happy with their care. They said staff were kind, caring, polite, and respectful to them. They confirmed they were involved in making choices and decisions in relation to their care. We observed positive interactions between staff and people who used the service. Staff maintained good eye contact with people. They were gentle in their interactions with them. They gave people time to express themselves and were supportive in encouraging them to engage in an activity.

These findings demonstrated to us the service was caring.

Is the service responsive?

People were encouraged to provide feedback on what they wanted through regular meetings and they were offered and supported to attend one to one activities or group activities if they wished.

One person's care plan had been updated in a new format. The person had been encouraged to be actively involved in outlining how they wanted to be supported.

At the previous inspection the service was non-compliant in meeting people's nutritional needs. As a result staff had attended training on nutrition. This ensured people were supported by staff who were trained to meet their nutritional needs.

These findings demonstrated to us the service was responsive.

Is the service well led?

Staff told us the manager and deputy manager were available, approachable and accessible and provided support when it was required. However we saw staff were not supervised and appraised in line with the organisations policy.

We saw a compliance action from the previous inspection in relation to assessing and monitoring the quality of the service had not been complied with.

Regular audits of practice were not taking place and as a result care planning was ineffective, some staff supervisions and appraisals were not taking place, complaints and accident and incidents were not being analysed and the required staffing levels were not maintained.

The provider was not carrying out any form of monitoring of the home and this meant health and safety, infection control and the environment were not being audited and monitored. This meant the home was not being effectively monitored to ensure the service being provided was effective and safe.

These findings demonstrated to us the service was not well led.

People we spoke with told us staff sought their consent before they received any care or treatment. One person commented “They always ask, even though they don’t need to as they know me very well.” Another person told us “The staff members do everything within our wishes. For example, they asked me if I wanted to go to the Bonfire Night today, but I said no to this and they respected my decision.”

People told us they enjoyed the meals provided for them. One person told us “I really enjoyed my lunch today. We now have a lot to choose from.” Another person said “The quality of the food is very good. We have variety of options to select from." However, we saw one person was not regularly weighed and their eating and drinking care plan and malnutrition risk assessment was not updated or reviewed frequently.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. People told us the home used this as a platform to ascertain feedback. One person told us “We have regular resident meetings, they tell us what is going on in the home, ask us what is going well and what we are not happy about.” Another person told us “They tell us in the resident meetings, when we are not happy about something, we can make a complaint about this.” However, we found the home did not have effective quality assurance systems in place to review care plans and risk assessments.

People’s privacy, dignity and independence were respected. During our visit we spoke with three people who told us staff treated them with respect and dignity. They told us "I like living here because the staff respect me" and "The staff are perfect, always polite and helpful."

People's needs were assessed and care and support was planned and delivered in line with their individual care plan. People told us "they understand me well here and meets my needs" and "I like living here as the staff help me to stay active by encouraging me to join activities and staff are always happy to help me."

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People told us "I feel safe in the home and when staff members help me with personal care."

There was an effective complaints system available. Comments and complaints people made were responded to appropriately. People told us "I have made complaints before, they have dealt with my concerns very well and I was happy with their response" and " I have no concerns and I have not had a reason to make a complaint."