This inspection took place on 27 and 30 November 2017 and was unannounced. Our previous inspection of 26 and 28 September 2016 had identified breaches of two regulations relating to safeguarding and the failure to submit statutory notifications to the Commission when incidents had occurred in the home. This November 2017 inspection found that improvements had been made in both areas and that the provider was no longer in breach of these regulations.

Gresham Care Home is a ‘care home’. It provides nursing care for up to 39 people in one adapted building. At the time of this inspection 35 people were living there. 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.

A registered manager was in post. They were also a qualified nurse and one of the two partners in the business. We have referred to this person as the manager in this report. 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.

Whilst we were satisfied that there were no breaches of regulations we have made two recommendations, one that the provider review their procedures for monitoring food and fluid intake and another that the provider review their quality assurance processes.

Staff were trained and understood their responsibilities in relation to safeguarding. Risks to people’s welfare were identified and action plans were in place to minimise the risks to people’s welfare as far as was possible. The premises was well maintained and kept clean which helped reduce the risks to people from cross contamination. People’s medicines were managed and administered to them safely.

There were enough staff on duty to meet people’s needs. There was a high ratio of staff to people living in the home as many people were living with complex health conditions which meant that two staff members were often required to support people. Recruitment processes were robust.

People received the support they required with their nutrition. Some people had cultural or religious dietary requirements; others had chosen to restrict their diet to certain food types. All of these individual requirements were catered for.

Staff received the training and support necessary for them to perform their roles effectively. The manager’s ethos was to expand the knowledge range and skills of their staff.

People’s day to day health care needs were met. When necessary staff obtained the advice and support of other health and social care professionals.

The staff were attentive, caring and treated people with respect and kindness. People’s views about their care were sought and acted upon. When appropriate the service involved people’s relatives in helping to determine the care people needed and how the person would wish to be supported.

Care was person-centred and was responsive to people’s needs. Any concerns and complaints were investigated. People and their relatives were confident that the service would act in a fair and responsible manner to resolve any concerns promptly.

The service was well led and held in high regard by people living in the home, their relatives, the staff and health professionals. However, quality assurance systems needed a review to ensure that they were fit for purpose and would identify any concerns if they were to arise.

This inspection took place on 26 and 28 September 2016 and was unannounced.

Gresham Care Home is a nursing home providing accommodation and treatment for a maximum of 31 people.

A registered manager was in post. This person is also the provider. However, we have referred to them as the manager throughout the report. 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 identified breaches of two regulations. These related to the failure to identify that safeguarding referrals and notifications to CQC were required in relation to two complaints made to the service. We have also made a recommendation that the provider seeks appropriate expert advice in relation to the identification of risks and management of the water system. You can see what action we told the provider to take at the back of the full version of the report.

The service was supporting people with complex physical health conditions. In addition, some people exhibited behaviours that challenged that could put them at risk of harm. The service was managing these challenging situations well with the support of health professionals. Risks to people were identified and staff were knowledgeable about how to keep people safe.

There were systems in place to ensure that people received their medication as prescribed. There was enough staff to meet people’s needs. Staff received thorough training and regular updates.

Whilst people’s needs were met, some staff interactions with people could be improved upon. People had access to healthcare professionals to support their wellbeing.

People's needs had been assessed and care plans outlined their preferences and how they should be supported. Staff showed a good knowledge of these preferences. The manager ensured that where people were unable to participate in planning their own care that the views of their relatives and representatives were sought.

The service had quality assurance systems in place. However, many of these lacked the final steps that were required to demonstrate their effectiveness.

We reviewed our findings at the inspection to help answer the five 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? Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who live and work at Gresham Care Home, feedback from other professionals and from looking at records.

This is a summary of what we found-

Is the service safe?

We spoke with three people who used the service and looked at quality survey responses from other people and their relatives. People were happy with the carer and support they received and comments made included one person who said, “I am wonderfully cared for." Another person said, "We get excellent care and kindness from all of the staff.”

Risk assessments had been carried out and measures were in place to minimise any risks to people who used the service and ensure that they were supported safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. While no applications had needed to be submitted, policies and procedures were in place and under review. Relevant staff had been trained to understand when an application might be necessary and how to submit one.

We looked at staffing rotas which showed that there were a sufficient number of trained and competent members of staff employed to provide people with safe and appropriate care as planned.

Is the service effective?

People who used the service were treated with dignity and respect. We observed staff during their day to day duties and saw that they were polite and kind to people they were helping.

People who used the service were supported in making choices, for example what to wear or what main meal they preferred. Where people found it difficult to make choices for themselves, staff supported them in making decisions based on best interest principles.

Quality assurance measures were in place to identify the effectiveness of the service. This included surveys of people who used the service, relatives, staff and visiting professionals and audits of infection control measures and medication

Is the service caring?

We saw that people were cared for in an appropriate manner. Staff were attentive to their needs and familiar with people’s likes and dislikes. Records we looked at showed that people’s needs had been assessed and in most cases details of likes, dislikes, routines and preferences were recorded.

Is the service responsive?

The records we looked at showed that in most cases people's needs, choices and personal preferences had been assessed and planned for. Staff we observed during our inspection were familiar with each person and their individuality.

People’s health and social care needs were attended to. People were supported to engage in social and recreational activities when they chose to do so. They were also supported to maintain contact with their friends and family members.

Is the service well-led?

There were monitoring and reviewing systems in place to ensure that the quality of the care and support provided was high.

Members of staff told us that they had the training and support to safely do their job, which they said they enjoyed.

Members of staff and family members of people, who used the service, were provided with opportunities to make suggestions and comments to improve the quality of people’s support and care.

Staff we spoke with told us that they felt well supported and records showed that regular supervision was now taking place.

During our inspection we spoke with four people who used the service. One person told us that the staff, "Always explain to me what they want to do, such as give me a wash. They ask if that's alright before they start." Another person we spoke with said, "I can't fault the quality of the home, I have everything I need and not had to worry about a thing."

We looked at a range of records used by the service. Care records and risk assessments were up to date and showed how the service identified and met the needs of people who used the service in a safe and effective way. Medication records were clear and up to date although more detail would assist staff when handling as required medication.

Recruitment records were not as complete as we would expect, and gaps were noted in the information available. This meant that we could not be certain that all staff had been recruited in a safe manner.

Maintenance records showed that all the required maintenance and servicing of equipment used to assist in providing care was up to date and records and certificates readily available.