This inspection took place on 18 January 2019 and was unannounced. At the last inspection completed 02 March 2016 we found the service to be ‘good’ and meeting all the legal requirements. At this inspection we found the service was now ‘outstanding’.

The Watermill 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. The care home accommodates up to 40 people in one adapted building. The service is split into four ‘houses’ each accommodating up to 10 people. At the time of the inspection there were 37 people using the service, all of whom were living with dementia.

A registered manager was 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.

People were supported by a passionate and committed staff and management team. People were made to feel valued, important and respected as individuals. The staff and managers went the extra mile to ensure that people felt cared for and that their lives were enhanced wherever possible. People’s independence was fully promoted and their dignity was upheld.

Care staff knew people well and fully understood their needs. Where people’s needs had changed they were reassessed and care staff understood how the support they provided needed to change. People’s equality, diversity and human rights were fully respected and the service took proactive steps to ensure that people felt comfortable to express who they were and to live how they chose.

People were given access to a wide range of leisure opportunities. The reminiscence coordinator considered people’s individual preferences and developed a unique range of activities that people could participate in. The registered manager and staff team placed a high level of importance on ensuring people’s quality of life was good and they were able to live as full a life as they wished.

People, relatives and care staff gave excellent feedback about the registered manager and the service as a whole. They were encouraged to be fully involved in the development of the service and making decisions. People felt they had a voice and that they were heard.

The registered manager was committed to driving improvements and ensuring people were able to live in a service providing excellent service to them. They were proactive in securing community links and volunteered to be involved in new initiatives and opportunities for learning. Professionals, partner organisations and people from the community all spoke highly of the management, staff and service as a whole.

People felt safe living at the service. They were supported by a staff team who understood how to protect them from the risk of abuse, accident and injury. Where incidents had arisen, lessons were learned to enable steps to be taken to reduce the risk of harm to people in the future.

People received their medicines as prescribed. People were protected by effective infection prevention and control. People were supported by sufficient numbers of staff who had been recruited safely.

People’s needs were assessed holistically and the service worked to meet their emotional, physical and health needs. People’s consent was sought before staff provided support. Where people lacked the mental capacity to make decisions or provide consent, decisions were made in their best interests in line with the law.

This unannounced inspection took place on 2 March 2016. At our last inspection in April 2014, the provider was meeting the regulations we looked at. The Watermill is a care home which provides accommodation and personal care for up to 40 older people, some who may have dementia. At the time of our inspection 34 people lived at the home.

There was a registered manager in post at the time of our 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.

People told us they felt safe. Staff we spoke with were aware of their responsibilities to keep people safe and report any concerns of potential abuse. The provider had systems in place that kept people safe and protected them from the risk of harm. People’s individual risks were assessed and staff knew how to support people safely when providing care. People’s care and support needs were met in a timely manner. People were supported with their medicines where needed by staff who had received training.

Staff understood the need to gain people’s consent to care before providing any support or assistance. However, some staff had limited knowledge of the requirements and their responsibilities to promote people’s rights in relation to MCA and DoLS. People were supported by staff that were recruited safely into their role. Staff received training and support to meet people’s care and support needs.

People told us that they had a choice of meals and that they liked the food and drinks provided. People told us that they were supported to have access to a wide range of healthcare professionals should they need to.

People told us staff were kind and caring and said that they received care from a consistent staff group. People felt involved in their day to day choices and were supported to maintain their independence. People’s dignity and privacy was respected by staff.

People and their relatives said they felt fully involved in developing their care plan and received care that met their needs. People told us they were happy living at the home and took part in a number of different activities. People and relatives knew how to raise any concerns and were confident any issues would be addressed. The provider had a clear complaints procedure in place and information was clearly displayed within the home.

Everyone spoke positively about the registered manager and their team. The registered manager was aware of their role and responsibilities. The provider had systems in place to listen to people’s views and provided regular feedback. Regular checks were completed to review and monitor the quality of the care that people received this included observing staff practice and reviewing records.

One inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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.

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

This is a summary of what we found:

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies. One relative told us "You can't fault the personal care. It's five star and security is very good."

Staff personnel records demonstrated that mandatory training was up to date and that staff were trained sufficiently to meet the needs of people who lived there. Not all staff had food and hygiene training but we found that this had been planned.

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

Is the service effective?

People told us that they were happy with the care that was delivered and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of the people's care and support needs and that they knew them well. People were cared for by staff who were supported to deliver care safely and to an appropriate standard although staff told us they felt under pressure. We were told that this did not compromise the care of people and we also found evidence of this by spending time observing in the home. Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. One person told us "It's very homely, I like the activities and the food is excellent." An advocate told us "Carers are very good, security is very good and the staff on a weekend are very good. People can go out into the garden for fresh air and still be safe and secure."

Is the service responsive?

People's needs had been assessed before they moved into the home. Records confirmed people's preferences and interests and pen portraits were used to help staff understand each person's personality and emotional state. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff had a good understanding of the ethos of the home and robust quality assurance processes were in place. People told us they were asked for their feedback on the service they received and a relative told us, "You can go to the manager with anything, they will always listen." People told us that the food was very good and that they were always listened to when making a special request. Staff told us that they were clear about their roles and responsibilities and that management support was good but support from senior carers was inconsistent and could be improved. They said that they were not consulted before changes were brought to working practices but that they were still able to provide safe and effective care.

During our last inspection in November 2012 we had identified non compliance in relation to the care and welfare of people who used the service, and staffing. We visited The Watermill to up date the information we hold about the service and to establish whether there had been improvements made since we last visited. The provider had sent an action plan detailing what they had done to meet the regulations. We used this information to check if the provider had addressed the improvements that were required. The visit was unannounced which meant the provider and the staff did not know we were coming.

We found that improvements had been made in relation to people’s care and welfare. We found care plans gave staff the information required to deliver care to people living at the home. We saw positive interactions between people living at the home and staff. The people living at the home and visitors we spoke with were complementary of the service provided at The Watermill.

We looked at the staff roster and asked people living at the home, visitors and staff about whether they felt there were sufficient staff. Staffing levels had been increased over night. Most people told us that they felt appropriate staffing was in place. However some staff felt staffing levels could be improved.

We carried out this review as a follow up to a routine, scheduled inspection which was carried out in July 2012 where non-compliance of Outcome 4: Care and welfare of people who use services, was identified. The provider was asked to complete an action plan setting out how they were going to achieve compliance.

We wanted to check the progress of those actions and to establish that the needs of people using the service were being met. The visit was unannounced which meant the provider and the staff did not know we were coming.

There was a new manager in post who had not yet submitted their registered manager application to CQC. We reviewed the action plan sent to us by the provider and discussed each part of it with the manager of the home and other senior staff members within the service.

We found some development of care plans had taken place, however not all the required information for managing behaviours that could be challenging was available in the care plans we viewed.

Staff we spoke with raised concerns about the staffing levels at the home. We were told staff did not have enough time to support people to take part in meaningful activities.

Two staff members were routinely scheduled to work on each unit of the home. We were told, by staff, that during busy periods providing quality care and support could be difficult.

We carried out this review to check on the care and welfare of people using this service. We visited The Water Mill in order to up date the information we hold about the service and to establish that the needs of people using the service were being met. The visit was unannounced which meant the provider and the staff did not know we were coming.

We involve people who use services and family carers to help us improve the way we inspect and write our inspection reports. Because of their unique knowledge and experience of using social care services, we have called them experts by experience. Our experts by experience are people of all ages, from diverse cultural backgrounds who have used a range of social care services.

An expert by experience took part in this inspection and talked to staff and three people who were living in the home. They looked at what happened around the home and saw how everyone was getting on together and what the home felt like. They took some notes and wrote a report about what they found, the details are included in this report.

The Water Mill is a residential care facility for people with dementia. The service provided 30 residential places and ten respite places over four separate ‘houses’. Each house having its own facilities, for example communal living area, kitchen and laundry and its own staff group. The registered manager had recently left the home. There was an acting manager in post, a recruitment process was in place for recruitment of permanent manager to the position.

During our visit we used a number of different methods to help us understand the experiences of people using the service. This is because some people had complex needs which meant they were not able to tell us their experiences. We used our SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences were like within the home. The SOFI tool allowed us to spend time watching what was going on in a service and helped us to record how people spend their time and whether they have positive experiences. This included looking at the support that was given to them by the staff. We observed interactions between staff and people using the service, spoke with five people who lived at The Water Mill, four people visiting friends and relatives, nine staff members.

A relative who was visiting the service told us, “I am 110% happy with the service here, if I couldn’t come for a month I wouldn’t worry”. One staff member told us, “I love my job” another said, “We try our hardest to meet the needs of people, but it would be nice to have time to do more”.

Through a process called 'pathway tracking' we looked at care plans, spoke with people about the care they received and asked staff about how they provided support. This helps us establish whether people were getting appropriate care that met their needs and supported their rights. The staff we spoke with were knowledgeable about the care requirements of the people living at the home. They were able to tell us people’s choices and preferences and gave details on how to manage challenging situations should they arise. The information in the care plans, particularly in relation to challenging behaviour, was not sufficient to ensure staff had all the relevant information to manage a potential challenging situation.

We viewed training records and spoke to staff about training that was available to them. It was difficult to see from records what training had been completed. The staff we spoke with told us that training was available and they were supported with regards to their learning and development needs.

During the inspection we looked at the process the service had in place to monitor the quality of the service provided at The Water Mill. We found systems were in place for auditing documentation within the service and saw that a satisfaction survey had been undertaken for people who used the respite facility at The Water Mill.