This comprehensive inspection took place on 31 December 2018 and was unannounced. We last inspected the service on 6 July 2016 where we rated the service good in all key questions and overall.

At this inspection we have rated the service requires improvement in the key questions of ‘is the service safe?’, ‘is the service effective?’, ‘is the service responsive?’ and ‘is the service well-led?’ The overall rating for the service is requires improvement.

Keats House is a 'care home' without nursing. People in care homes receive accommodation and 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. The service is registered to provide care for up to seven people with mental health needs. There were seven people using the service at the time 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 and associated Regulations about how the service is run.

During the inspection we found there were risk assessments in place but these did not identify all risks, and where risks were identified the risk management plans did not always include guidelines about how to mitigate these.

There were no person-centred care plans in place, so people’s individual needs and wishes about how they wanted their care delivered were not recorded, so staff were clear about how to meet people’s needs.

Until September 2018, people’s records were reviewed and updated monthly. However, there had been no reviews in the last three months. Most records were not signed by people who used the service although the registered manager told us people were able to.

People's health and nutritional needs had been assessed before they moved into the home. People had access to healthcare professionals to support them. However, staff had failed to take action and refer two people who used the service when they had lost a significant amount of weight and were at an increased risk of malnutrition.

There was no evidence that people were engaged in activities, consulted about what activities they wanted to do. There were no individual activity plans in place and some people reported they were lonely and had nothing to do.

The provider told us they had systems in place to monitor the quality of the service and put action plans in place where concerns were identified. However, these were not recorded and had failed to identify the issues we found at this inspection so the necessary improvements could be made.

Recruitment checks were carried out before staff started working for the service and included checks to ensure staff had the relevant previous experience and qualifications.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, person-centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We also found that the environment was not always tailored to the individual needs of people and areas of the home needed updating and decorating. We have made a recommendation about this.

People were protected by the provider’s arrangements in relation to the prevention and control of infection. Communal areas were clean. However, some bedrooms were not always clean thoroughly.

The provider had a policy about end of life care. However, staff had not received training in this subject and none of the people who used the service had an end of life needs assessment or care plans. The provider acknowledged that this area needed to be developed further to ensure they could meet people’s needs when they reached the end of their lives.

The inspection took place on 7 June 2016 and was unannounced. The last inspection took place on 21 February 2014 and at the time we found the service was meeting the regulations we looked at.

Keats House provides residential care for up to seven adults with mental health needs. There were six people living at the service at the time of our inspection.

There was a registered manager in post at the service 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 and we saw there were systems and processes in place to protect people from the risk of harm. There were sufficient staff on duty to meet people's needs and the provider had contingency plans in place in the event of staff shortage to ensure people's safety.

Staff had undertaken training on the Mental Capacity Act 2005 (MCA) and were aware of their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS). They ensured people were given choices and opportunities to make their own decisions.

There were arrangements in place for the management of people's medicines and staff had received training in administration of medicines.

People's nutritional needs were met, and people chose what they wanted to eat and drink.

Staff received effective training, supervision and appraisal. The registered manager sought guidance and support from other healthcare professionals and attended workshops and conferences in order to cascade important information to staff, thus ensuring that the staff team were well informed and trained to deliver effective support to people.

Staff were caring and treated people with dignity and respect. Care plans were clear and comprehensive and written in a way to address each person's individual needs, including what was important to them, and how they wanted their care to be provided.

A range of activities was provided both in the home and in the community. We saw that people were cared for in a way that took account of their diversity, values and human rights.

People, staff, relatives and healthcare professionals told us that the management team were approachable and supportive. There was a clear management structure, and they encouraged an open and transparent culture within the service. People and staff were supported to raise concerns and make suggestions about where improvements could be made.

The provider had effective systems in place to monitor the quality of the service to ensure that areas for improvement were identified and addressed.

We carried out this inspection to check whether the provider had made improvements to the premises. The previous inspection on 27 June 2013 found that the provider had not taken steps to ensure care was being provided in an adequately maintained environment. The provider wrote to us and told us the action they were going to take to make improvements.

At this inspection we looked at the steps the provider had taken to ensure the premises was being adequately maintained. We found that improvements had been made. This meant that people benefited from a safe and well maintained home.

We spoke with four people who use the service, two of whom said they had a care plan based on the care programme approach (CPA). People said they had consented to and signed their care plan. People told us they had a daily routine which included looking after their bedroom and completing light house work which staff assisted them with. People said they watched television and sometimes did crosswords.

People had their needs assessed and care was planned with the support they required documented in their care plan. Risk assessments had been completed and a record of risk management was contained in their records. Arrangements were in place for the safe management of people's medication. There were enough staff on duty to meet people's needs and staff were suitably qualified and skilled.

The provider had not ensured that the environment was maintained to a standard that would promote people's health and wellbeing. Parts of the home were not maintained adequately and in need or cleaning, repair or replacement. The provider has not met the required standard for safety and suitability of the premises.

All four people who we spoke with told us staff asked them about their choices with their day to day life and mostly respected the choices they made. We found that there were some restrictions on some people which were recorded in their care plans and risk assessments which meant that not all their choices could be fully respected by staff.

People’s rights and independence were promoted by the service. We observed that some people were able to go out in the local community independently. Where this was not possible, people had information in their risk assessment to explain the reason why this was so.

One person said “my personal care needs are well met in the home”. Another said “It is very nice here and they look after you well”. All people who spoke with us told us that staff supported them appropriately to meet their needs. We also observed that people were appropriately dressed and looked well cared for. People knew that they could speak to the manager if they had concerns about their care and safety as he would take their concerns seriously and would resolve these.

People who use the service and their representatives were asked for their views about their care and support and they were acted on. People confirmed they had the opportunity to express their views and give feedback about the quality of the services provided in daily and monthly meetings and in six monthly satisfaction surveys. Where necessary action plans were in placed to address areas where improvement had been identified.