We undertook an unannounced inspection of La Fontana on 12 and 13 September 2018.

La Fontana 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.

La Fontana provides accommodation for up to 76 older people who need nursing and personal care. At the time of the inspection there were 69 people living at the home. The majority of people were living with a dementia and many had complex nursing or other support needs.

The service had 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.

Although people who were able to, told us they felt safe living in the home, the systems in place to protect people from harm needed to be improved. There were frequent incidents involving people becoming anxious and physically challenging to other people. These incidents were not always being reviewed to identify factors that could prevent further incidents from occurring. Care plans and risk assessment were not always updated following incidents.

Risks to people were not always being identified and management plans put in place to mitigate risks. Staff told us at times they were using unplanned restraint for one person during personal care. Staff had not received all of the training required to ensure they felt confident to manage incidents.

Some improvements were required to the processes in place where people lacked the capacity to make decisions for themselves.

People’s care plans were of mixed quality, were not consistently person centred and some contained contradictory information. Some of the plans lacked specific details of people’s communication needs, and preferences for how they wanted to be supported.

The provider had not notified the Care Quality Commission and the local authority of safeguarding incidents in line with their legal responsibility. The governance systems had not been fully effective in improving the quality and maintaining the safety of people. A new governance system had been introduced and had not been fully embedded to demonstrate its effectiveness.

Staff knew how to recognise and report abuse and felt confident concerns would be acted upon. Staff told us they felt supported in their roles.

Medicines were stored and administered safely. Some improvements were required to the recording of external creams, ‘when required’ medicines, and the competency checks of nursing staff.

We received some mixed feedback from people and relatives regarding the staffing levels in the home, there were enough staff available to meet people’s needs. The provider had procedures in place to ensure that suitable staff were recruited.

There were systems in place to protect people from the risk of infection. There were a range of checks in place to ensure the environment and equipment in the home was safe.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm.

People’s nutritional needs were assessed and their weights were monitored where required. Our observation of the mealtime experience was mixed. People commented positively about the food, although some said it was repetitive. The registered manager had plans in place to review and update the menu.

People were supported to access a range of healthcare professionals. The home maintained links with the local community.

People and their relatives spoke positiv

The inspection took place on 9 August 2016 and was unannounced.

At the last inspection on 16 and 22 July 2015 we found there were breaches of legal requirements. We asked the provider to take action to make improvements to: People’s food choices and the support they received at meal times; the accuracy and completeness of care records; the effectiveness of their quality monitoring system; and the deployment of sufficient numbers of suitably qualified staff. We received a provider action plan stating the relevant legal requirements would be met by 28 February 2016. At this inspection we followed this up and found the actions had been completed, although some further improvement was needed to ensure people’s care records were consistently up to date. We have also made a recommendation about best practice in relation to dementia care.

People’s mealtime experiences had improved greatly and there were more regular staff employed to meet people’s nursing and personal care needs. Management was more visible around the home and the registered nurses were far more active and effective in providing support and leadership to the care staff.

La Fontana provides accommodation for up to 76 older people who need nursing and personal care. At the time of the inspection there were 74 people living at the home. The majority of people were living with a dementia and many had complex nursing or other support needs.

The service had 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 registered manager told us the service philosophy was to provide a high standard of care, meet people’s needs and provide a safe environment. People and their relatives told us the service was responsive to their needs and the registered manager was open, accessible and approachable.

We observed staff supported people in a caring and considerate way and they had a good understanding of each person’s needs and preferences. A person who lived in the home said “The staff are nice and caring and on the whole they are patient and respectful”. A relative said “The best thing about this place is the care and attention they [staff] give to the residents. I would recommend this home; it's just like a big family”.

People told us they felt safe and secure. A person who lived in the home said “There are always staff around and they are there within minutes if anything happens”. A relative told us they felt well informed about changes in their relative’s needs and felt their relative was being cared for safely.

There were always three qualified nurses on each day shift to ensure people’s clinical care needs were met. The service also worked in close partnership with other local health and social care professionals to meet people’s health and wellbeing needs.

People received their medicines safely from registered nurses and people were protected from the risk of infection. The home’s environment was spacious, clean and bright throughout with lots of natural light.

The home had good facilities for people living with a dementia, including secure spacious gardens, a reminiscence room with traditional shop displays and its own animal farm. People, relatives and other members of the local community were invited to various events at the home, including: open days, Alzheimer’s days, fetes and other celebrations. This encouraged social interaction with the community and helped to raise awareness of dementia care.

We saw that people or their representatives were involved in the planning and delivery of their care. One person’s relative told us, “The manager and staff have always listened to me. There is a great open culture in the home.”

People’s care needs and risks were assessed and care was delivered to meet their needs. One person said, “I’m very well looked after. I really do thank my daughter for getting me here.”

People were protected from harm as there were appropriate safeguarding procedures.

Staff were supported by the provider through appropriate training and the home had suitable systems to monitor the quality of service provided.

Care was delivered to meet people’s needs. One person told us, “If I say I want to see a doctor they will get him to see me. If the nurses notice anything out of the ordinary they will refer it to the doctor. I have regular visits from the chiropodist.” People’s agreement was gained before staff provided support. One person told us, “If I don’t want to do something, I just say. They always ask me first.”

Medicines were managed safely. One person told us, “My medication comes on time usually.”

There were sufficient numbers of staff to meet people’s needs. One person told us, “There are enough staff. I don’t use the call bell often but when I do they come quickly.”

People’s care records were accurate and contained relevant information.

This visit was part of our routine schedule of planned inspections; however concerns had also been raised about people living in the home being made to get up early in the morning regardless of their personal wishes.

We visited the home at 7.30am on the first day of our inspection. On one unit we found that three people were up washed and dressed with a cup of tea. We spoke to them about whether they were happy to be up at that time of the morning. All three said they had wanted to get up. One person said they had always been an "early bird" whilst another said they couldn't lie around in bed once they were awake. Whilst we were there a fourth person came out of their room and they were assisted to wash and dress. We spoke to this person and they said they were usually up early as they liked to see what was going on.

During our two day visit we spoke with eight people about the care they received. Some people were unable to communicate their experiences verbally so we observed interactions between staff and people living in the home. People appeared very comfortable and relaxed with the staff member who supported them. We also spoke with staff and people visiting the home.

People told us that they were generally very happy with the care they received. One person said they were very happy and enjoyed the company of the staff, they said that staff would take the time to "sit and chat and look at magazines". We observed that staff interacted with people in a polite and friendly manner. We asked people who they would speak to if they had any worries. One person said “I could talk to most staff, they are all very nice.” One visitor said they were very happy with the care provided and confirmed that there was always plenty for people to do during the day.

This inspection took place on16 and 22 July 2015 and was unannounced.

The home is registered to provide accommodation with nursing or personal care for up to 76 older people with a dementia or with other mental and physical disabilities. At the time of the inspection there were 73 people living at the home. People had complex nursing care and support needs and many of the people found it difficult to engage in meaningful conversations because of their health needs. The home was purpose built and is situated in a rural setting with modern well maintained premises and grounds.

Most of the people in the home were living with a dementia and this limited the number of people we could have conversations with. To help us gain more information about people’s experiences of the service we also spoke with visiting relatives and observed the care and support practices in the home.

People and relatives told us they felt safe but we found areas that required improvement. For example, the service did not always have enough suitable staff to consistently meet people’s needs in a timely way. The staffing structure was clear but improvements were needed in the supervision and support provided to staff at all levels.

People had a choice of meals from a four week rolling menu. Alternatives were available if requested. The quality and quantity of food served was satisfactory but people were not always given appropriate support to eat their meals. Staff attitudes, at times, during lunchtime were not always caring.

There were inconsistencies and inaccuracies in people’s care records. This meant people may not have received the care they required. The provider’s quality assurance system had not operated effectively in identifying and making changes without delay when improvements were needed.

Although we identified areas where the service needed to improve, feedback from people and their relatives was generally complimentary. One visiting relative said “The best thing in the home is the friendly staff. There is no point in having a lovely home if the staff are not nice. They all seem to work as a team”.

In the provider’s annual satisfaction survey of people and their relatives the quality of service and buildings were rated as excellent overall; food and activities were rated as good. We were shown numerous compliment cards and letters from relatives referring to the excellent care people had received at the home, particularly those people approaching the end of their lives.

Relatives told us they were always made to feel very welcome and the management and staff actively encouraged their involvement in care planning and service developments.

People received their medicines safely and were protected from the risk of infection. The home was clean and tidy throughout and all areas were well maintained.

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.