Magdalen House is a purpose built residential care home without nursing for 53 people, some of whom are living with dementia. The service is set over three floors, with a dementia unit on the second floor and suites on the top floor for people who need less support. At our last inspection we rated the service Good. At this comprehensive inspection, which we carried out on 17 and 20 August 2018 we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. Because the rating remains Good, this inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Since our last inspection in 1 March 2017, there has been a change of registered manager, however, the people who lived in the service told us that they continued to feel safe and well cared for. There were systems in place which provided guidance for care staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe. Risk assessments were still in place to identify how the risks to people were minimised. There continued to be sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support.

Both the registered manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The manager knew how to make a referral if required, meaning that people living in the home were still being supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People’s needs were assessed and the service continued to support people to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and to have access to healthcare services.

We saw many examples of positive and caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff continued to protect people’s privacy and dignity.

People received care that was personalised and responsive to their needs. The service still listened to people’s experiences, concerns and complaints. Staff took steps to investigate complaints and to make any changes needed. People were supported at the end of their lives to have a comfortable, dignified and pain free death.

The registered manager told us that they had been well supported by the organisation while they settled into their position. The people using the service and the staff they managed told us that the registered manager was open, supportive and had good management skills. There were still good systems in place to monitor the quality of service the organisation offered people to ensure it continued to meet their needs.

Further information is in the detailed findings below.

The inspection took place on 1 March and was unannounced. The service provides accommodation and personal care for up to 53 people some of whom are living with dementia. On the day of our inspection 52 people were using the service.

The service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At our last inspection of 09 June 2016, we found there were not always enough staff to meet the assessed needs of the people using the service. An action plan was sent to us by the service of how this would be addressed. At this inspection, we found that there sufficient numbers of staff to meet the needs of the people using the service.

People were protected from the risk of abuse as staff had attended training to provide them with knowledge and an understanding of their roles and responsibilities with guidance in how to respond if they suspected abuse was happening. The manager had shared information with the local safeguarding authority when needed and the service had a safeguarding policy and procedure.

The manager had ensured appropriate recruitment checks had been carried out on staff before they commenced work to determine they were suitable to work with the people living at the service. Emphasis was placed on providing care and support in ways that people preferred as part of the interview process. Staff were supported through staff meetings and regular supervision and relevant training sessions.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. MCA, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. People at the service were subject to DoLS. Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and DoLS.

People’s health needs were managed appropriately with input from relevant health care professionals. People were treated with kindness and respect by staff who knew them well. People were supported to maintain a nutritionally balanced diet and sufficient fluid intake to maintain good health. Staff ensured that people’s health needs were effectively monitored. The staff were aware of individual health needs and responded to people’s concerns and behaviours in an appropriate and compassionate manner.

Positive and caring relationships had been developed between people and staff. People were supported to make day to day decisions and were treated with dignity and respect at all times. People were given choices in their daily routines and their privacy and dignity was respected. People were supported and enabled to be as independent as possible in all aspects of their lives.

Staff knew people well and were trained, skilled and competent in meeting people’s needs. Staff were supported and supervised in their roles. People, where able, were involved in the planning and reviewing of their care and support.

People were supported to maintain relationships with friends and family so that they were not socially isolated. There was an open culture and staff were supported to provide care that was centred upon the individual. The manager and deputy were approachable and enabled people wh

The inspection was unannounced and was a responsive inspection. The purpose of this inspection was to follow up on a number of concerns which related to people’s safety and well-being. We passed these concerns on to the Local Authority safeguarding team so they could be investigated. The Local Authority found most concerns to be unsubstantiated. The provider is usually proactive in raising concerns with the safeguarding team but a number of issues had not been reported by previously employed staff.

We also inspected the service to determine if people were receiving safe care and to assess if the service was being well managed with an adequate number of staff.

The last inspection to this service was on the 25 May 2015 and the service was rated good in all the outcomes except safe which required improvement. At our inspection on the 09 June 2016 we also regarded safe as requiring improvement but there was no change to the overall rating.

This report only covers our findings in relation to Safe. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Magdalen House on our website at www.cqc.org.uk.

The service provides accommodation and care for up to 53 people and it was situated on three separate floors, One is a designated dementia care unit, the other a residential unit and the third unit was for people who are more independent.

There was no 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.

Since the last inspection in May 2015 the Registered manager and Deputy Manager had left. This led to a degree of uncertainty for the staff and people using the service. An acting deputy manager had recently been appointed and we found that they were experienced and knew people’s needs well. They were supporting staff who told us they had confidence in their skills. The provider was providing leadership and had acted quickly to address the management shortfalls. They told us they had already appointed a new manager and would support them through their induction.

Staff had knowledge about safeguarding people in their care however there had been a failure to report matters of concern. These concerns were being investigated by the Local Authority. The provider acknowledged this was an oversight but one which would be rectified.

There were not always enough staff to match the dependency levels of people using the service. Staff told us changes in management had affected staff morale, but said that they enjoyed working at the home and seemed to be happy with the present acting up/interim management arrangements. However staff shortages meant that some staff were not familiar with people’s needs and were not sufficiently experienced. There had not always been enough to staff to provide adequate stimulation or activity to promote people’s well-being. The provider had a plan to address this.

We have made a recommendation about audits to include call bell response times as this is a good indicator as to whether there are enough staff.

Risks to people’s safety appeared well managed and health care professionals reported favourably about the care provided in the home.

People received their medicines as required by staff trained and assessed as competent to administer it.

We found a breach of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 in multiple regulations. You can see what action we told the provider to take at the back of the full version of this report.

The inspection took place on 21 May 2015 and was unannounced. The service provides care and support to older people, some of whom are living with dementia. At the time of our inspection 43 people were residing at the service.

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.

Staff were trained in safeguarding people from abuse and they understood their responsibilities. Safeguarding concerns had been raised appropriately with the local authority.

Risks to people and staff were assessed and actions taken to minimise them.

Staffing levels were not assessed based upon the needs and numbers of people at the service, nor was this kept under review. There was a recruitment procedure in place which ensured that staff were safe to carry out this kind of work, however this was not routinely followed.

People received their medication as prescribed. Records related to regular prescribed medicines were accurate but we found that medicines relating to ‘when required’ could have been more safely managed.

Training was provided for staff to help them carry out their roles and increase their knowledge about the conditions of the people they were caring for.

People gave their consent before care and treatment was provided and most staff had received training in the Mental Capacity Act (MCA) 2005. We found that staff had some knowledge of it and decisions had been taken in line with it. The MCA ensures that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. The service needed to further develop its practice and understanding in relation to Deprivation of Liberty safeguards which would ensure people’s rights were protected.

People were supported with their eating and drinking and records, when needed, were maintained. In one case we found someone who was not correctly supported with their choice of meal and therefore was placed at potential risk. Staff also supported people with their day to day health needs and were quick to refer people to appropriate healthcare services if required. A visiting health professional confirmed that the service had a good working relationship with the local surgery and health professionals.

Staff were very caring and people were treated respectfully and their dignity was maintained. Relationships were good between staff and the people they were supporting. We observed staff providing high quality care along with friendly humour which was very well received by the people they were caring for. People praised the staff that supported them.

People and their families were involved in planning and reviewing their own care and were encouraged to contribute to regular review meetings. People were in control of what care they received and how it was provided.

Formal complaints had been made and we could see that these were dealt with promptly and to the satisfaction of the people raising the issue. Records showed the actions taken to prevent a reoccurrence.

Staff understood their roles and felt supported by the local ‘friendly’ management team. People who used the service, their relatives and staff were very positive about the local management of the service and praised the open culture and excellent communication.

Quality assurance systems were in place to audit the delivery of the service. However, these could be developed further to analyse trends and therefore potentially prevent and improve practice. Proposals sent to us since inspection would demonstrate that the provider had oversight of how the service was operating.

Prior to our inspection we had been informed about an incident in the service. This is in the process of being investigated other professionals. We will monitor the outcomes to this investigation. The reason for this inspection was to check that the people who lived in the service were receiving safe and effective care.

We spoke with nine of the 33 people who used the service. We also spoke with two people's visitors, the provider, the registered manager and four staff members. We spent some time in communal areas of the service to observe the care that people were provided with and the interaction between staff and the people who used the service. We looked at five people's care records. Other records viewed included records associated with medication management, meeting minutes and records relating to the quality assurance in the service. We considered our inspection findings to answer 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?

This is a summary of what we found;

Is the service safe?

When we arrived at the service the provider saw our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that they would speak with the staff if they had concerns.

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 had been trained to understand when an application should be made, and how to submit one. The provider and the registered manager were aware of the recent changes in the law, following the supreme court ruling in March 2014. They told us that they were considering making applications, if appropriate, in this respect.

We saw that medication was stored safely. There were improvements needed in the way that the service managed people's medication. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service effective?

People told us that they felt that they were provided with a service that met their needs. One person said, "I am very happy." Another person said, "I think I am well looked after." Another person said, "I would not want to be anywhere else."

People's care records needed improvement to show how people's needs were met. Due to the shortfalls in the records we were not assured that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. However, we saw two staff interactions which did not respect people's choice. We discussed this with the registered manager and the provider and they assured us that this would be addressed.

People told us that the staff treated them with respect. One person said, "They (staff) are very pleasant and kind." Another person said, "They (staff) are very nice."

People using the service, their relatives and other professionals involved with the service completed satisfaction questionnaires. Where shortfalls or concerns were raised these were addressed.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

People told us that they knew how to make a complaint if they were unhappy. We saw that where people had raised concerns appropriate action had been taken to address them.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and district nurse. People told us that if they told staff that they were not well, the staff took appropriate action. One person told us about a recent fall and they said that they were satisfied that the staff acted quickly to ensure they were provided with the treatment that they required from other professionals.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed. As a result the quality of the service was continuing to improve and actions were taken to learn lessons.

We spoke with three people using the service. One person told us, “I am very happy with the service I receive”. One person said, “Staff are very nice”. Another person told us, “I am very happy here”.

We spoke with four relatives who were positive about the service their relatives received. One relative told us, “We love it, the staff are excellent, we don’t have to ask, everything is just done for my relative”. One relative said, “If I do need to query anything about my relative’s care all I have to do is ask and it is dealt with”. Another relative told us, “Seems to be loads of staff, don’t have to go looking for staff”. However, one relative commented, “Overall, very happy, no real concerns, but sometimes I can’t find a member of staff”. Other comments included, “Staff look after my spouse well”. “In the short time my relative has been here, they are looking better, eating better, we are more than happy with the service”. “So far very happy” and “Very happy with the care, I have no issues”.

We found that people who used the service experienced care and support that met their needs and protected their rights. There were enough qualified, skilled and experienced staff, however we observed that there were periods of the day, such as meal times, where more staff were needed. The provider had effective systems in place to regularly assess and monitor the quality of the service. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

On this occasion we did not speak with anyone who used the service about the way their medicines were managed. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People told us that liked living at Magdalen House because they found it homely and comfortable and they were able to choose how to spend their day. One person described, how they felt contented and safe living at Magdalen House. They told us that they enjoyed sitting in the courtyard garden outside their room, having a coffee and reading their paper. One person commented, “I feel very comfortable here”. We observed a group of people using the service preparing vegetables for lunch. There was a buzz of conversation. One person said, “We enjoy helping with the meal, we feel needed and it’s good fun”. Another person told us that, they formerly belonged to a creative writing club and had been asked to help with developing a Magdalen House newsletter”.

We spoke with two people visiting the service. One relative told us that, “Staff are kind and helpful, sometimes the service could do with more staff, although if you ring the bell staff usually come quick”. One relative told us, “I visit every day and find the staff are very caring, I am very satisfied with the care and staff report any issues about my relative to me”.

We found that systems were not in place to regularly assess and monitor the quality of the service and accurate and appropriate records were not being maintained. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

We spoke with four people to find out what it was like to live in Magdalen House. One person told us that, "The staff are very nice, they have helped me to feel comfortable and safe, they are all very kind”. They said the were very happy living in the service and that it was very clean. One person described the service and the food as, "Very good”, and stated, “I am very happy here". One person told us that, "The staff are very friendly, kind and helpful".

We spoke with three people visiting the service. One visitor told us, "I can not fault the home, and the way the staff support my relative". They told us that they trusted that the staff were meeting their relatives needs and that they felt that the staff knew what they were doing. One relative told us that they had been kept informed about their next of kin following a fall and that necessary improvements had been made to minimise the risks of their relative experiencing further falls. One relative commented, “It couldn’t get better, the staff will do anything for you, it is a really good service”.

We found that care was not being provided according to people's assessed needs. The records relating to people who used the service were not being properly completed to provide an accurate reflection of their needs. We had concerns that people’s needs were not being monitored and responded to promptly where there were factors, such as weight loss that presented a risk to their health and welfare.