The inspection took place on 5 June 2018. At our last inspection in May 2017 the service was incorporated into the registration of the adjoining nursing home, Saffron Gardens and the service was rated Requires Improvement. However, the shortfalls we found related to the nursing home rather than the reablement part of the service. In December 2017 the registrations were separated in to the reablement centre and the nursing home. This was the first inspection of the service under the new registration arrangements. The service can accommodate 24 people. At the time of our inspection 15 people were being supported at the service.

The inspection was unannounced and took place on 19 June 2018.

Orchard Grove is a reablement centre. People attend the service for packages of care to support them in returning to their own home. Nursing care is provided along with rehabilitation provided by Occupational Therapists and Physiotherapists. On the lower floor of the centre, therapy staff were provided by Bristol Community Health. On the second floor therapists were self-employed but paid for by the provider.

We found that the service was safe. People told us they felt safe and well supported. People told us that staff came to help them promptly when they used their call bells and that there were always staff available when needed. The manager had identified some issues with medicines administration and had plans in place to address them.

The service was effective. Staff were positive about the training and support they received and had regular supervision to support their development. The building was well suited to its purpose. There was a gym located on the second floor to support people in their rehabilitation. Overall people were well supported to meet their rehabilitation goals. People had the support of regular GP visits to the service. Feedback from GP’s was positive about the support people received.

Staff were kind and caring and treated people with respect. People commented positively about staff telling us they were able to share jokes and laughter. People’s views and opinions were sought in order to help the provider monitor what was working well and identify areas for improvement.

The service was responsive to people’s individual needs. There was a process of assessment prior to people coming to the service to ensure their needs could be met. People’s progress was monitored closely and discussed in multi-disciplinary meetings. There were activities taking place for people to take part in if they wished to do so. This included an art club and a visiting organisation specialising in activities for older people. There was a process in place for responding to complaints. These were investigated thoroughly and a response provided to the individual concerned.

The service was well led. There was a manager in place who was in the process of registering. The manager was well supported by senior staff within the organisation. There was an open and transparent culture within the service. Staff felt able to discuss issues or concerns and were confident they would be listened to.

The inspection took place on 18 April and was unannounced. The service was last inspected in January 2015 and was rated Good at this time. No breaches of regulation were found.

The service provides accommodation and nursing care to older people, many of whom are living with dementia. The home provides care for up to 94 people; this includes a reablement unit for up to 24 people who are being supported to return to their own homes. There are also private flats included in the building and the people living in them are able to access support from care staff if required. At the time of our inspection, one person living in the flats was receiving a package of care from staff.

There were two registered managers at the service. One was in day to day charge of the reablement unit and the other in day to day charge of the rest of the home. 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 living in the home felt safe and well cared for. We received positive comments about staff and how safe people felt. Comments included; “Yes I feel safe everyone seems so pleasant and easy to talk to” and “Couldn’t be better, I feel safe here and the staff are very sociable and kind to me.”

There were inconsistent practices across the home in relation to medicines and risk assessment which meant improvements were required. When medicines were being crushed and administered covertly, we saw that in some cases pharmacist support had been sought in making the decision but not always. Pharmacist input is necessary in order to establish that crushing medicines is safe to do so. There were also inconsistencies in the recording of topical cream administration.

Where risk assessments were being used to assess people’s needs, we found in some cases these were clear and gave clear information about how to support people. In other cases we found errors in how they had been calculated and therefore didn’t accurately reflect the person’s needs.

These concerns had not been identified through the provider’s own quality and safety monitoring procedures.

We found some good practice in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Where best interests decisions were required, these were documented. We discussed with the provider further ways that they could ensure the requirements of the act were fully met, in terms of ensuring all views were sought from relatives when making decisions.

Staff received training and support to carry out their roles effectively. Staff received regular supervision to ensure their performance and development needs were monitored.

People were supported by kind and caring staff. We saw staff demonstrating care and attention to the people they supported. People were able to take part in a range of activities suited to the needs of people living with dementia.

There was a clear management structure in place in the home. The two registered managers were supported by a deputy manager and senior staff leading individual units. Staff felt that communications was good within the team and told us regular meetings were held to ensure important information about the running of the service was shared.

We inspected Saffron Gardens to follow up on improvements we had asked them to make following a previous inspection 22 August 2014. We issued a warning notice to the provider in respect of infection control. Following the inspection the provider told us about the changes they intended to make in the action plan by 11 October 2014. A single adult social care inspector undertook this inspection on 24 October 2014 to check whether the improvements had been made.

Below is a summary of what we found. The summary is based on our observations during the inspection, what staff and relatives told us and the records we looked at.

Due to the focus of this inspection we did not speak with people who used the service and considering one of our five key questions relating to the safety of the service.

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

Is the service safe?

When we inspected the home on 22 August 2014 we found that people were not protected from the risk of infection because appropriate guidance had not been followed. We observed that the home environment was not clean. This meant that there was a risk of people being cared for in an unclean environment.

We visited the home on 24 October 2014 to check how the provider had ensured that they were meeting the regulation for this outcome.

We toured the building and found the home generally clean, tidy, hygienic and with no malodorous smell. We saw hand sanitising gels in communal areas of the home for people who used the service, staff and visitors to use in order to prevent spread of infection.

We observed staff used personal protective equipment such as gloves during our visit. The home had an infection control policy and had undertaken an infection control audit of all areas of the home in line with the policy guidance. This meant that the provider had put measures in place to protect people who used the service from the risk of infection.

Is the service safe.

The home was not safe because people were not protected from the risk of infection at the home. We observed staff washed their hands after attending to people’s personal. We saw staff were not wearing disposable aprons whilst providing people with personal care. Although there were adequate supply of gloves and aprons these were not used by staff consistently. This increased the risk of cross contamination to both people who used the service and the staff members.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. This was because staff did not have up to date guidance about how to provide people with the care they required.

Is the service effective?

Mental capacity assessments were not carried out appropriately. There was no evidence that decisions had been taken in the best interest of people unable to make their own decisions about their care

We saw that people had access to health services in the community. We viewed records that detailed contact with other professionals such as; doctors, chiropodists and consultants. We saw that people who were at risk of losing weight were weighed regularly and their diet was monitored.

Where there had been a deterioration noted by staff the person had been referred to the appropriate professional for an assessment. This meant that people were supported to maintain their health and wellbeing.

Is the service caring?

People who lived in the home were not always able to tell us about their experiences because many of the people live with dementia. We spent time talking with people and observing how staff and interacted with the people who lived in the home. We also spoke with relatives who were visiting.

The staff talked with people in a caring and respectful way and were responsive to people’s needs. We saw staff provided encouragement to people and engaged with them in a positive way.

People who were able to speak with us said they were happy with the care they received and staff treated them in a caring way. One person told us, “The staff are very good I am happy with the care I receive”. Another person told us, “I’m very happy here I have no complaints. The staff look after us and I am treated very well”.

One staff member told us, “our residents are very important to us and we do our best to provide them with high quality care. Another staff member told us “we treat our residents with respect and dignity. We know them well and whatever they are able to do for themselves we support them and don’t take it away from them”.

Is the service responsive?

Not all care plans were sufficiently detailed or up to date to give staff full information about people's needs and risks to their care.

Accidents and incidents that occurred in the home were reported and recorded accurately. Records were maintained so that actions could be put in place to prevent further accidents. Records showed that action was taken when any untoward incidents occurred and steps were taken to minimise the risk of reoccurrence. This meant that there were systems in place to make sure that people were protected from risk of harm.

The complaints system for the home showed people how to make a complaint. We saw a copy of the complaints system was displayed in the main entrance of the home. Complaints were acknowledged within five days and resolved within 28 days. We saw that a recent complaint had been dealt with by the manager.

Is the service well-led?

People were put at risk of poor care as records were not fully completed and did not give staff sufficient information about a person's care needs and these could not be monitored effectively.

A recent survey of the views of staff and relatives of people using the service had been completed and the results had been collated. Action plan had been put in place to address the issues identified

We saw the registered manager had not ensured proper checks were carried around the home. These included checking bedrooms that were in use for cleaning standards. This meant that the cleanliness of the home was below standard expected and this put the people who used the home at risk of acquired infection.

We saw the manager had arranged for regular safety checks to be carried out on fire equipment used in the home and also medical equipment such as hoists. All these measures meant the provider was carrying out on going checks to ensure the environment people lived in was safe.

This inspection was part of a themed inspection programme specifically looking at the quality of care provided to support people living with dementia to maintain their physical and mental health and wellbeing. The programme looked at how providers worked together to provide care and at people's experiences of moving between care homes and hospital.

At the time of the inspection there were 69 people living at Saffron Gardens. The manager told us that the majority of people had a diagnosis of dementia.

We spoke with eight people who lived in Saffron Gardens, the manager, six members of staff and peoples relatives.

We used our SOFI (Short Observational Framework for Inspection) tool during the visit. The SOFI tool allows us to spend time observing the care and support people receive.

We left comments cards at the home to enable people to tell us about the care people received at Saffron Gardens. We did not receive any comments back from people.

We reviewed seven people’s records in depth. We saw they had been regularly updated but some had not been fully completed to reflect the needs of the people concerned. This put people at risk of unsafe care.

We saw that if someone needed to go to hospital information was sent with them to enable them to be supported appropriately.

Although systems were in place to monitor the quality of care that was provided, we found they were not always effective in identifying areas for improvement.

We spent some time talking with people and observed interactions between people and staff during the inspection. We saw staff reassuring people, listening to what they were asking or saying and acting on it. We saw staff kept people engaged people in different activities throughout the home.

We observed people were confortable in the company of staff drinking tea and coffee and chatting with staff and each other.

People were not rushed and were supported to do things in their own time. A relative told us " they are quite patient, they don't rush my relative”.

We saw the provider had a policy on safeguarding people from abuse. Staff had attended training to help ensure that people who lived in the home were protected from the risk of abuse.

We saw there were sufficient numbers of qualified and experienced staff at all times in the home to support the people who used the service.

People said they would let the staff know if they were unhappy. One person said “I have no complaints”.

Three relatives visiting the home told us their family members were in the right place, were happy and settled. One relative said I am really pleased my relative is gradually settling down, thanks to the way staff have been helping them”.

We saw the environment was suitably designed and adequately maintained to provide care for people who used the service.

We saw the provider had effective systems in place to regularly monitor the quality of service that people received.

The inspection of Saffron Gardens took place on 26, 27January and 4 February 2015 and was unannounced. At the last inspection on 23 August 2014 we found the service did not meet the regulations we inspected. These were in relation to the care and welfare of people who used the service, staffing and quality assurance. We found that the provider had made the improvements required.

Saffron Gardens provides accommodation for nursing and personal care for 72 people living with dementia. It also has a re-ablement unit which provides support for 24 people who had been discharged from hospital before going back to their own homes or a different care setting.

A registered manager was in post at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirement of the law; as does the provider.

People, who were able to answer our questions, told us they felt safe living at Saffron Gardens and felt able to raise any concerns. Comments included “I didn’t like it at first but I got used to it I feel safe”.

Staff knew how to keep people safe. They were able to describe the different types of abuse and what they should do if they suspected abuse. The provider had a policy on protecting people from abuse. It contained detailed information about definitions of abuse.

There was sufficient staff to meet the needs of people using the service. People were observed to receive a consistent and safe level of support and received their medicines as they needed them.

There were policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). This guided staff on how to protect people who lack capacity to make their own decisions.

Effective systems were in place to reduce the risk and spread of infection. The home was clean, hygienic and well maintained. The environment had been adapted to meet the needs of the people using the service.

People told us staff were caring, kind and compassionate. One person said “ staff are kind to me, they are really nice”

Appropriate checks were undertaken before staff began work. This helped to make sure people were supported and cared for by staff that had been judged safe to work with vulnerable people.

Equality and diversity were promoted at the service. People's needs in relation to ethnicity, gender, age and disability were recorded in their care plans so that these needs would be met. People told us staff were caring, kind and compassionate. One person said “staff are kind to me, they are really nice”.

There were various effective quality assurance systems in place. These included audits, house checks and through regular discussions during the annual care plan review.