This inspection took place on 10 and 11 April 2018. The first day of inspection was unannounced. At our last inspection in December 2016 we rated the service good overall. Due to a number of concerns recently raised about the service we carried out this inspection to check the provider was still meeting all legal requirements.

Order of The Sisters of St Joseph of The Apparition, known as and referred to in this report as Lady of the Vale care home, is registered to provide nursing, personal care and accommodation for to up to 39 people in 35 single and 2 double bedrooms, some of which have en-suite facilities. The two double rooms were being used as single rooms and at the time of our inspection there were 35 people living at Lady of the Vale. There is a chapel on site which people living at the home can attend on a regular basis if they wish. The chapel is also open to members of the public. There is a convent in the same grounds however this is separate to the care home and did not form part of the inspection. The home is surrounded by mature gardens, which are accessible to people using the service.

Lady of the Vale 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.

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 we spoke with told us there were enough staff available when they needed help and support and added that staff responded to their needs in a timely manner. Rotas we saw confirmed that sufficient staff were deployed to meet the assessed needs of the people using the service.

The home had effective systems for ensuring concerns about people’s safety were managed appropriately. Staff had received safeguarding training and all staff we interviewed were aware of the various types of abuse and could explain how they would act if they suspected abuse.

People felt they were safe. Care records contained individualised risk assessments and risk management plans and risks had been discussed with either the person or their relative.

The provider followed a robust recruitment and selection process to ensure staff recruited had the right skills and experience to meet the needs of people who lived in the home. All required functions of servicing and maintenance were undertaken either by staff employed by the service or by external contractors. Records were thorough and well maintained.

We identified an area of concern for people’s safety as the door on the first floor corridor could be opened. This meant that people who were mobile had access to the stairwell and could potentially injure themselves. Due to the risk posed to people’s safety a coded lock was fitted to the door during our inspection.

Systems in place for the receipt, storage and administration of medicines were robust and accurate. A GP from a local practice attended on a weekly basis, carried out reviews of medicines and care and dealt with any individual health concerns as identified by the home.

Changes were made in response to complaints and the registered manager learned lessons from complaints and took action to try and ensure these did not reoccur.

Staff gained consent from people before carrying out care and explained to them why their support was needed. Where people lacked capacity to consent, consent forms were included in care plans These were signed by a member of the person's family however the home was not always gaining consent in the correct way.

Concerns had been raised direc

The inspection took place on 25 October 2016 and was unannounced. We last inspected Order of The Sisters of St Joseph of The Apparition in April 2014. At that inspection we found the service was meeting the legal requirements in force at the time.

Order of The Sisters of St Joseph of The Apparition provides nursing and personal care for up to 39 older people, including people with dementia-related conditions. At the time of our inspection there were 34 people living at the home.

The service had a registered manager. 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.

We found that people were cared for in a clean, comfortable and well-maintained environment. Risks to personal safety had been assessed and actions were taken to prevent people from coming to harm. The service had established systems for protecting people from abuse and responded appropriately to any safeguarding concerns.

A robust recruitment process was followed to check the suitability of new staff. Sufficient staff were employed to provide safe and consistent care. The staff team were supervised and given training to help develop their skills and care for people effectively.

The service worked with health care professionals to maintain and improve people’s health and well-being. People were supported to receive their medicines as prescribed. A varied diet was provided and people told us they enjoyed the food. Nutritional needs were monitored and staff supported people with their eating and drinking needs.

People’s rights under mental capacity law were understood and upheld. Formal processes were followed when necessary to make important decisions about people’s care and treatment.

Staff had a good understanding of people’s needs and treated them as individuals. They were kind, had caring attitudes and were respectful of people’s privacy and dignity. Measures were in place to enable people and their families to express their opinions about their care and the service they received. Any complaints were taken seriously, though records did not always support how complaints had been addressed.

Care needs were assessed and work was in progress to embed electronic care recording, including making care plans more personalised to the individual. A variety of stimulating activities and events were offered to support people in meeting their social needs.

The management were committed to developing the service and promoting an open culture. Staff told us they were well supported, given leadership and could air their views. Methods to monitor the quality of the service were being better structured to ensure standards were maintained and improved.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Suitable policies and procedures were in place and staff had been trained to understand their responsibilities under the DoLS Codes of Practice. No applications had been made to deprive people living in the home of their liberty. Care plans and our observation of staff provided evidence of good practice in applying the least restrictive options to promote each person's autonomy.

Staff records contained all the information required by the Health and Social Care Act. This meant the provider could demonstrate that staff employed to work at the home were suitable and had the skills and experience needed to safely support the people accommodated.

We saw a robust system in place to maintain cleanliness and hygiene in the home. Prompt action had been taken to improve the management of infection control in response to the recommendations of an infection audit conducted by NHS England in 2013.

Care plans provided evidence of good risk management. For example, information in records provided evidence of staff taking prompt action to prevent a person from becoming malnourished.

Is the service effective?

Procedures were in place to obtain consent to care, treatment and support from people living in the home. Two people told us, "The staff are very good. They always discuss things with us and would never force us to do anything against our will" and "Yes, I make my own decisions and the staff go over and above to give me the help I need."

We saw handicrafts, artwork and photographs of activity sessions on display around the home. We noted a varied range of stimulating activities was being provided. Five people and two visitors spoke positively about activities. Their comments included, "There are stimulating activities on offer each day and staff encourage X to join in", "I like the art and craft sessions and they display our work on the wall" and "I join in some of the sessions, but staff don't force me if I'd rather not get involved."

Is the service caring?

During the midday meal we observed interactions between care staff, nurses and the people they cared for. We saw care staff use good observational skills to provide person-centred and compassionate care. Staff addressed people by their preferred titles and spoke with them in a quiet and calming manner to preserve their privacy and dignity.

Eight people living in the home and three relatives told us the care and support provided was very good. Their comments included, "We are really spoilt here. I'm glad you came to speak to me, because I want everyone to know that we get excellent care here," "I cannot praise the home enough" and "I get on well with all the staff. They are very patient, kind and caring"

Is the service responsive?

People living in the home had their needs assessed and their care plans told us how staff would provide care, treatment and support to meet their needs. Care plans also contained each person's choices and preferences for how their needs should be met. Eight people and three relatives spoke positively about the way the service was provided. They said they were listened to and consulted about the way the service was provided. One of the people we spoke with said, "I get the help I need, the food is first class and I enjoy the activities provided."

The Trustees Director told us they listened to and responded to the views of people living in the home and their representatives during their monthly quality audits. They gave us examples of the changes they had made in response to people's views and suggestions, which demonstrated that the service was being delivered in the best interests of the people accommodated.

Is the service well-led?

The manager had embedded effective quality assurance processes to protect people living and working in the home from accidental injury.

The people we spoke with during our visit told us the home was managed well. A relative said "This home is much better than the other homes I looked at and good value for money. I couldn't wish for better care for X. The home is always clean and they keep the decor, fixtures and fittings well maintained. Each time I come I notice new carpets have been laid. Tony, the manager, always comes and talks to me and asks for my views. The food is always good, because X tells me so and they offer me drinks and a meal each time I visit." A member of staff confirmed they were always consulted about decisions concerning the running of the home. One of the people accommodated told us, "I feel really fortunate to live here. The carers are so kind and they look after me very well. The food is excellent and we have activities we can join in every day."

We conducted this inspection in response to anonymous concerns that were received by the Care Quality Commission (CQC) two days prior to our visit.

We found no evidence to substantiate the allegation that people were being got out of bed early against their will. Eight people accommodated in the home told us staff respected their rights to privacy dignity and independence.

The allegation that people living in the home could not request food and drink outside set mealtimes was unsubstantiated. Seven people told us they were satisfied that their dietary needs were being met.

It was alleged that the health of people living in the home was being placed at risk because medicines were not being administered safely. We did not find evidence to substantiate this during our visit. Four people told us they were satisfied that they received their medicines as directed by their GPs. Two people told us, "The nurses always make sure I take my medicine" and "Yes I get my correct medicine at the right times."

We found new staff had been appointed to replace staff who had left. Additionally, changes to staff working patterns were being made in the best interests of the people receiving this service.

During our visit we saw evidence to demonstrate that systems had been maintained to ensure improvements were made in the best interests of the people accommodated. One of the people we spoke with said, "I don't think there is anything that could be improved."

Please see Outcome 16 for details about the current management of this service.

We found that people's rights to dignity, respect, privacy and independence were being maintained in a person centred way. A person living in the home said, "Things have definitely improved. Staff do treat me with respect."

Since our last visit a schedule of activities had been introduced at the home. Five people told us about the activities that they enjoyed and they confirmed that this provided them with stimulation and interest. One person said, "The staff took me out in my wheelchair the other day and it was good to get some fresh air."

Five people told us that they felt safe living in the home. One person commented, "I am confident that staff would step in if they thought we were not safe."

Significant improvements had been made to ensure that people living in the home received their medicines safely, as prescribed by their doctors. The people we spoke with knew what their medicines were for and they confirmed that they received their medicines at the same times each day.

We found that staff received the support they needed to care for people living in the home in a safe way.

Since our last visit robust systems had been implemented to ensure that there was a continuous protocol for assessing and monitoring the quality of the service provided to people living in the home. This included a process for checking that records were accurate and up to date.

A pharmacist inspector and a compliance inspector, from the Care Quality Commission, visited the home on 17 October 2012 to assess the improvements that had been made in the management of medicines since our visits in April and June 2012. Although we found that a limited number of improvements had been made, people still did not have all their medicines at the times they needed them in a safe way.

A person recently admitted to the home did not have care plans or risk assessments in place. This meant that staff had no written guidance on how to support the person in a safe way. We were also concerned to find that no action had been taken to refer the person to the local authority safeguarding team for investigation of suspected neglect during their stay in hospital.

We found further concerns in relation to dignity, respect and social stimulation. Two conversations that we overheard between staff and a member of staff speaking to one of the people accommodated, demonstrated a lack of respect and consideration for the two people concerned. We also found that the people accommodated were not provided with interesting or stimulating activities. One person told us that they were bored. They said they had not said anything to staff because, "What's the point, they don't care." Another person told us that they preferred to stay in their room because there was nothing going on in the lounge and they had difficulty communicating with other people living in the home.

We spoke with people living at the home they told us: "I was asked what type of food I liked and what time I liked to go to bed, things like that" "They asked me about the type of things I like and how I prefer to spend my time." and "I signed my care plan to show I was happy with it."

We spoke with people about the care they received and they told us: "The staff are lovely they do a lot for me." "I don't know what I would do without them they are angels." "Nothing is too much to ask." "They treat me with respect" and "If I need anything I just have to ask I have my bell here and if I press it they come to me."

We spoke with people about the staff and they told us: "Matron is always around to speak to if I need her" and "The girls know what they are doing they are experienced."

People told us they felt listened to one person said: "Matron pops in and asks if I am alright and if I need anything."

We spoke with people and their relatives who told us: “It’s ok in here”, “I love the food and the staff are very nice.” Visitors told us: “The staff are very good”, “He is always well presented”, “Yes, staff do respect his privacy and dignity”, “They let me know if they are worried about him”, “Staff gave me all the information (verbally) about the home before he moved in” and “I have no concerns about his care.”

Some of the people using this service had been diagnosed with dementia and were unable to express their feedback on the quality of the service they received. However, we observed people during the two days we spent in the home. Each person living in the home appeared to be relaxed, contented and well cared for.

Five people expressed their views to us about the service they received. Four people said that staff respected their preferences for how they would like their care to be provided. They told us that they decided what they wanted to do with their time, what they would like to eat, what time they got up in a morning and went to bed at night. However, none of the five people could recall being asked to sign to say that they agreed to the care and treatment they received in the home.

When we asked why they spent so much time in their rooms, five people using the service told us that they preferred to spend time in their bedrooms and liked to entertain their visitors there. Four people told us that they preferred to eat their meals in the privacy of their own rooms. One person said that she did go down to the dining room for her meals when staff asked her.When asked about the quality of meals provided in the home four people using this service said that the food was good, the menu was varied and they were given choices in the meals they liked to eat.

Five people told us that they felt safe living in the home and that they were satisfied with their accommodation. They told us that they liked the staff and they felt that the home was managed well. None of the people we spoke to expressed any concerns about the service provided.