This inspection took place on 29 November 2016 and was unannounced.

Pelsall Hall is a care home that provides accommodation and personal care for up to 41 people. There were 39 people living at the home on the day of our 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.

At our last inspection on 17 February 2016, we found breaches of Regulations of the Health and Social Care 2008 (Regulated Activities) 2014. We gave the service an overall rating of requires improvement. These breaches related to the provider’s failure to protect people from the risk of harm, consistently meet people’s nutritional needs or establish robust quality assurance systems. The provider sent us an action plan setting out the improvements they intended to make.

At this inspection, we found the provider had made significant improvements to the service. They had taken steps to protect people from harm and abuse. Staff had been given training in, and understood, how to recognise and report abuse. The risks associated with people’s care and support needs had been assessed and plans put in place to manage these. The provider assessed and organised their staffing requirements in order to meet people’s individual needs. People received their medicines safely from trained staff.

Staff had the necessary skills and knowledge to meet people’s needs and to communicate with them effectively. The provider protected people’s right under the Mental Capacity Act 2005. People had the support they needed to eat and drink. Staff monitored people’s health and helped them to access healthcare services.

Staff adopted a caring approach towards their work and knew the people they supported well. The provider encouraged people’s involvement in care decisions that affected them. Staff treated people with dignity and respect.

People received care and support that was shaped around their needs and preferences. People and their relatives knew how to complain, if they were unhappy with any aspect of the service provided.

The provider promoted an open and inclusive culture within the service. People and their relatives felt the provider took their views into account. Staff felt well supported and able to challenge working practices. The provider made use of quality assurance systems to drive improvement at the service.

The inspection took place on 17 and 18 February 2016 and was unannounced. At the last inspection completed 28 August 2013 the provider was meeting all of the legal requirements that we looked at.

Pelsall Hall is a residential home that provides personal care and accommodation for up to 41 older people, many of whom are living with dementia. At the time of the inspection there were 39 people living at Pelsall Hall. Six of these people were living in a specialist dementia unit at the service called Eden Rise. A registered manager was 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.

People felt safe living at the service and were protected by a staff team who could recognise signs of potential abuse. Staff knew how to report any concerns about people and were confident in ‘whistle blowing’ if this was ever required. People were put at risk of injury due to unsafe moving and handling practices. Accidents and incidents were not consistently recorded and reported to managers. People were not always supported by sufficient numbers of staff, in particular at meal times. People received their medicines as prescribed.

People were supported by staff who had access to regular training, however their competency in their role was not assessed. Some staff members did not always demonstrate the skills required to support people effectively. Decisions about people’s care were not always made in line with the Mental Capacity Act 2005 when people lacked mental capacity. People did not always receive the support they needed to meet their nutritional needs.

People were supported by staff who were kind and caring. People were made to feel valued and were supported to make choices about their day to day care. People’s privacy, dignity and independence were protected and promoted. People were supported to maintain relationships that were important to them.

People were not protected by effective quality assurance systems. Systems did not identify all issues and areas of risk within the service. People spoke highly of the management team within the service. People, their relatives and staff all felt involved in the development of the service and had confidence in managers to make any required improvements.

We found that the provider was not meeting all of the requirements of the law. You can see what action we told the provider to take at the back of the full version of the report.

We visited Pelsall Hall unannounced, this means that the home were not aware that we were going to visit. The manager, deputy manager and a senior care assistant provided us with information throughout the visit. We also spoke with two staff, six visitors and four people who lived at the home.

We looked at records, spoke with staff, visitors and people who lived at the home to find out about the food available to them. We were told that the food was good and that there was plenty of it. We observed the lunchtime meal being served and saw that people had a choice of food and drink. Records showed that people's likes and dislikes had been recorded and that satisfaction surveys were used to check that people were happy with the quality of the food served.

We looked at the storage and management of medication. A senior carer explained the systems in use which appeared to be robust and made audit of medication easy.

There were 38 people living at the home at the time of our visit. We spent some time in the lounge observing the interaction between staff and people who lived at the home. We saw staff spending time chatting to people and singing and dancing with them. Everyone that we spoke with praised the staff. One person commented: "(My relative) has excellent care, it is the best place ever, a wonderful service, it's like a four star hotel". Another person said: "All of the staff are friendly and chat with you".

We carried out this review to check on the care and welfare of people using the service. The home had a separate six bedded dementia care unit. There were 37 people living at the home at the time of this visit including five people who were living in the dementia care unit. We spoke to seven people, six relatives, four staff, and the deputy manager.

There was a very friendly and pleasant atmosphere in the home. One relative said, “We went to many homes for my mum and dad, this was the best one.” We saw that people looked well presented and wore clothes that reflected their own preferences, style, and gender.

We saw that staff had a good relationship with relatives and welcomed them at the home. One relative said, “We are always welcomed, I visit nearly everyday without any restrictions.” One person said, “My daughter can visit any time.” We saw that there were refreshments for relatives to help themselves when they visited people at the home. This meant that relatives could visit people at the home at any time. We saw that relatives could sit with people in the lounge or in people’s bedrooms, where their privacy was respected.

We saw that staff helped one person celebrate her 105th birthday at the home. We saw that people and relatives were involved in the celebrations. The relatives of this person said, “She came to this home and has been poorly so many times but they have looked after her so well. She is a testament to how good the care is here.”

Arrangements were in place to ensure people are safeguarded from the risk of abuse.

People and their relatives were complimentary about the staff and the home. We saw that staff had meaningful conversations with people, which people were enjoying. One person told us, “Staff spend time with me all the time, they even painted my nails for me today.” This meant that people were involved in meaningful activities throughout the day and had one-to-one interaction with staff.

People told us that they knew how to raise any concerns if they had any, however all the

people we spoke to told us that they did not have any concerns.