Puttenham Hill House Care Home 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. Puttenham Hill House Care Home is registered to provide nursing and personal care for up to 30 people. There were 21 people living at the service at the time of our inspection.

This inspection site visit took place on 9 October 2018 and was unannounced.

There was a registered manager in post at the time of the inspection. 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 the last comprehensive inspection in September 2017, we found that improvements were required in relation to the management of medicines and the information around how people needed to be supported in an emergency. We also identified that people’s records were not always kept up to date and there was insufficient oversight of clinical care. At the latest inspection we found that this had improved.

People told us that there were enough staff at the service. We found that there were sufficient levels of staff to provide support to people when needed. The management of medicines was being undertaken in a safe way. Updates had been made to the clinic rooms since the last inspection. People told us that they received medicines when they needed.

People told us that they felt safe at the service. Staff understood the risks associated with people’s care. Clinical risks were regularly monitored by the nursing staff. There were robust recruitment procedures in place to ensure that only suitable staff were employed. Accidents and incidents were responded to well by staff and actions were taken to reduce further occurrence. The registered manager reviewed all accidents and incidents to ensure that patterns were identified and actions taken.

In the event of an emergency such as a fire or flood there were plans in place to ensure that people were evacuation safely. There was a business continuity plan in the event the building needed to be evacuated. Staff understood how to protect people from the risk of infections spreading. The service was clean and well maintained. Staff understood safeguarding adults procedures and what to do if they suspected any type of abuse.

Staff were sufficiently training and supervised to ensure that they were undertaking their duties appropriately. People had access to health care professionals where needed. Where people were nutritionally at risk staff monitored and took action to address this. People liked the food at the service and had access to drinks regularly.

Staff understood the principles of the Mental Capacity Act 2005 (2005). People’s consent was sought before care was delivered. Appropriate applications were submitted to the Local Authority where people may have been deprived of their liberty. Staff worked well together within the service and followed guidance from health care professionals.

People were cared for by staff that were kind, attentive. Staff treated people in a dignified and respectful way and developed good relationships with people. People were encouraged to be independent and were involved in discussion around their care. Visitors were welcomed to the service. People were supported to practice their faith.

Detailed assessments were undertaken before people came to the service. Care plans contained detailed guidance for staff on how to deliver care. Staff read and understood the care plans. People had access to appropriate activities and regular outings were arranged. People in their room had regular contact with staff to prevent th

This inspection was carried out on the 20 September 2017. Puttenham Hill House provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 30 people. At the time of our inspection 22 people were living at the service.

There was a registered manager in post and present on the day of the inspection. 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.

We undertook this inspection to check that actions had been taken in relation breaches around the lack of staff. We found that this had been addressed.

Records at the service were not always kept up and date, accurate and there was a risk that staff may not provide the most appropriate care. Records were not always being completed when needed. Staff were not always being monitored to ensure they were undertaking the work they needed to do.

People told us that they felt safe with staff. Relatives felt their family members were safe at the service.

On the day of the inspection we found that medicines were not always stored appropriately. The medicine room was cluttered and untidy. After the inspection we were contacted by the registered to confirm that this had been addressed. We also found that people’s evacuation plans were not always accurate. We have made recommendations around these matters.

There were aspects to people’s medicines that were being managed in a safe way. People told us that they had access to medicine when they needed.

There appropriate numbers of staff to meet the needs of people. We did ask the registered manager to ensure that staff did not leave the top floor as this left people at risk; They assured us that this would be addressed. Staff underwent robust recruitment checks before they started work to ensure that they were safe to work with people.

When clinical risks and risks to people’s mobility were identified appropriate management plans were developed to reduce the likelihood of incidents occurring.

Staff understood what they needed to do to help keep people safe. There were systems in place to ensure that people were protected from the risk of abuse. Incidents and accidents were recorded and action taken to reduce the risks of incidents reoccurring.

People confirmed that staff asked their consent before care was delivered. Staff had received training around the Mental Capacity Act (MCA) 2005 and how they needed to put it into practice. DoLS applications had been completed and submitted in line with current legislation to the local authority for people living at the home. For example, in relation to bed rails.

Staff had the appropriate training and were sufficiently skilled to carry out their role. Staff had received appropriate support that promoted their professional development.

People told us that they liked the food at the service. People’s health and nutritional needs were monitored. People had access to health care professionals when they needed.

People and relatives told us that staff were caring and respectful towards them and these were our observations. People were involved in their care planning and made choices around their care delivery. Visitors were able to visit the service when they wanted. People were supported at the end of their lives with the appropriate care.

People care plans showed detailed guidance for staff. They were reviewed on a monthly basis or more frequently when required. Staff communicated people’s changing needs effectively.

There were sufficient activities for people to get involved in including those that were cared for in their rooms.

Complaints and concerns were reviewed and used as an opportunity to improve the service. Compliments wer

This inspection was carried out on the 25 August 2016. Puttenham Hill House provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 30 people. At the time of our inspection 25 people were living at the service.

There was a registered manager in post however they were on annual leave on the day of the inspection. 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. Instead on the day we were supported by the interim manager and the clinical lead.

There was insufficient numbers of care staff deployed at the service to meet people's needs. This was a continued breach from the previous inspection around staffing levels.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided. They had not acted on concerns we identified at our last inspection.

Qualified staff had not always received appropriate clinical supervision. However other staff were having one to one support with their manger that promoted their development. We found the staff team were knowledgeable about people's care needs. People told us they felt supported and staff knew what they were doing.

People told us they were safe at the service. Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from harm. Recruitment practices were safe and relevant checks had been completed before staff started work.

Medicines were managed, stored and disposed of safely. Any changes to people's medicines were prescribed by the person's GP and administered appropriately.

Fire safety arrangements and risk assessments for the environment were in place to help keep people safe. The service had a business contingency plan that identified how the service would function in the event of an emergency such as fire, adverse weather conditions, flooding or power cuts.

Staff were up to date with current guidance to support people to make decisions. Where people had restrictions placed on them these were done in their best interests using appropriate safeguards. Staff had a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff involved and treated people with compassion, kindness, dignity and respect. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy and dignity were respected and promoted when personal care was undertaken.

People's needs were assessed when they entered the service and on a continuous basis to reflect changes in their needs. People's care and welfare was monitored regularly to ensure their needs were met within a safe environment.

People were encouraged to voice their concerns or complaints about the service and there were different ways for their voice to be heard. Concerns and complaints were used as an opportunity to learn and improve the service. The provider actively sought, encouraged and supported people's involvement in the improvement of the home.

People had access to activities that were important and relevant to them. People we

This inspection was carried out on 28 July 2015. Puttenham Hill House provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 30 people and on the day of our inspection 27 people lived at the service. The accommodation is arranged over two floors. The service also provides end of life care to people.

On the day of our visit the registered manager was on leave. 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 were assisted by the relief home manager and the regional quality manager.

There was not always enough staff deployed around the service to meet people’s needs. One member of staff said “On some days and at some times we are really pushed for time and this means we cannot do the things we want with people that we know they would benefit from.”

Nurses had not been provided with up to date clinical training or recent clinical supervision. Staff were kept up to date with the required service mandatory training and their competencies were assessed regularly.

We recommend that all staff receive appropriate and ongoing or periodic supervision in their role to make sure competence is maintained.

Staff received training around their responsibilities under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). However there were not enough assessments of people’s capacity. Staff gained consent from people before they provided care.

People said that they felt safe at the service. One relative said “I absolutely feel that (my family member) is safe, I leave here with confidence when I have visited, it’s a safe place.”

Staff had knowledge of safeguarding adult’s procedures and training had been provided to all staff.

People understood about the medicines they received. Medicines were managed in a safe way and staff recorded, stored and administered medicines safely.

Risk assessments for people were detailed and informative and included measures that had been introduced to reduce the risk of harm.

In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and made them safe.

Accidents and incidents were recorded and the deputy manager analysed the information from this to look for trends. This was then discussed with staff at handovers and staff meetings.

Checks were undertaken when staff were recruited to the service that ensured that they were suitable.

People felt that their re care needs were being met. One person told us “The staff are very good.”

People liked the food at the service. One person said “The food is very tasty; I get plenty to eat and drink.”

Where people needed to have their food and fluid recorded this was being done appropriately by staff. People received nutritious food and drink that met their needs.

People had access to a range of health care professionals, such as the GP, opticians, community dentist and physiotherapist.

People and relatives felt that staff were kind and caring. One relative said “I feel that they look at (family member) as a person, staff are very engaged and I feel encouraged that they (staff) ask me about (family member).” One staff member said “I would be happy for my mum to be here.”

People and relatives said they felt involved in the planning of their care. One relative said “I was involved in the discussions around my (family members) care.”

People felt that they were treated with dignity and respect as did relatives of people. Staff at the service used an advocacy service where people needed the support.

A pre-assessment of people’s needs was undertaken before them moved in. One relative said “(The manager) came out to assess my (family members) needs.”

Staff did not always have the most up to date and accurate information about people. This meant that there was a risk that people may not receive the most appropriate care.

People who used the service and relatives said the management of the service was good. One person said “I think the manager is nice, he makes time to come and speak to me.”

People’s and relative’s comments, and the records we saw, demonstrated the provider had consulted with people about the service provided. This included the use of surveys and questionnaires.

We saw various audits had been used to make sure policies and procedures were being followed and to improve the quality of the service provided. This included infection control, resident involvement, health and safety and housekeeping.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The manager had informed the CQC of significant events in a timely way. This meant we could check that appropriate action had been taken.

During the inspection 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 the report.

We spoke with three people and four people’s relatives about their experience of the care provided at the home. People were pleased with the quality of the service they had received. One person’s relative said “I can’t praise it high enough.” One person said “Very good” and another commented “Staff treat me well.”

We found that people had been consulted about their care and their verbal consent had been sought. Where people lacked the capacity to make a decision for themselves the correct procedures had been followed.

People’s care records showed that their care needs had been assessed and risks to them had been identified. We found that a specific risk to one person had been identified and managed by staff. However there was no care plan or risk assessment within the person’s care record in relation to this.

We found that people had been offered a range of foods to meet their needs. People had received appropriate support to ensure that their nutritional needs were met.

We saw evidence that the home had liaised with a range of professionals and other agencies to ensure that people’s needs had been met.

The complaints system had been brought to people’s attention and any complaints had been responded to. However as we were unable to see any records of the complaints received we were unable to review how effectively they had been dealt with.

During the course of the inspection we spoke with three people who used the service and four relatives. We found people who used the service were very satisfied. They told us "it’s very good” and said staff were polite and respectful and looked after them well. We found three people’s relatives were very pleased with the care provided. One said “it’s excellent” whilst another said “I could recommend the place”. One relative we spoke with was not satisfied with all aspects of the service.

We found people who used the service were treated with dignity and respect. The home had sought people’s opinions in relation to their preferences regarding their care.

We saw people’s needs were assessed and care plans and risk assessments were in place to ensure their needs were met and their care was delivered safely.

Medicines were stored and administered safely in the home.

We found there were sufficient staff to meet people’s needs. The home used some agency staff. Measures had however been put in place to maintain continuity of care for people who used the service.

There were systems in place to seek people’s views and to monitor the quality of the service provided.

People who used the service were very complimentary about the care they received at the home. They told us that they had always felt very safe at the home, that staff were very kind and treated them with respect.

They stated that all staff were very friendly, they were always polite and they treated them in a respectful manner.

People who used the service told us that they believed there was always enough staff on duty. They stated that staff were always around the home, and they do talk to them at any time. Most people told us that staff always arrived promptly when they had used their call alarm. Some told us that sometimes it could take about five minutes before staff attended to them when they had used their call bell. They also stated that they realised that there were other people living at the home who staff could be attending to at the time of their calls.

We were told that all staff looked after them in a very caring manner. People said staff were very respectful, they would knock on our doors before entering our rooms and they called us by our preferred names.

They stated that staff were very caring, and they would attend to their personal care needs in the privacy of their rooms with the door closed. They stated that they were provided with choices, and it was their decision of how their care needs were attended to. One person told us that the staff had a good sense of humour.