We inspected Richmond on the 8 and 9 November 2018. This was an unannounced inspection.

Richmond 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. Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people requiring support with a dementia type illness and who are at risk of falls and live with long term healthcare needs such as Parkinson's. The home is set out over two floors. There is lift access between the ground floor and upper level. At the time of our inspection there were 49 people living at the home.

Following our inspection in March 2017 a number of breaches were identified and the service was rated requires improvement with the well led domain rated as inadequate. We served a number of Requirement Notices in relation to meeting people’s preferences, providing support in line with the Mental Capacity Act, unsafe medicine procedures, not reporting possible abuse effectively, inadequate systems for assessing and monitoring the service and insufficient staff levels. The provider sent us an action plan that told us how they would address these. We inspected again in September 2017 to check the provider had made improvements and to confirm legal requirements had been met. We found improvements had been made in several areas but in relation to the management of ‘as required’ medicines and the overall assessment of staff levels there were still shortfalls that needed to be addressed to fully meet the regulations.

This inspection found that whilst improvements seen in September 2017 had not deteriorated, there had not been the necessary improvements to change overall the rating to Good.

This is the third consecutive time the service had been rated as Requires Improvement.

Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included updating care plans when an identified need or directive of care changed. For example, a deterioration in health and nutritional needs.

Not all care plans had been reviewed and updated to ensure they reflected people’s current needs and associated risks. For example, when a person’s skin integrity changed and the equipment used to manage the risks to their skin, such as pressure reliving mattresses.

We have made a recommendation about the management of some medicines and in how staff administered medicines.

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 associated Regulations about how the service is run.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

Most care plans reflected people’s assessed level of care needs and care delivery was person specific, holistic and based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, swallowing problems and risk of choking, and moving and handling. The care plans also highlighted health risks such as diabetes and leg ulcers. People said they felt comfortable and at ease with staff and relatives felt people were safe.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. The provider was actively seeking new staff to ensure there was a sufficient number with the right skills when people moved into the home.

Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people requiring support with a dementia type illness and who are at risk of falls and long term healthcare needs such as Parkinson's. The home is set out over two floors. There is lift access between the ground floor and upper level. At the time of our inspection there were 49 people living at the home, one of whom was in hospital.

Richmond was inspected in March 2017. A number of breaches were identified and the service was rated requires improvement with the well led domain rated as inadequate. We served a number of Requirement Notices in relation to meeting people’s preferences, providing support in line with the Mental Capacity Act, unsafe medicine procedures, not reporting possible abuse effectively, inadequate systems for assessing and monitoring the service and insufficient staff levels. Following our inspection the provider sent us an action plan telling us how they would make improvements. This inspection found improvements had been made in several areas but in relation to the management of ‘as required medicines and the overall assessment of staff levels there were still shortfalls that needed to be addressed to fully meet the regulations. We acknowledge the management structure had changed following the last inspection and there had been difficulty in staff recruitment.

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 associated Regulations about how the service is run. A manager had been appointed and was in the process of submitting their application for registration. Since our inspection we have received this application and it is currently being processed.

There have been a number of changes to the management of the home in the past two years. In recent months CQC have received a number of concerns about the service and where appropriate, these have been sent to the local safeguarding team for investigation. During our inspection we received concerns from two whistle blowers (WB). Immediately following our inspection a third WB contacted us. Concerns included poor record keeping, a lack of availability of some prescribed creams and poor care. We looked at some of the concerns raised and asked the provider to carry out an investigation. We found some of the concerns were substantiated. However, a number of concerns were historical and actions had already been taken to address these areas.

The management team confirmed staff turnover had been high and in a number of cases disciplinary actions had been taken. This had led to low staff morale. The management team had responded robustly to this and to the impact this had on the running of the home and the care and support people received. Feedback from staff, visitors and people confirmed significant improvements had been made in relation to the running of the home.

Whilst we found improvements had been made we also found there were areas where improvements were needed. For example in relation to the management of medicines prescribed on an ‘as required basis,’ in relation to monitoring of mattress settings to ensure people’s skin integrity, and in consideration of risks when caring for people whose behaviour can challenge.

There were particular times of the day when calls bells were busy and this had an impact on people and staff. Whilst there were systems to monitor this, they needed to be implemented more frequently to ensure people’s needs were met safely and if necessary to revise staff levels. Systems for monitoring staff levels also needed to take account the overall impact of a high use of agency staff and a high number of falls.

Despite the above concerns we found staff understood w

We carried out an unannounced comprehensive inspection at Richmond in January 2016. A breach of Regulation was found. As a result we undertook an inspection on 2 and 3 March 2017 to follow up on whether the required actions had been taken to address the identified shortfalls. At this inspection we found the previous breach had been met; however we found additional concerns and further breaches of regulation.

Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people requiring support with dementia type illness and who are at risk of falls and long term healthcare needs such as Parkinson’s. The home is set out over two floors. There is lift access between the ground floor and upper level. At the time of our inspection there were 50 people living at the home.

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 and associated Regulations about how the service is run.

People living on the first floor of the service were not consistently responded to in a timely manner due to insufficient numbers and deployment of staff. Throughout our inspection we heard call bells ringing for extended periods; staff told us their responsiveness was impacted by the provider’s high use of agency staff.

We found two occasions where the providers own safeguarding procedures had not been consistently adhered to in regard to notifying appropriate external authorities in a timely manner.

The shortfalls in the recording of PRN (as required) Medicines we found at our last inspection had continued and additional concerns were identified in the administration and disposal of medicines.

Staff told us their morale was low and that they did not always feel listened to by senior staff. We found staff knowledge and understanding in areas such as the Mental Capacity Act 2015 (MCA) and behaviours that challenge required improvement. The provider had not ensured that staff completing MCA assessments had a clear understanding of how to capture and record people’s capacity in line with legislation. MCA assessments did not evidence how staff had arrived at decisions related to people’s capacity via best interest meetings and discussions.

Although we saw kind and caring interactions between people and staff we also found instances when there had been shortfalls in the staff approach in regard to confidentially, dignity and respect.

The provider had not ensured people’s care was consistently responsive to their support needs. Care plans did not always reflect people’s individual care and support needs and were not consistently person centred. The provider’s reliance on care agency for an extended period meant that the continuity of care people received was variable. We found there were occasions during our inspection where there was a lack of provision for people in respect to social activities and interaction with staff.

Some of the established quality assurance systems had failed to provide senior staff with clear oversight of the service. Audits related to care plans and call bells had not identified the concerns we found during our inspection. Effective leadership was not evident on the floor and the issues which had impacted on low staff morale had not been addressed.

Appropriate checks had been completed when new staff were recruited to ensure they were safe and suitable to work within a care environment. There were systems and processes in place to routinely check all equipment including those related to fire safety and health and safety.

People had a choice as to where they ate and they and their relatives were positive about the food provided. People told us they felt listened to in regard to their comments and suggestions about food and meal

We used a number of different methods to help us understand the experiences of people using the service, because some people had complex needs which meant they were not able to tell us their experiences. We spoke with people living at the home, their relatives and care staff in both Richmond and Heatherbank units. We spoke with a volunteer, the chef, the deputy manager and the manager.

When we inspected this service on 3 September 2013 we found that people were not receiving holistic care on one of the units; and some practices did not show that people were involved in decisions about the care provided. Staff spoken with said they did not feel supported by the management, and there were inconsistencies in the way that records were kept.

Following our inspection we received an action plan from the provider that told us that processes were in place that ensured people and their relatives were involved in decisions about the care they received. A holistic approach to care had been developed, staff were supported to provide this and record keeping was appropriate. The provider said the service was compliant. This inspection was carried out to check that the home had complied with the compliance actions made at our previous visit.

People told us they were quite comfortable living at the home. One person told us, “You’d find it hard to get a better home than this, and the food is excellent, 5*. You can make suggestions to the chef and he will get it for you.” Another person said, “They are very kind to me and I do appreciate it.” A relative told us, “The care is very good. Staff know how to support people who have dementia, and we would not be able to find anywhere better.”

We found that staff provided appropriate care and support for people in each unit at the home. We looked at six care plans and found that people, and if appropriate their relatives, were involved in planning and reviewing the care they received.

Staff spoken with said the management were very supportive and they felt able to provide holistic care for people.

The records we viewed were up to date and relevant to the services provided.

We spoke with ten people and three relatives. People told us they liked living at the home. One person said, “I’m quite comfortable here. Staff are very good especially the night ones they are wonderful.” One relative told us, “Our (relative) is looked after very well.” Another relative said, "We looked at several homes, and Richmond was the best one."

We found that there were differences in the way that services were provided on the two units. We looked at the processes in place to gain consent. We found that some practices did not show that people were involved in their care decisions. We observed that people did not receive holistic care on one of the units.

We looked at the processes for the administration of medicines.

We spoke with eight staff and the two peripatetic managers. There had been some improvements to staffing levels in the three weeks prior to our visit and the rotas showed that future staffing levels reflected the increased numbers. There had been temporary management arrangements in place since June.

Although there was a comprehensive programme of training in place we found that learning had not always been transferred into practice. Overall, staff felt unsupported.

We looked at eight care plans and four staff files and found that there were inconsistencies in the way that records were kept.

We asked the acting manager to provide additional evidence. This was not available at the time the draft report was produced.

During our inspection we spent time on the Richmond unit as our last inspection looked at the care and treatment provided on the Heatherbank unit. We spoke with three people from the Richmond unit and carried out an observation of three people. We spoke to four members of staff who worked on both units as well as the managers of the service. These discussions helped us to get a picture of the home as a whole.

Although the two units at Richmond were run separately there were a number of joint activities that took place and brought people and staff together. For example, a summer garden party was held in the grounds for all people using the service their family and friends. Weekly church services were held in the communal lounge for everyone. The singing activity we observed that took place on the Heatherbank unit was attended by people from the Richmond unit too.

People told us that they were well cared for and that the staff met their needs and they received the care and treatment they expected to have. One person told us “Its very nice here, I can’t fault it”. Another person told us, “Staff are very kind and helpful from the managers down”.

The eight people who use the service and two visitors we spoke with all stated that they were happy with the care received at the home.

Specific comments included – “Nothing is too much trouble.” “We couldn’t ask for more.”

We inspected Richmond on the 27 and 28 January 2016. This was an unannounced inspection. Richmond provides accommodation, care and support for up to 58 people. On the day of our inspection 55 older people were living at the home aged between 74 and 101 years. The service provided care and support to people living with dementia, risk of falls and long term healthcare needs such as diabetes.

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 and associated Regulations about how the service is run.

We last inspected Richmond on 11 March 2014 where we found the provider was meeting all the regulations we inspected against.

Throughout our inspection, people spoke positively about living at Richmond. Comments included, “Nice place to live” and, I’m very happy here.” However, we identified a number of areas that required improvement.

We found not all aspects of security had been considered by the provider in relation to visitors’ access to the service outside of office hours. There were periods of the day when the number of care staff available impacted on their ability to respond in a timely manner to people. We found domestic staffing levels did not match the planned rota which had impacted on the quality of the domestic cleaning with the home.

The administration of medicines was seen to be safe and people told us they received their medicines promptly and correctly. However staff who were providing people with ‘as required’ medicines were not consistently recording why they had been given it. This meant patterns may not have been identified by staff in a timely manner.

Staff were unable to evidence what steps had taken to ensure a person who had been identified at risk of skin pressure areas was being regularly supported to check on this area of care.

Although people spoke positively about food at Richmond we found suitable systems to ensure food was hot when served had not been consistently implemented.

Although we saw many kind and caring interaction between people and staff we found occasions when peoples’ confidentially and dignity was not consistently respected.

Peoples’ were supported to be involved to follow their interests and take part in social activities however we found there were periods of time such as weekends when people told us there was not a consistent provision available.

People, their relatives and staff spoke highly of the leadership at Richmond. There were regular quality assurance checks however these had not always been effective at identifying the areas we saw required improvement. We found examples where records did not reflect an up-to-date picture of changing health support needs.

Appropriate checks had been undertaken when new staff were recruited at Richmond to ensure they safe to work within the care sector. Staff were trained in safeguarding and knew what action they should take if they suspected abuse was taking place. A range of training was provided to ensure staff were able to meet people’s needs.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made and how to submit one. Where people lacked the mental capacity to make specific decisions the home was guided by the principles of the Mental Capacity Act 2005 (MCA) to ensure any decisions were made in the person’s best interests.

Staff had a clear understanding of their roles and the philosophy of the home and spoke enthusiastically about working at Richmond and positively about senior staff. The registered manager and operations manager undertook regular quality assurance reviews to monitor the standard of the service which had been and drive improvement.

We found a breach in Regulation. You can see what action we told the provider to take at the back of the full version of this report.