About the service: Rosemary Residential Care Home provides accommodation and care for up to ten people with mental health needs.

The home is a single provider run family business.

At the time of our inspection there were ten people living at the home.

People’s experience of using this service:

People liked the meals and their dietary needs were well catered for. There was up to date nutrition guidance set out in their care plans.

The care plans had been improved and were being developed further to provide more information about people and their care needs. One person did not have a fully up to date care plan. This had not been picked up by the by the registered manager and their quality checking system.

People enjoyed living at the home, and several people said they felt it was “their home”.

People and staff felt the registered manager was supportive and caring.

Staff had been on training to support their role and received supervision to continue this support.

People had the right health care support from professionals to meet their mental health and physical care needs. When people were physical or mentally unwell, staff had responded swiftly and worked with health professionals to address their health care needs.

Staff followed guidance from Mental Health Professionals to ensure they knew how to support people's mental health needs.

The way the quality of the service was monitored had improved. Sufficient helpful checks and audits were completed to determine the quality of the care. The provider had swiftly acted on some areas already identified for improvement.

We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: This service was rated Requires Improvement at the last inspection in December 2017.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

At this inspection we found that improvements had been made to the environment and governance systems. However, we also identified some other areas which required Improvement.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. We have also asked for an improvement plan.

Rosemary Residential Care Home provides accommodation and personal care for up to ten people with long term mental health needs. On the day or our visit there were eight people living at the home.

The service was last inspected in November 2016. At that inspection we found that staff members did not consistently receive training and supervision to enable them to carry out their duties. The provider had taken some action and staff were now receiving more regular training to carry out their roles effectively. However staff were still not being formally supervised in the work they did. This meant the overall quality of staff’s performance was not being properly monitored. This in turn meant there was a risk people may receive unsafe care.

This was a continued breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, for good governance.

At the last inspection we found that the provider had failed to complete the process of creating new person centred records. At this inspection we found that actions had been taken to ensure each person had a care plan in place that set out how to meet their needs in a person centred way.

There was a registered manager for the service. 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 received their medicines when they were needed. However systems for medicines that were to be given only when required were not fully safe. This was because there was no protocol or guidance to inform staff when to give people these medicines.

We also found that care plans were not always reflective of people’s current needs. This was because parts of certain care plans were not up to date and had not been regularly reviewed. This was key information as staff needed to have up to date guidance to support people with their needs safely.

The registered provider had not taken sufficient action to make sure the systems used to monitor and check the quality and safety of services provided were up to date. This meant these systems were not being used to drive up and support improvements.

This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, for good governance.

People felt safe living at the home and staff treated them well. Staff knew how to recognise abuse and what to do if they were concerned about someone’s wellbeing.

People were supported to have enough to eat and drink to maintain health and wellbeing. The menu options were chosen based on each person’s preferences. People told us they liked the meals served at the home, and they could eat what they liked.

The requirements of the Mental Capacity Act were followed when needed for people at the home. People were supported to have as much choice and control of their life. Staff supported people in the least restrictive way possible. There were policies and systems in the home that supported and guided staff and people who lived at the home.

People were encouraged and supported by the staff to maintain their independence. The staff team respected people’s privacy and dignity. People were cared for by a staff team who knew and appreciated their unique needs well. People were relaxed and able to talk with staff members and raise any concerns or worries with them.

Staff understood their roles and responsibilities and understood the provider's vision of a good quality service.

People felt that the registered manager was approachable and they felt comfortable to raise any concerns or issues they had.

This inspection took place on 19 November 2016. The inspection was announced, which meant the provider knew we would be visiting. This is because we wanted to make sure the provider, or someone who could act on their behalf, would be available to support the inspection. When the service was last inspected in April 2015 it was rated as ‘requires improvement.’ There were no breaches of the legal requirements identified.

Rosemary Residential Care Home provides accommodation and personal care for up to 10 people who have mental health needs. At the time of our inspection there were 10 people living at the service. The service was family run and had a small staff team supporting the provider.

A registered manager was in post at the time of 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. The registered manager was also the provider.

Staff members did not consistently receive regular training and supervision to enable them to carry out their duties.

This was the third inspection that the provider has failed to complete the process of creating new person centred records. This has not resulted in any immediate risk to people, but continues to demonstrate poor management in failing to complete these plans.

People were supported to maintain good health and had access to external health care professionals when required.

Risks to people were assessed and where required a risk management plan was in place to support people to manage an identified risk and keep the person safe.

Staffing numbers were sufficient to meet people’s needs and this ensured people were supported safely.

People’s medicines were in the main managed safely. People were receiving their medicines in line with their prescriptions. Staff had received training in medicines.

Staff demonstrated they had a good understanding of people’s individual needs and told us they understood people’s preferences. Staff were knowledgeable about people’s different behaviours and specific needs such as the person’s preferred personal care routines.

People received care that was personal to them and staff assisted them with the things they made the choices to do. We observed that people appeared content living in the service and they received the support they required.

People undertook activities personal to them and in the main were independent. They could come and go as they pleased. Where people required assistance to access the community they were supported by the staff.

Staff felt well supported by the registered manager. Staff were confident and knowledgeable of all aspects of the service and felt they worked well as a team.

We found two 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 this report.

We carried out this inspection on 28 April 2015 and this was an unannounced inspection. When Rosemary Residential Care Home was last inspected in June 2014 there were no breaches of the legal requirements identified.

Rosemary Residential Care Home provides accommodation and personal care for up to nine people who have mental health needs. At the time of our inspection there were nine people living at the service.

A registered manager was 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 felt safe and staff could identify and respond to allegations of suspected abuse. The provider had safeguarding and whistleblowing policies which gave guidance for staff on the identification and reporting of suspected abuse.

People and staff employed at the service felt staffing levels were sufficient and that people’s needs were met. The service had a small stable staff team and all had been employed at the service for a long period of time. The provider had operated a safe recruitment process.

Records did not always demonstrate people’s risks were regularly assessed. Although this did not present an immediate risk to people as their needs had not changed, it did not demonstrate the provider had robust review systems in operation.

People received their medicines on time and medicines were stored correctly. There were suitable arrangements in place for the ordering and disposal of medicines and records had been completed accurately.

People were happy with the care and staff at the service. Staff told us they were happy with the level of training provided and there was a regular supervision process.

Staff understood the Mental Capacity Act 2005 and training had been provided. The provider was aware of their legal responsibilities in regard to the Deprivation of Liberty Safeguards (DoLS) and appropriate policies were in place.

People had access to healthcare professionals when required and records demonstrated the service had made referrals when there were concerns.

Staff were caring towards people and people were involved in the planning of their care and support. Some people’s support records reflected their involvement and the decisions made in their care planning.

Support provided to people met their needs. Supporting records highlighted the important people and locations in people’s lives. The provider had a complaints procedure and people told us they could approach staff if they had concerns.

People and staff spoke positively about the provider and registered manager and communication with staff was regular. The provider had not completed some people’s person centred care records and the auditing system to monitor the service provision and safety had not been consistently used.

During our inspections we set out to answer a number of key questions about a service: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

During this inspection we looked at the arrangements being made for cleanliness and infection control in the home. This helped us to answer the question ‘Is the service safe?’

At the previous inspection of Rosemary Residential Care Home on 3 April 2014 we had found that not all parts of the house were in a clean and hygienic condition. There was a risk of cross infection because good standards of cleanliness were not being maintained. The service had not been complying with the regulation in relation to cleanliness and infection control. We told the provider and the manager that they must take action to ensure that improvements were made.

We visited Rosemary Residential Care Home again on 6 June 2014 in order to check on the action that had been taken. Below is a summary of what we found.

Is the service safe:

We found that improvements had been made and we judged that the service was complying with the regulation. People who used the service were now better protected from the risk of cross infection. Arrangements were being made which helped to ensure that good standards in relation to cleaning and hygiene were being maintained.

We looked at five standards during this inspection and set out to answer these key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

The provider had not been meeting three standards when we inspected the home on 17 July 2013. We looked at these standards again to see what improvements had been made. The provider had sent us a report after the inspection in July 2013 which set out the actions they were going to take to become compliant with the regulations and to maintain this.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service and with staff, and looking at records.

Is the service safe?

Staff received training so that they knew how to provide safe care to people. There were procedures in place to ensure that people received support with their medicines in a safe way.

Risks to people’s health and safety were being assessed. This helped to ensure that people received the care and support that they needed in order to be safe.

There had been a number of improvements to the accommodation and the facilities since the last inspection. This meant that the home was being better maintained and was a safer environment for people.

However, there were shortcomings in the standard of cleanliness in some areas of the home. We found that parts of the bathrooms and a kitchen were dirty and the risk of cross-infection was not being reduced. We have told the provider that they must take action to improve cleanliness and hygiene in the home.

Is the service effective?

People who used the service told us that the home was meeting their needs. A new system of care planning was being implemented which promoted a more person centred approach to supporting people. Staff had received training in ‘person centred care’ planning. They were provided with good information about people’s care needs and how they liked to be supported.

In the care records, we saw that risks to people’s health were being assessed, for example in relation to tissue viability, mobility and nutrition. This helped to ensure that the right support was being provided to meet people’s needs.

People received support to access specialist services outside the home, such as a memory clinic. Appointments were made with health and social care professionals to ensure that people’s health and care needs were met.

Is the service caring?

The relationships between staff and the people who used the service appeared to be friendly and positive. When speaking about the staff, one person told us “they look after me very well”; another person commented “I like it because the staff are here to talk to me”.

Is the service responsive?

Care and support was planned and provided in ways which promoted people’s independence. One person told us that they had a plan for moving from the home to a more independent type of accommodation.

Routines were flexible to take account of people’s personal circumstances and individual preferences. Daily reports were written by staff which helped to identify any changes in people’s health and care needs.

Is the service well-led?

The provider had procedures in place for assessing and monitoring the quality of the service. This included a system for learning from incidents and for implementing any changes that may be required. Staff training and supervision were being monitored to ensure that staff were appropriately supported and competent for the work they carried out.

The provider had a system in place for gaining feedback about the care and service that people received. This helped to ensure that people’s views were taken into account and included in plans for improving the service.

The provider had developed policies in relation to infection control since the last inspection. However audits and other procedures were not effective in ensuring that good standards of cleanliness and hygiene were being maintained.

People told us that they were happy living at the home, they got on well with the staff and the food was good. People said they spent their time as they wished. Staff had a good understanding of people's capacity to consent and supported their right to make their own decisions.

People had care plans which had been reviewed monthly until January 2013 and the manager told us that they were developing new person centred care plans for each person in response to a Bristol City Council recommendation. People's risk assessments had been updated as appropriate and management plans were in place.

The home was not clean and the environment was in poor condition in some areas, including flooring and the furniture in some people's bedrooms. The manager had not identified these shortfalls and had no system in place to carry out regular checks,

Staff received regular training and supervision and felt supported by the manager. They enjoyed their training and told us they liked working at the home.

The provider had some systems in place to monitor the quality of the service. They had implemented a system to learn from incidents and had carried out surveys with people who lived at the home and professionals who visited the home. The provider was in the process of collating this information.

There were 10 people living at the home at the time of the inspection. We spoke to five people to ask their views. Four people from the five we spoke to told us they liked living there and one person told us it was "alright".

Staff supported people to make choices about their care in relation to both daily and longer term decisions. One person told us about how staff were supporting them with their independent living skills in line with their wishes to move on.

We looked at three care files and observed the care delivered to be an accurate reflection of these. Risk assessments were in place but were not consistently updated to reflect people's current situations. Risks were not consistently identified as a result of notable events or incidents.

All of the people we asked told us they felt safe. One person said "sometimes there's trouble when I don't get on with someone but I feel safe enough". There was an effective safeguarding procedure in place. Staff were knowledgeable about managing aggression through behaviour management techniques.

We observed staff had time to interact with people individually and people had access to personalised care. One person told us "they look after me very well. My mind and mood have been stable for such a long time".

There were systems in place to monitor the quality of service provision and to enable people to express their views. There was minimal evidence to show that learning from incidents took place.

We asked four people about living at the home and with the exception of one person, who said living at the home was ‘boring’, people made positive comments.

People at the home told us they were able to make decisions about their day to day lives at the home and the goals that staff had helped them to achieve, these included budgeting, reducing smoking and alcohol intake.

People at the home felt safe living at the home and said the staff were good and knew what their needs were and how to meet them.

They also told us they knew who to approach with complaints and felt confident that the staff would resolve their concerns.

When we asked about the food served, we were told they had a varied diet, the food was good and where necessary, alternatives were provided