This inspection took place on 19 and 20 October 2017 and was unannounced. The previous inspection was carried out on 6 September 2016 and there had been several breaches of legal requirements at that time. We rated the service requires improvement in the key questions which included, safe, effective and well led. The service was rated good in caring and responsive. We found at this inspection significant improvements had been made since the last inspection. The registered manager had submitted an action plan to the Commission so that we could monitor the improvements made.

St Joseph's Home provides accommodation for people who require nursing or personal care for up to 42 people. At the time of our visit there were 36 people living at the service.

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 of the Health and Social Care Act 2008.

People were protected from abuse because staff understood how to keep them safe, including understanding the processes they should follow if an allegation of abuse was made. All staff informed us concerns would be followed up if they were raised.

Appropriate numbers of staff had been deployed to meet people's needs and keep them safe. Staff had attended training relevant to people's needs and they had received effective supervision from the management team.

Effective recruitment procedures were in place to check that potential staff employed were of good character and had the skills and experience needed to carry out their roles.

Risk assessments were in place to mitigate the risk of harm to people and staff.

People received their medicines when they required them and in a safe manner. Staff received training and guidance to make sure they remained competent to handle people's medicines.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Staff had received appropriate training, and had a good understanding of the Mental Capacity Act 2005 (MCA) and the DoLS. Staff had the right skills and training to support people appropriately.

People told us they enjoyed the food at the service. They were offered a choice of meals which were appropriate for a balanced diet.

Staff knew the people they supported and offered care in kind and compassionate ways. People's dignity was maintained and staff gave people the time they needed when speaking with them. People were supported to maintain their independence.

People were encouraged and supported to engage with activities that met their needs. People accessed their local community independently and with the staff.

People were supported and helped to maintain their health and to access health services when they needed them.

Effective systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service.

The registered manager promoted an open and inclusive culture within the service. People and their relatives felt the service was well managed.

We undertook an unannounced inspection of St Joseph’s Home - Bristol on 6 September 2016. When the service was last inspected in April 2014 no breaches of the legal requirements were identified.

St Joseph’s Home – Bristol provides accommodation and nursing care for up to 42 older people. At the time of our inspection there were 39 people living at the home.

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 home is run.

The home was not consistently safe as robust recruitment procedures had not been followed. This meant that staff had begun work without the full range of checks being completed or documented. Medicines were not always administered or stored safely, as recording omissions were identified. Risk assessments identified potential risks to people. However, these were not consistently accurate or detailed enough to be able to inform staff of how to reduce the risks to people.

Staffing levels were safe. Staff were supported through an induction process, regular supervision, training and meetings. Training needs were identified for staff and planned accordingly. Care was not always effective as care plans did not always provide accurate or detailed enough information in regards to people’s nutrition and hydration needs.

People and relatives told us that staff were kind and caring. We observed positive interactions and relationships between staff and people living at the home. The home supported people to maintain their independence and respected their privacy. People’s needs were fully assessed to ensure the home was able to meet them.

The registered manager was aware of their responsibilities in regards to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to assess if the deprivation of liberty for a person when they lack the capacity to consent to care or treatment or need protecting from harm is required. The registered manager kept clear records of the steps taken in the DoLS process. Staff were aware how the Mental Capacity Act 2005 was relevant to their role and applied the guiding principles through choice and enablement. Staff were not always confident in their knowledge of DoLS. We have made a recommendation about staff knowledge and understanding of the Deprivation of Liberty Safeguards.

The home was not always well-led. There were quality assurance systems in place. However, these did not always highlight areas that may need improvement. Feedback was sought from people and relatives through surveys. However, further investigation or changes as a result were not always completed. People were given the opportunity to feedback and make suggestions through regular meetings and we saw changes made as a result. The home had established positive community links and held events which were inclusive to the wider community. Volunteers were encouraged at the home and supported the home in the activities it provided to people.

We found three 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 this report.

The inspection helped answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People living in the home were treated with dignity and respect by the staff that supported them. We received a number of positive comments about care workers, such as "they're wonderful". Another person told us "it's great here". One person told us that they totally trusted the home to care for their relative.

Where there were risks associated with people's health, these were assessed and appropriate support plans put in place. For example, we saw that Waterlow assessments were used to assess whether people were at risk of pressure damage to the skin. Bed rail assessments were used to ensure that these were used safely. Risk assessments were reviewed on a regular basis.

Is the service effective?

People living in the home and their representatives were involved in the care planning and review process. This helped ensure that support was person centred and reflected the needs of each individual. One person that we spoke with told us that they had received a very prompt reply when they had emailed the home to discuss an aspect of their relative's health.

Staff told us that communication was good in the home, so that staff would be aware of any particular issues relating to individuals. This information was discussed at handovers.

Is the service caring?

People that we spoke with during our inspection gave positive feedback about the home and the staff. One person told us that they'd been very well looked after when they came back to the home from hospital. This person also told us that staff had gone out to buy their favourite drink for their birthday.

We made observations of people receiving the support they needed, in line with their care plan. For example, we saw one person being supported with their breakfast meal and the food they were given was identified as their preferred breakfast in their care plan.

One person told us about how staff took time to discuss an album of photographs with their relative. The photographs in the album showed important and significant events in the person's life.

Is the service responsive?

We saw that the service worked well with other healthcare professionals. For example, in the case of one person who was under the care of district nurses, we saw that staff communicated with the nurses when the dressing required changing. One family member told us that staff would always speak with the GP if they had any concerns about their relative's health.

When any areas for improvement were identified by other agencies, we saw that the service took action to address them. For example, a report by commissioners found that there needed to be more 'dementia specific' activities. We asked what had been done in response to this finding and we were told that 'rummage bags' had been put in place for two people in the home with dementia.

We also saw minutes of health and safety committee meetings where any accidents and incidents were discussed. This provided opportunity to identify any learning points and put any required action plans in to place.

Is the service well led?

We saw that there were systems in place to monitor the quality and safety of the service provided. This included gathering the views of people living in the home and their relatives. People had opportunity to attend a monthly service user meeting if they wished to do so, and were also asked for feedback through a survey every 15 months.

The home received regular visits from a 'development advisor' within the organisation and these visits focused on specific themes each visit. For example we saw reports on personal care/resident's rights and another on maintenance.

Any accidents and incidents that occurred in the home were recorded and analysed on a monthly basis.

We spoke with two relatives of people receiving care at the home, and four people who were living there. The comments that we received were very positive and demonstrated that people thought very highly of the care that was provided. One person said that the care their relative received was "fantastic". Another person told us that they "wouldn't want to be anywhere else". People told us that the food was good and that they had enough to eat. Choices were provided and drinks were given between meal times.

During our visit we saw that the home was kept clean and well maintained. People said that their rooms were cleaned daily. Although we found no concerns in relation to cleanliness and hygiene, we found that cleaning audits were not recorded and it was therefore unclear how cleaning was monitored.

We found that care plans were sufficiently detailed and gave staff good information about how to support people in the home. These were reviewed regularly. People enjoyed a range of activities and on the day of our visit, we saw that a party was being held for St George's day.

We saw that consent was sought where appropriate on day to day issues such as the taking of photographs. The manager of the home had an understanding of the Mental Capacity Act 2005 and this meant that decisions were taken in the best interests of people who lacked capacity. However decisions were not always appropriately recorded.

We carried out this inspection on 28 May 2012. This was a scheduled review although we did follow up on the improvement actions for outcome 1 and outcome 12 served at our last visit in December 2010.

We found that action had been taken as a result of the improvement actions served and St Joseph's Home - Bristol was now compliant with outcome 1 and outcome 12.

We spoke with four people using the service. They told us they were happy living in the home and that they felt safe. People told us the food was "excellent" and that they missed it when they went out for lunch. We were told that staff enabled people's independence within the home and that they were encouraged and supported to go out into the community when they wanted.

We saw there were activities ongoing within the home. On the day of our inspection there was a coffee morning followed by games.

We reviewed the care plans of four people using the service and saw that they were involved in the development of their care plans. We also saw that the care plans were individualised and provided clear information to staff about how to care for each person.

We spoke to people living in the home and to a relative during our visit.

We asked people about their decision to move into St Joseph’s Care Home. People said that either they or their relative visited before making a decision about moving into the home. They also told us there was a discussion about the way their care needs would be delivered.

It was stated that staff are good and know how to respect their rights and explained the way staff respect their privacy and dignity, for example, knocking on doors and waiting for an invitation to enter.

We asked people at the home about moving and handling. We were told that staff receive training to use hoisting equipment and it is always used when needed to support someone around the home.

People explained the way they kept themselves occupied during the day, some were happy staying in their bedrooms and following solitary activities, whilst others joined group activities. One person told us about a recent hobby they were pursuing since their admission.

When we asked people about feeling safe at the home they responded in a positive way. We then asked when they would not feel safe and we were told if they were physically abused or shouted at. People knew how to make complaints and felt confident with approaching the manager to raise complaints.

Visitors to the home were made welcome and the staff take steps to ensure that people at the home maintain links with relatives.

It was also said that the food is good, alternatives are served and there is always enough to eat.