This inspection took place on 21 and 22 March 2019 and was unannounced.

St Paul’s Residential 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. St Paul’s Residential Home accommodates 32 people in four adapted buildings. At the time of our inspection there were 31 people using the service.

At our previous inspections in April 2016 and March 2017 the service was rated "Good". At this inspection we found the service was rated Requires Improvement.

St Paul’s Residential Home had 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 2008 and associated Regulations about how the service is run.

People received their medicines as prescribed, but some improvement was needed to ensure best medicine management practice would always be followed. When people fell, regular observations had not been completed and recorded to support staff to identify injuries. We made a recommendation about people’s post falls management.

The provider had completed pre-employment checks to protect people against the employment of unsuitable staff. Some improvement was needed to ensure when information of concern was identified records would be kept of how risks had been mitigated.

Effective systems were not always operated to monitor and improve the quality of care people received. The provider had not identified the shortfalls we found prior to our inspection.

People were protected from harm and abuse through the knowledge of staff and management.

Staff were supported through training and meetings to maintain their skills and knowledge to support people. Sufficient staff were deployed to support people.

We found the environment of the care home was clean and had been well maintained. People were supported to eat a varied diet which met their needs and preferences.

People received personalised care and support from caring staff who respected their privacy, dignity and the importance of independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People had opportunities to take part in a variety of activities. People were supported to maintain contact with their relatives. There were arrangements in place for people and their representatives to raise concerns about the service. Care was provided for people at the end of their life.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced comprehensive inspection of this service on 22 and 25 April 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to staff recruitment checks.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. In January 2017 we received concerns about the techniques staff were using when helping people to move. The provider investigated and wrote to us to inform us of the action they were taking, to make sure the way people were moved was safe and appropriate. We also checked these actions had been completed during this inspection. This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Paul’s Residential Home on our website at www.cqc.org.uk

St Paul's Residential Home provides care to older people with a physical and/or sensory disability. At the time of our inspection 31 people were living in the home and of these 30 people were living with dementia.

The registered manager was present during the 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.

This unannounced inspection was carried out on 28 March 2017. At the inspection on 22 and 25 April 2016, we asked the provider to take action to make improvements to staff recruitment checks. In particular to account for gaps in staff employment records. We found that the actions in the provider’s plan had been completed.

Staff recruitment processes had been reviewed and a new application form was in use. This included information to explain gaps in prospective staff members’ employment history. Gaps in employment history had also been recorded for three existing staff members, where this information had not previously been documented. One new staff member had been employed since our last inspection and we found legal requirements for recruitment checks had been met.

The moving and handling techniques used by staff were safe and appropriate. Information about people’s individual needs was recorded in their moving and handling assessment records. Staff were clear about their responsibility to report poor practice to the registered manager.

This inspection took place on 22 and 25 April 2016 and was unannounced. St Paul’s Residential Home provides care to older people with a physical and/or sensory disability. At the time of our inspection 31 people were living in the home and of these 30 people were living with dementia. Accommodation was provided over two floors with shaft lifts to access the first floor. 28 bedrooms had en suite facilities and there were an additional three bathrooms and four shower rooms. People had access to four lounges with dining facilities.

There was a registered manager in post, who was also the owner of the company. 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 had not been protected against the risks of employing unsuitable staff. Safe recruitment and selection procedures had not been followed. This was a breach 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.

People’s care was highly personalised reflecting their individual wishes, likes, dislikes and the way in which they had previously lived their lives. People and their relatives were involved developing their care and support and took part in reviews. People’s care records had been kept up to date with changes in their needs and provided an individualised record of their needs. People were protected against the risk of harm and supported to take risks whilst staying as safe as possible. Their independence was promoted and they were encouraged to help around their home, to maintain their mobility and to do as much as they could for themselves. Staff had a good understanding of people’s needs, treating them with dignity, respect and compassion. When people were upset or unhappy staff knew how to help them to deal with their emotions. People had access to healthcare professionals and their medicines were administered satisfactorily.

People had access to a range of meaningful activities which reflected their interests and preferences. External entertainers provided music and exercise alongside craft sessions and games. Students from colleges and children from schools visited the home, keeping people company and playing music or singing to entertain people. People’s cultural needs and diversity were considered and celebrated. The diversity of the staff team reflected people’s backgrounds. People were able to talk with staff in their first language and staff respected their nutritional and religious needs. People enjoyed their meals and had access to snacks and drinks throughout the day and night. They were able to help themselves to drinks and help to prepare their meals. People knew the registered manager well and would talk to her about any concerns or issues they might have.

People benefited from staff who felt supported to develop in their roles. They had access to a range of training to equip them with the skills to meet people’s needs. Staff were observed delivering care and support to make sure they were able to put this knowledge into practice. There were sufficient staff to meet people’s needs. Staff worked together as a team. They said they worked hard, were happy in their roles and were confident raising concerns or expressing their views to the registered manager.

People were asked for their views about their experiences of living in the home. They took part in annual surveys and had individual meetings with the registered manager. When shortfalls were identified actions were taken to remedy these. Quality assurance audits monitored the quality of the service provided and strove to make improvements when needed. The registered manager’s visions for

The inspection was carried out by one adult social care inspector, who answered the five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? 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.

Is the service safe?

We found the service to be safe because people were treated with respect and dignity by the staff. When people displayed behaviour, which challenged others, staff dealt with it effectively and respected people’s dignity and protected their rights.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

Where appropriate, a person’s capacity was considered under the Mental Capacity Act 2005. When a person did not have capacity, decisions were always made in their best interests. Advocacy support was provided when needed. The manager was in the process of re-assessing the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) for people who use the service and was having discussions with local authorities about this. This meant people were protected from discrimination and their human rights were protected.

People received their medicines as prescribed. Prescribed medicines (including controlled drugs) were stored and administered safely in line with current and relevant regulations and guidance.

The service followed safe recruitment practices. People were safe because the service had considered the skill mix and experience when arranging staffing.

Is the service effective?

We found the service to be effective because care plans reflected people’s current individual needs, choices and preferences. People’s health was regularly monitored to identify any changes that may require additional support or intervention.

People’s health was regularly monitored to identify any changes that may require additional support or intervention. Referrals were quickly made to health services when people’s needs changed.

People’s choices for end of life care were respected by staff. People had access to the specialist palliative care services they needed. Staff received training in ‘end of life care’.

Is the service caring?

We found the service to be caring because people were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. Staff responded in a caring way to people’s needs when they needed it.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. Appropriate professionals were involved in planning, management and decision making.

Staff knew the people they were caring for and supporting. People were as independent as they wanted to be.

People, and those that matter to them, were involved in the assessment and planning for their end of life care. People’s expressed preferences and choices for their end of life care were clearly recorded and acted on.

Is the service responsive?

We found the service responsive because people had their individual needs regularly assessed and met. There were arrangements in place to speak to people about what was important to them.

People had privacy, dignity and a dignified death. Emotional support was available to people, their families, friends and staff.

People felt confident to express any concerns or complaints about the service they received.

There was an advocacy service available if people needed it. This meant when required, people could access more support.

Is the service well-led?

There was a registered manager in post on the day of our visit.

The service worked well with other agencies and services to make sure people received their care in a joined up way. Staff knew and understood what was expected of them.

Senior management were aware of the culture of the service and they kept this under review. There was an emphasis on fairness, support and transparency and an open culture. The manager enabled and encouraged open communication with people, those that mattered to them and staff.

The service worked in partnership with key organisations, including the local authority to support care provisions and service development.

During our visit we spoke with five people who were able to tell us about their experience of living in the home. People we spoke with told us they enjoyed living in the home and could choose how and where they wanted to spend their time. People told us, “staff are wonderful – they think about people” and “staff understand me”.

We also spent time with people in the lounge and dining room and observed people having lunch. We observed staff interacting with people respectfully, offering people choices and communicating at a pace and manner suitable for their needs.

During our inspection we spoke with 15 relatives of people living in the home. Everyone we spoke with had only positive feedback about the home. Comments made by relatives included: “the best care home in Gloucester”, “extremely pleased with the home – staff are very kind” and “We can visit anytime we want to and are always made welcome”.

We looked at the care records for six people and spoke with or observed these people to see if records accurately reflected their needs. We found care plans were detailed and personalised to the individual, reflected people’s needs and were regularly reviewed.

Care was provided in an environment that was safe, well maintained and met people’s needs. Staff were appropriately trained and supported to meet the needs of people living in the home. The provider sought the views of people who used the service and used these comments to improve and develop the service.

We spoke to one person using the service. They made positive comments about the staff and the meals offered. They told us that they received enough help for their needs and that they had "no complaints".

We spoke to two people using the service and the relative of another person. We received positive comments about the staff working in the home. We were also given examples of how the staff worked to meet people’s individual health and welfare needs.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector and joined by an Expert by Experience (People who have experience of using services and who can provide that perspective).

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

People were positive in their views of how they were supported by staff with their care needs. Examples of comments they made included, “They are all smashing people, and we have a laugh here.” “It’s better here than it was at home, I definitely have no complaints”. “The manager is absolutely marvellous; he can’t do enough for us, he’s really super”. “I think I’m very lucky to be here”. “We have a lot of fun with the staff”. “They are all smashing people, we have a laugh here”.