Stainsbridge House 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. The service can provide accommodation and personal care for up to 46 people at this location. At the time of our inspection there were 42 people living in the home. The inspection took place on 4 and 5 June 2018 and was unannounced.

At the last inspection on April 2017 we asked the provider to take action in response to the concerns found around staffing levels. The service was in breach of Regulation 18 Staffing. At this inspection we found that the service had met this previous breach, however a further three breaches of Regulations were identified. This is the second consecutive time that this service has been rated as requires improvement and we are considering what further action will be taken in response. Full details of CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The home did not currently have a registered manager in place. The previous registered manager had recently left the service and the deputy manager was in the role of acting manager. The acting manager was being supported by a registered manager from another of the provider’s services and the director who were present throughout 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.

Prior to this inspection we received concerns about the service which we asked the provider to investigate and report back to us. We further assessed these concerns during this inspection and full details of what we identified is in the main body of this report.

Medicines were not always managed safely. There were concerns identified regarding the safe use of prescribed fluid thickeners for people who had swallowing or choking difficulties.

Risk management and documentation to support identified risks was not always managed safely. For example, one person’s support plan contained a body map, dated 24th May 2018, which recorded that the person had a bruise on their forehead. The manager was unaware of this; there was no further information in the person’s daily record and it had not been reported as an incident or accident. This meant that the cause of the bruising had not been investigated.

During our inspection we observed staff were visible on the floors to support people. We heard call bell times answered in a timely manner and people and relatives felt the staffing levels were mostly good. Staff we spoke with however consistently told us they felt the staffing levels could be better. We observed on the first day of inspection that three people were walking around at 5:30pm in their night wear, which staff attributed to staff shortages.

There was a lack of understanding around the appropriate process to follow for people who lacked capacity and were unable to consent to the care and treatment provided.

We found that some care plans lacked detail and person-centred information. Information relevant to the needs identified were not held together for staff to gain an overall picture on how to meet the needs. Monitoring records were not appropriately completed to ensure action could be taken in a timely manner.

Quality monitoring of the service was in place; however, it did not provide a clear rationale of what this attributed to the overall picture of the service. The previous registered manager had been quite insular in managing the documentation and due to this there had been a lack of provider oversight in the day to d

Stainsbridge House is a residential care home that provides accommodation for up to 46 adults, some of whom are living with dementia. At the time of our visit 46 people were using the service. The bedrooms are arranged over three floors. There are communal lounges with dining areas on all floors with a central kitchen and laundry.

The inspection took place on 25 and 26 April 2017 and was unannounced.

There was a registered manager in post at 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.

Feedback we received from people's relatives, staff and health care professionals stated staffing levels were often poor and this led to people not always being supported in line with their needs. This was also confirmed by our observations during the inspection. Staff told us they had raised these concerns with the management team but that steps to deploy agency staff had not been sufficiently or promptly addressed. The registered manager and operations director told us they had a clear staffing policy and staffing was based upon dependency. The service was in the process of recruiting new staff and agency and bank staff were deployed on both days of the inspection.

There was a wide and varied activities program run by an activities coordinator, two activities support workers and two activities volunteers. People looked happy and comfortable during the group activities we observed and also from photographs on display around the home. However, people who remained in their rooms or were unable to participate in group activities did not have the same degree of attention. Staff told us this was due to there not being sufficient numbers of staff to support people. Whilst there were details in people’s care records about their likes, dislikes, preferences, interests and hobbies this information did not always provide specific details and staff had difficulty locating this information. Although staff said they knew people well, there was insufficient information documented for staff to refer to.

Medicines were mostly managed safely. However, advice had not been sought from a pharmacist regarding adding medicines to foods when giving them covertly. This requirement was not detailed in the service’s policy on medicines. This put people at risk from receiving medicines that may have had their therapeutic effects altered by being administered in this way.

Whilst systems were in place to monitor the quality and safety of the service provided issues around staffing, care planning and enrichment had either not been identified or not sufficiently or promptly acted upon.

Where people had risks which had been identified, there was guidance available in people’s care records to guide staff on how to mitigate these risks.

Staff were able to tell us what the different types of abuse were and how to report safeguarding concerns.

People were supported to have access to healthcare professionals in line with their changing needs. The service worked well with these professionals to ensure advice was recorded and followed up as appropriate.

Training records were up to date. Staff told us they were supported with training needs. The registered manager told us they had recently responded to feedback from staff on the type and quality of training offered in order to further enhance and improve their learning experience.

People said they liked the food and told us alternatives were offered when they did not like what was on the menu for that day.

People and their relatives spoke positively about the care they received from staff who treated them with compassion and kindness in their day to day care.

We found a breach of the Health and Social care Act 2008

A single Inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. There were 44 people living at Stainsbridge House at the time of our inspection. They had varying degrees of dementia, which meant that many had limited ability to express their views about their care and treatment, or how they were involved in the service.

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

This is a summary of what we found:

Is the service safe?

We saw that people who lived at Stainsbridge House were not overly agitated and appeared relaxed in the company of staff and others who lived there. We found that the staff were aware of what to do if they witnessed abuse and had been trained with regard to safeguarding adults. One staff member told us ''Nothing like that goes on.'' The manager was aware of what actions to take in response to abuse allegations and had previously taken action to move a person to a more appropriate service, in order to safeguard those who lived in the home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no applications have needed to be submitted in relation to people currently living in the home, proper policies and procedures were in place and the manager and relevant staff had received training in relation to DoLS.

We found that systems were in place to regularly assess risks to people who lived in the home, visitors and staff. This meant that people benefited from safe care, treatment and support, due to effective management of risks to their health, welfare and safety.

Is the service effective?

We found that staff delivered the care that was detailed in people's care plans. Staff were trained and had received good support from the management team in order to carry out their role effectively. For those people who were physically unwell, we found that staff were providing appropriate care and that health care professionals had been contacted and were involved.

During our inspection, we found that some charts used for recording food and fluid intake and changes of position had not been filled in at the time the intervention had been carried out and that they were being completed retrospectively. We informed the manager and the registered provider that completing forms retrospectively was not seen as good practice as it may increase the possibility of inaccurate recording. They told us that they would consider an alternative to the current practice, in order to eliminate the need for retrospective recording.

We found that people were supported to access the local community. People were also supported to access the home's communal areas. This enabled them to experience a degree of social interaction.

Is the service caring?

We saw that the staff were kind and supportive towards people and a relative had stated on a survey 'Residents (are) treated with respect.' A person we spoke with said ''Yes, it's alright I like it'' when we asked if they liked the home and three others responded ''yes'' to the same question.

We found that the home had several systems to allow people to comment on the service it provided. This included annual surveys sent to people who lived there and to their relatives. We found that responses to the surveys were mainly very positive. Meetings were held with people and their relatives, which gave them the opportunity to raise any concerns. We saw that action was taken in response to concerns, which meant the home cared about the people who lived there.

Is the service responsive?

People's needs were assessed and care plans were in place in response to their needs. More work was planned to ensure that people's personal preferences were detailed. We saw that, where complaints had been received, the manager had responded promptly and appropriately.

Is the service well-led?

There were regular quality assurance processes in place, which included satisfaction survey's and meetings. This enabled people and their relatives an opportunity to comment on the home.

The staff received regular appraisals and staff meetings were also held. The majority of the staff felt that they were able to speak with the manager at any time; one described the support they received as ''excellent.'' The registered provider normally visited the home twice a week in order to support the manager and monitor service provision.

We carried out an inspection on 4 June 2013 to see what improvements the provider had made following an earlier inspection in January 2013. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We saw evidence that the provider had completed mental capacity assessments for all but two of the people who lived in the home. Records demonstrated that people and their families were consulted and involved in this process.

The provider had introduced paper files for recording incidents and accidents, daily notes and doctors notes to ensure that all staff had easier and quicker access to this information. We saw copies of care plans and risk assessments in people's bedrooms which were reprinted on a monthly basis or sooner if required. This ensured that staff had access to current information.

We spoke with 15 people who lived in the home. All but one person said they thought there were enough staff to support them appropriately. People said they were very well looked after and one person said "The staff are absolutely wonderful". We spoke with one family who were visiting. They told us "Yes most of the time there are now enough staff, maybe on a weekend there could be a few more but the staff are fantastic and very patient".

One care worker stated that the home had consulted with staff regarding the hours they worked. They told us that more staff now worked half days and said "For me the hours fit in really well with family life". The provider told us they now had more care workers on half day shifts which had resulted in it being easier to cover for absences.

We looked at the written care plans and risk assessments for three people. The documents were person centred as they included more detail about the person's care needs and preferences. Documents were now signed and dated and we found all records were more complete.

We spoke with four members of care staff. Staff told us they had received training in record keeping and care planning training and found this to be very helpful. Each member of care staff we spoke with was able to demonstrate a clear understanding of the information process for record keeping and their responsibility in ensuring accurate records.

Staff demonstrated in conversation with us, that they were knowledgeable about the people they cared for and understood their preferences and how they liked things to be done. Staff told us that some information about people's preferences was available in the care plans. The home acknowledged that they needed to update people's personal profiles to include more information around preferences and choices.

We received information of concern which related to the number of staff on duty. The provider informed us that the home used an agency and had a core of bank staff to cover events such as staff sickness, holidays, training and any vacancies. Care workers told us that existing staff were asked to fill in for absences. They said they were not pressured into taking on additional shifts but did feel obliged to. Two care workers said they did not mind doing the extra shifts but other staff said the hours were too long.

We saw that Information was available to people and their families on how to make a complaint, we also saw that information was available about advocacy services. Staff told us that people would tell them in their own way if they did not like something.

We found that the home had upgraded their computerised data management system and the staff we spoke with reported that internet access had improved, however the required improvements to the care records had not been met and the system for the monitoring of the services was not robust.

In April 2012, we carried out a review of Stainsbridge House in response to information of concern. At this inspection we found that some people living at Stainsbridge House received inadequate support with their continence needs and there were concerns regarding staffing levels, support support and morale.

We visited the home on 12 and 13 July 2012 and saw that improvements had been made in the management of continence care. During our visit we spoke with five relatives. Three relatives stated that continence care had improved for the better. The other relatives had not previously had any concerns and were happy with the care provided.

One relative told us, "it's a lovely place, they look after [person] really well and involve them in doing things around the home, such as dusting and hanging out the washing, [person] is always well dressed. The staff work very hard to support [person] appropriately. And, they always phone me if [person] is not well".

We spoke with the provider who told us the home was staffed at night to a level they determined as optimum to care for the current number of residents. We were shown the staffing rotas for the last month which evidenced that four care workers covered the night duty and that staffing levels at night had been maintained.

Staff said morale had improved and they felt supported to do their jobs well and were happy with the supervision, training and mentoring they received.

During our visit we looked at recent concerns which related to record keeping. We found that improvements were needed in this area.

We visited the home at night and there were limited opportunities to talk to people who lived at the home, most of whom did not have the understanding to provide meaningful feedback about the service. We made the visit to follow up concerns which had been brought to our attention by staff who wished to remain anonymous. They told us that they were concerned about staffing levels at night, which they thought were sometimes inadequate to care for 37 people, some of whom were highly dependent and required assistance with all aspects of daily living.

Staff also told us that some of the most dependent people did not receive adequate assistance with continence and were frequently left in wet and soiled clothes. They told us that the home had insufficient supplies of continence pads.

Staff said that when they reported concerns to the home’s acting manager, they were assured that things would be put right but this never happened. They told us that staff were demoralised and stressed because they felt they were not supported to provide the level of care that people needed and deserved.

We spoke to a number of people who lived at the home but most people had limited capacity to provide meaningful feedback about the service. One person said of her care worker, “She’s my lovely girl; she’s got patience”. A relative told us “the staff are very kind”. Relatives felt that standards of cleanliness in the home had improved but some people told us that they remained dissatisfied with the laundry service.

We spent some time observing staff interacting and providing care and support to people. People were clean and well presented and appeared to be content and relaxed in the company of staff that they were familiar with. Staff were gentle, warm and attentive, friendly and informal, but at all times polite.

We visited the home for a short period of time early in the morning. We did not have the opportunity to talk to people who use services, although we had spoken to some people at a previous visit.

Residents and their relatives said “the staff are lovely; they work very hard and they are very caring”. One relative told us their relative was" so contented here and always kept so lovely and clean”. They said “it’s my (parent’s) home and I can come any time and feel part of it. I know all the staff and they always offer me tea when I come.”

However several relatives felt that sometimes there were not enough carers, particularly at weekends.

People liked their bedrooms which were spacious, light and comfortable, but comments were made about poor quality bedding and frayed towels. People said that the housekeeping staff worked very hard but some areas of the home were not clean. One person said “the dining room smells” and another said that their relative’s room “could be cleaner”. One relative told us that cracks in their relative’s bedroom walls had been plastered before Christmas and the walls had still not been painted. Several relatives complained about the laundry, telling us that their relatives’ clothes had been shrunk or discoloured through incorrect laundering, and some chose to take their relatives’ laundry home.

Relatives told us that the residents enjoyed the food at Stainsbridge House and were appreciative of the support given to them at mealtimes. They also told us that their relatives enjoyed the many varied activities organised for them.

This inspection took place on 16 and 17 February 2015 and was unannounced. At the time of the inspection the service did not have a registered manager. However, the new manager in post had applied to the Care Quality Commission to become the registered manager. 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.

Stainsbridge House is a residential care home which provides accommodation for up to 45 adults, some of whom are living with dementia. At the time of our visit there were 45 people living in the home. Stainsbridge House is set on the edge of the town of Malmesbury in Wiltshire. Bedrooms are en-suite and there is a lift between floors. The gardens are landscaped with several seating areas.

People and their families praised the staff and manager at Stainsbridge House for their kindness and the care they gave. We could see that people had developed caring relationships with staff and were treated with dignity and respect. People told us they enjoyed the surroundings of the home and the calm attitude of staff as they went about their work.

The care records demonstrated that people’s care needs had been assessed and considered their emotional, health and social care needs. People’s care needs were regularly reviewed to ensure they received appropriate and safe care, particularly if their care needs changed. Staff worked closely with health and social care professionals for guidance and support around people’s care needs.

People’s rights were recognised, respected and promoted. Staff were knowledgeable about the rights of people to make their own choices. This was reflected in the way in which staff supported and encouraged people to make decisions when delivering care and support.

People told us they felt safe living in Stainsbridge House. Staff had received training in how to recognise and report abuse. There was an open and transparent culture in the home and all staff were clear about how to report any concerns they had. Staff were confident that the manager would respond appropriately. People we spoke with knew how to make a complaint if they were not satisfied with the service they received.

There were systems in place to ensure that staff received appropriate support, guidance and training through supervision and an annual appraisal. Staff received training which was considered mandatory by the provider and in addition, more specific training based upon people’s needs. Staff were encouraged by the manager and provider to be involved in improving the service and outcomes for people who live at Stainsbridge House.

The manager and provider carried out audits on the quality of the care delivered, the safety of the environment and all aspects of health and safety.