Our inspection was unannounced and took place on 22 August 2017.

At our last inspection on 12 August 2015 the service was rated as good in all five questions we ask: Is the service safe? : Is the service effective? Is the service caring? Is the service responsive? And, Is the service well-led?

The service is registered to provide accommodation and personal care to a maximum of four people. On the day of our inspection four people lived at the home. People lived with a range of conditions that included learning disabilities or autistic spectrum disorder.

The manager was registered with us and was present on the day. 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 knew who the registered manager was and they were visible within the service. Quality monitoring processes, the use of provider feedback forms and meetings helped to ensure that service was being run in the best interests of the people who lived there. However, the provider had not consistently notify us of Deprivation of Liberty Safeguarding [DoLS] authorisations.

People told us that they felt safe. Systems were in place to prevent people from the risk of harm and abuse. Staffing levels ensured there were enough staff to meet people’s needs. Recruitment systems were in place to prevent the possibility of unsuitable staff being employed. Medicines were managed safely and in a way that ensured people were supported to take their medicines as they had been prescribed.

Staff were provided with the training they required to ensure that they had the skills and knowledge to provide safe and appropriate care to people. Staff confirmed that they were adequately supported in their job roles. People received care in line with their best interests and processes were in place to ensure they were not restricted unlawfully. People were supported to have the food and drink to suit their needs and preferences. People had access to a range of healthcare services.

Relationships and interactions between staff and people were positive. Staff were friendly, polite and helpful to people. People were encouraged to make everyday choices and they were supported to enhance and maintain their independence and daily living skills. Staff enabled people to maintain contact with their family. Visiting times were flexible.

People needs were reviewed regularly to ensure that they could be met. A complaints system was available for people and their relatives to use if they had the need. A varied range of activities were available each day for people to engage in. The views of people and their relatives were sought regularly regarding their satisfaction with the service provided.

Our inspection was unannounced and took place on 12 August 2015. The inspection was carried out by one inspector. We started our inspection early in the morning so that we could meet and speak with the people who lived there and staff before they went out.

The provider is registered to accommodate and deliver personal care to four people who live with a learning disability or associated need. Two people lived there at the time of our inspection.

At our last inspection in April 2014 the provider was meeting all of the regulations that we assessed.

The manager was registered with us as is required by law. 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.

Where people received support from staff with taking prescribed medicines, this was done in a way that people preferred and minimised any risk to them.

Staff knew the procedures they should follow to ensure the risk of harm to people was reduced.

Staff were available to meet peoples individual needs. Staff received induction training and the day to day support they needed to ensure they did their job safely.

Although, not all staff had received training they understood the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This ensured that people received care in line with their best interests and would not be unlawfully restricted.

Staff supported people with their nutrition and health care needs. We found that people were enabled and encouraged to make decisions about their care and were involved in how their care was planned and delivered.

People were encouraged and were supported to engage in recreational activities and to secure educational input which they enjoyed.

People were encouraged and supported by kind and caring staff to be independent and attend to their own needs when they could.

All people received assessment and treatment when needed from a range of health care professionals including their GP, specialist consultants and nurses which helped to promote their health and well-being.

Systems were in place for people and their relatives to raise their concerns or complaints.

People communicated to us that the quality of service was good. The management of the service was stable. The registered manager and provider undertook regular audits and took action where changes or improvements were needed.

We visited this service and talked with people to gain a balanced overview of what people experienced, what they thought and how they were cared for and supported. We spoke two members of staff. People using the service had limited verbal communication skills and so we were unable to get any verbal comments from them. Staff told us that the person understood simple verbal communication, and used body language, facial expressions and some signs to communicate. We used these to understand their view of the support they received. We observed how people were cared for and how staff interacted with them during our visit. We were not able to speak to any relatives of people using the service when we visited.

We considered all of the evidence that we had gathered under the outcomes that we inspected. We used that information to answer the five questions that we always ask:-

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

We saw that people's individual needs had been assessed and that there were enough suitably trained staff to care for people. We saw that medicines were managed safely so that people received their medication as prescribed. CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes and hospitals. No applications had been made and staff had access to clear policies and procedures regarding this. The manager understood how an application would be made, if needed and had experienced the use of DOLS in a previous employment. Staff were alert to the signs of, or potential for, abuse of vulnerable adults and procedures were in place, which were reviewed regularly to prevent abuse. We saw that the provider regularly monitored the quality of service provision and assessed safety risks.

Is the service effective?

Staff training was sufficient to meet all the needs of people using the service. The manager completed a comprehensive assessment of people’s needs. Support plans and activity plans were developed in response to individual risks, preferences and needs. People's physical health and care needs had been assessed with them and care workers who had known them in the past, from a different service. People's dietary preferences where taken into account so that people could eat the food that they liked. We saw that there was an enclosed and secure outdoor space where people could walk and sit. People living in the home had been effectively supported to meet goals and improve communication skills.

Is the service caring?

Staff cared about the welfare of people living at the home. This was apparent when they talked about them and we saw interactions throughout the day that confirmed the happy relationship between staff and service users. People took part in a range of activities that they had chosen and enjoyed.

Is the service responsive?

People enjoyed activities that were important to them and staff regularly suggested new activities and discussed these with people. Staff concerns about people's safety had resulted in changes to the way people were observed and the security of bedrooms. Concerns raised by people were discussed at staff meetings and actions or changes agreed in response.

Is the service well led?

The home had a registered manager, whom we met. The service had a robust system in place to monitor the quality of the service they provided. This included regular audits of all aspects of the care and support given to service users and appropriate safety inspections. Action plans were produced and implemented when necessary. The manager was experienced and caring. The manager appraised all staff annually and conducted supervision meetings at least every two months. Staff had a clear understanding of their roles, supporting and enabling people living at the home to be as independent as possible.

At the time of our visit there was only one person living in the home. They were able to give us only minimal information verbally but expressed through their body language and one word answers to simple questions that they were happy at the home. They told us that they were staying at El Marsh Care Home for a long time. They told us they were happy. They told us they were going out and having a sandwich for lunch. We spoke with an advocate and one member of staff as well as the manager and owner of the service.

We saw staff using a variety of communication methods such as makaton and flash cards to assist them to make choices about the activities they wanted to do and what they wanted to eat. This showed that staff involved people in making choices and planning their daily life. We saw that plans were in place to meet the people's needs in the way they preferred. Records showed and staff confirmed that people's health needs had been assessed and plans put in place to meet them.

We saw records and staff confirmed that they had received training in protecting people. There were policies, procedures and contact numbers available for staff to enable them to raise concerns if they had any. The recruitment procedures were robust and ensured that all the required checks were undertaken to ensure that only suitable people were employed. This meant that people should be protected from harm.