The Firs Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This service does not provide nursing care. The Firs Residential Home accommodates up to 40 older people, some living with dementia. There are four units in the service over two floors, Willow, Cedar, Pine and Holly. Each of the units held bedrooms, and communal kitchenette/dining and lounge areas. People could move freely between these units. There was a main kitchen where meals were prepared, laundry and communal areas that people could use.

On the day of our comprehensive unannounced inspection on 9 August 2018, there were 33 people living in the service.

At our previous inspection of 17 October 2017, this service was rated requires improvement overall. The key questions for effective, caring and well-led were rated good and the key questions for safe and responsive were rated requires improvement. Improvements were needed in how the service ensured people received their medicines for external application, including creams and how people’s care records identified how their needs were planned for and met. There were no breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had brought this inspection forward because of concerns received. At this inspection of 9 August 2018, improvements had been made and the service was now rated good overall. However, the key question for safe was rated requires improvement, this was because improvements were needed in how the service ensured that there were enough staff to meet people’s needs safely. The registered manager and district manager took immediate action to put additional staff on duty and we were assured that a staffing review would be taking place.

There was a registered manager in place. The last registered manager had left the service in November 2017 and the current manager was registered with the Care Quality Commission in April 2018. 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 were provided with their medicines when they needed them. There were systems in place to manage people’s medicines safely. Improvements had been made in how the staff recorded that people were provided with medicines administered externally, including creams. The risks to people were assessed and staff were guided on how to reduce these risks. Staff were trained in safeguarding people from abuse and where incidents had happened the service learned from these and used the learning to drive improvement. Staff recruitment processes reduced the risks of staff being employed in the service who were not suitable.

There were infection control systems in place to reduce the risk of cross contamination. The environment was well maintained and designed to meet the needs of the people using the service.

People were supported by staff who were trained to meet their needs. People shared positive relationships with staff. People’s privacy, independence and dignity was respected. People had access to health professionals when needed. Staff worked with other professionals involved in people’s care. People’s nutritional needs were assessed and met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were listened to in relation to their choices, and they and their relatives, where appropriate, were involved in their care planning. Improvements had been made in how people

The Firs Residential Home provides accommodation and personal care for up to 40 people, the majority living with dementia. The service was divided into four units, Willow, Cedar, Pine and Holly. Each of which had bedrooms, communal kitchenette/dining and lounge area. People could move freely between these units. In addition there was a main kitchen where meals were prepared and communal rooms where activities took place, which people could sit in and where they could entertain their visitors.

There were 38 people living in the service when we undertook this comprehensive unannounced inspection on 17 October 2017. We brought this inspection forward following concerns we received about and from the service. These included concerns about staffing, medicines and the care provided to people.

There was a registered manager in place. 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 service was rated as Good at our last inspection of 12 January 2016. During this inspection of 17 October 2017 the overall rating was Requires Improvement this was because improvements were needed in Safe and Responsive.

Improvements were needed in people’s care plans to identify how people were provided with person centred care which was tailored to meet their specific needs. The registered manager told us that they had introduced guidance for staff to improve the care planning documentation. However, this was not yet fully implemented at the time of our inspection.

Improvements were needed in how people were provided with their medicines which were prescribed to be administered externally, including creams. Discussions with the registered manager and records showed that this had been identified as an area for improvement but this had not yet been fully implemented to ensure that people received these medicines as prescribed.

Staff were available to provide the support needed by people. There had been some issues in staff numbers and the registered manager, staff and relatives told us this had improved. These improvements were ongoing.

Recruitment of staff was done safely and checks were undertaken on staff to ensure they were fit to care for the people using the service.

There were systems in place to keep people safe, this included appropriate actions of reporting abuse. Staff were trained in safeguarding and understood their responsibilities in keeping people safe from abuse.

People were cared for and supported by staff who were trained and supported to meet their needs effectively.

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’s nutritional needs were assessed and met. People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

People were treated with respect and care by the staff working in the service. People’s choices and routines were listened to and respected.

There was a system in place to manage complaints and these were used to improve the service.

People were provided with the opportunity to participate in activities that interested them.

There were quality assurance systems in place which assisted the provider and the registered manager to identify shortfalls and address them. Where shortfalls were identified there were plans in place to address them to improve the service. However, these were not yet fully implemented to ensure that people were provided with good quality care at all times.

We inspected this service on 12 January 2016 and the inspection was unannounced. The Firs Residential Home provides personal care for up to 40 older people, some living with dementia. One the day of the inspection there were 38 people living in 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were enough staff to support people safely and staff knew what to do if they suspected someone may be being abused or harmed. Recruitment practices were robust and contributed to protecting people from staff who were unsuitable to work in care. Medicines were managed and stored properly and safely so that people received them as the prescriber intended.

Staff had received the training they needed to understand how to meet people’s needs. They understood the importance of gaining consent from people before delivering their care or treatment. Staff were clear about their roles. Where people were not able to give informed consent staff and the manager ensured their rights were protected.

People have enough to eat and drink to meet their needs and staff assisted or prompted people with meals and fluids if they needed support.

Staff treated people with warmth and compassion. They were respectful of people’s privacy and dignity and offered comfort and reassurance when people were distressed or unsettled. Staff also made sure that people who were becoming unwell were referred promptly to healthcare professionals for treatment and advice about their health and welfare.

Staff showed commitment to understanding and responding to each person’s needs and preferences so that they could engage meaningfully with people. Outings and outside entertainment was offered to people and staff offered activities on a daily basis.

Staff understood the importance of responding to and resolving concerns quickly if they were able to do so. Staff also ensured that more serious complaints were passed on to the management team for investigation. People and their representatives told us that any complaints they made would be addressed by the manager.

The service had consistent leadership. The manager was supportive and easy to talk to. The manager was responsible for monitoring the quality and safety of the service and asked people for their views so that improvements identified were made where possible. The organisation also carried out quality assurance visits and supported the manager.

This visit was a responsive inspection to follow up on progress on the two standards the provider was found to be failing to meet at our visit on 10 April 2014. At our visit on 10 April 2014 we found the provider had failed to safeguard the health, safety and welfare of people using the service by failing to take the appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified, skilled and experienced staff to deliver care and support at the service. During our April 2014 we also found the provider did not have suitable arrangements in place to support staff. This included a lack of supervision and training for staff.

Prior to this inspection we reviewed all the information we had received from the provider. This included an action plan submitted to us by the provider in response to the report of our visit on 10 April 2014. The action plan detailed the action the provider intended to take in order to make the required improvements in relation to staffing levels and staff support.

During this inspection we spoke with people who used the service and asked them for their views. We also spoke with three care workers, the activities coordinator, the acting manager and a senior manager. The acting manager had applied to become the registered manager with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

We looked at some of the records held in the service including staff rotas, records of staff supervision, staff training records and automated records of call bell activity.

The summary below describes what people using the service, and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

During this inspection we found improvements had been made.

We found the provider had ensured there were enough qualified, skilled and experienced staff to meet people's needs. We saw the provider had increased the amount of staff available to provide care and support. Staff told us the additional staff provided at mealtimes had proved successful. One staff member we spoke with told us, “Having an extra pair of hands means meal times are quicker, people's food doesn't go cold” and, “Not only does it help in supporting people with their meals it means we can interact more people more as well”. We saw that call bells were answered promptly and observed that people’s needs were met. A person using the service told us they felt there were enough staff to meet their needs.

We found the provider had ensured that people were cared for by staff who were being supported to deliver care and treatment safely and to an appropriate standard. Staff members we spoke with told us they received regular supervision and appraisal. We saw that a record of supervision and appraisal was held and that these were planned in advance. We saw the provider had ensured staff were trained to meet people’s needs. The records we looked at showed an increase in the numbers of staff who had received training. For example the number of staff who had a nationally recognised qualification in health and social care had risen from 27% in April 2014 to 66% at the time of this inspection. We were told training had been provided for staff to develop their professional skills and abilities. One staff member told us, “I hope to do my internal verifier award so that I can help staff get their QCF awards”. The QCF awards are nationally recognised qualifications in health and social care.

We spoke with three people who used the service and eight staff including the acting care manager, visiting business manager and two team leaders. We looked at three people's care records. Other records viewed included staff training records, health and safety and quality checks, medication administration records, satisfaction survey results and the service improvement plan. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service we gained access via a locked magnet controlled front door, we introduced ourselves to the office staff and signed in using the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

Due to the majority of people living with dementia they were unable to specifically tell us if they felt safe but they told us they were happy. We saw that all staff interactions were kind and respectful. People were relaxed and accessed all areas of the service.

We saw that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS), which were updated every year. Some staff were still awaiting updates on some of this and other training, however the five staff we spoke with were able to tell us how they would report any concerns they might have. This meant that staff had the knowledge that they needed to ensure that people were safeguarded.

People were provided with their medication in a safe manner and at the prescribed times. We saw that medication was stored safely.

The service was safe. We saw records which showed that the health and safety in the service was regularly checked. This included regular fire safety checks, this meant that people were protected in the event of a fire.

Is the service effective?

People told us that they felt that they were provided with a service that met their needs. One person said, "Great place." Another person said, "I'm alright."

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

We observed that at times the service did not have sufficient staff on duty to support people effectively during busy times. The provider told us that they would review the staff rota and dependency levels assessments which they used to assess people's needs to ensure that there were sufficient numbers of staff to meet their needs. They confirmed that they were going to protect mealtimes and increase staffing levels whilst they reassessed the level of staff required to support people's needs.

We saw that the service had not been conducting regular staff supervision and that training needed updating. The service had an improvement plan to address these issues and was in the process of arranging supervision for all staff and updating staff training.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with respect. One person said, "There is always someone to talk to and someone to talk to you."

We observed staff treating people with compassion and patience when they became distressed or disorientated.

Is the service responsive?

People's choices were taken in to account and listened to. We observed staff asking people what they needed and waited for them to respond before providing further support.

We saw from recent safeguarding information and other professionals visiting the service that the service responded to any concerns raised by people and staff and acted on these concerns. Action was taken as required to improve the service and stop events from reoccurring.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor, district nurses, mental health teams and chiropodists.

Is the service well-led?

Staff told us that they were happy with the recent management changes and that they felt comfortable accessing management and team leaders for support.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

In July 2013, we carried out an inspection and found that the service was not compliant with three essential standards of quality and safety. The provider sent us an action plan to tell us what action they would take to become compliant. The purpose of this inspection was to check if they were meeting the essential standards.

The majority of people who used the service were living with dementia and had limited ability to communicate with us verbally their views of the service provided.

We saw that action had been taken by the provider to cease the system previously used by the service which involved writing people’s room numbers into their clothing as this was viewed as an undignified, institutionalised practice.

During our inspection we spent time observing lunch on two units, Pine and Holly. We noted the experiences of people as they ate their meal. We noted that the atmosphere on both units was relaxed and people were not rushed. People who required support to eat their meal were treated with dignity and respected.

During our inspection we spoke with three care staff employed by the service. We saw that the provider had implemented a supervision matrix for all staff who had line management responsibilities to record a plan of dates which had been organised to provide staff with at least six supervision meetings each year.

We looked at the provider's complaints procedure which explained how people could raise concerns about the service if they needed to and how they would be managed. We saw that action that had been taken to train and support staff in gaining the required knowledge and skills needed to support people wishing to make a formal complaint. However, further work was needed to ensure that there was easy access to records which demonstrated the action that had been taken with the outcome of the complaint for people who used the service.

The majority of the people who used the service were living with dementia and had limited ability to verbally communicate with us. However, as part of our inspection we spoke with four people who were able to communicate with us but with limited capacity. We also spoke with a district nurse. One person we spoke with told us, “Staff are kind to me. I have not had any cause for concern.” Another told us, “I would rather be back at home but I am learning to live here.”

During out inspection we saw that the provider’s current system for managing people’s laundry did not ensure that people’s dignity was considered and maintained.

We found shortfalls in the support provided for staff due to a lack of annual appraisals, supervision and planning of the training and development needs of staff employed by the service. This meant that we could not be assured that people received care and treatment from suitably qualified staff.

We looked at a range of records which showed us that maintenance and safety checks were regularly carried out to ensure that people lived in a well maintained and safe environment.

The provider did not have an effective complaints system in place for identifying, receiving, handling and responding appropriately to complaints and comments made by people who used the service, or persons acting on their behalf.

Most of the people who used the service were not able to communicate with us. As part of our inspection we spoke with one person and four relatives of people who used the service. We also spoke with six members of staff.

We found that people’s care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. One relative of person who used the service we spoke with told us, “I feel confident that if we needed a doctor they would ring straight away.” Another relative we spoke with said, “The staff are very accommodating and always speak respectfully.”

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We also found that the provider responded appropriately to any allegation of abuse. One member of staff we spoke with told us, “There was a lot about vulnerable adults in my induction and I found it useful.”

We looked at some aspects of infection control as part of our inspection. We found that there were not always effective systems in place to reduce the risk and spread of infection.

We also found that people’s personal records were not always accurate and fit for purpose.

We did not talk to the people who use this service on this occasion as we concentrated on checking that the service was compliant with an outcome that they were not compliant with on a previous visit, Outcome 9, Regulation 13 ‘the management of medicines’.

When we visited the service on 12 October 2012 we found that the people living there were living with dementia and were unable to tell us about the quality of care they received. To enable us to be able to access people’s wellbeing we spent time sitting with them observing the care they received and the level of staff interaction with the people.

During that inspection we observed that the staff were attentive to people’s needs. Staff interacted with people living in the service in a friendly, respectful and professional manner. We saw that staff sought their agreement before providing any support or assistance.

Most of the people we saw were relaxed, engaged with their surroundings and interacted well with each other. If people became distressed or disturbed others, staff attended to them quickly and acted to distract them or to offer them comfort.

Most of the people who used the service were not able to communicate with us. However as part of our inspection we spoke with five people who were able to communicate in a limited way. We also spoke with three people’s relatives.

One person told us, “You can do mostly what you like. You’re not tied down to one thing.” Another person told us, “Oh gosh I think it’s marvellous. If you rang the bell they’d be here instantly.” A relative we spoke with said, “I think it’s lovely. Everyone’s always polite and welcoming.”

We found that before people received any care or treatment they or their relatives were asked for their consent and the provider acted in accordance with their wishes. We saw that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plans.

We also found that appropriate checks were undertaken before staff began work.

An inspection that took place on 18 February 2013 found that systems in place to reduce the risk and spread of infection were not effective. As part of our inspection we found that improvements had been made and people were now protected against the risks of infection

People’s personal records including their medical records, were found not to be accurate and fit for purpose when we inspected on the 18 February 2013. During our inspection on the 29 and 30 April 2013 we found that personal records were now fit for purpose as a new system of care records had been implemented.