The Orwell provides accommodation and nursing care for up to 40 people, some living with dementia.

There were 33 people living in the service when we inspected on 20 June 2017. This was an unannounced inspection.

At our last inspection of 6 March 2015 this service was rated as Good. During this inspection we found that the service had continued to maintain a Good service and Outstanding in Responsive.

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 systems in place to guide staff to ensure the safety of the people who used the service. Risk assessments provided guidance to staff on how risks to people were minimised. There were arrangements in place to ensure people’s medicines were stored and administered safely. Staff were available when people needed assistance, care and support. The recruitment of staff was undertaken to make sure that they were suitable to work in the service and the risks to people were minimised.

Staff were trained and supported to meet the needs of the people who used the service. 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.

Staff had good relationships with people who used the service and were attentive to their needs. Staff respected people’s privacy and dignity and interacted with people in a caring, respectful and professional manner. People and/or their representatives were involved in making decisions about their care and support.

The service was flexible and extremely responsive to people’s individual needs. People were provided with exceptionally personalised care and support which was planned to meet their individual needs. Care and support was planned proactively and in partnership with people.

Arrangements for activities were innovative and met people’s needs. People were provided with the opportunity to participate in activities which interested them and designed to enhance their wellbeing and enable them to live a full life as possible. People were encouraged to share their hopes and aspirations and the service used creative ways of meeting them to ensure they were valued.

People were actively encouraged to give their views about the service. A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to drive improvements in the service.

There was an open and empowering culture in the service. Staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service. The service had a quality assurance system and shortfalls were addressed promptly. As a result the quality of the service continued to improve.

The Orwell provides accommodation and nursing and personal care for up to 40 people who require 24 hour support and care. Some people are living with dementia. There were 37 people living in the service when we inspected on 6 March 2015. This was an unannounced inspection.

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 was a manager in the service who had made a registered manager application with CQC, which was being processed.

Our previous inspection on 24 September 2014 found that improvements were needed in the care and support that people were provided with to meet their needs and staffing levels. The provider wrote to us to tell us how they were planning to address the shortfalls. During this inspection we found that improvements had been made.

There were sufficient numbers of staff who were trained and supported to meet the needs of the people who used the service. Staff were available when people needed assistance, care and support.

People, or their representatives, were involved in making decisions about their care and support. People’s care plans had been tailored to the individual and contained information about how they communicated and their ability to make decisions. The service was up to date with recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were protected.

There were processes and procedures in place to ensure the safety of the people who used the service. These included checks on the environment and risk assessments which identified how the risks to people were minimised.

Staff were provided with guidance on how people were safeguarded from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

There were appropriate arrangements in place to ensure people’s medicines were obtained, stored and administered safely.

Staff had good relationships with people who used the service and were attentive to their needs. Staff respected people’s privacy and dignity at all times and interacted with people in a caring, respectful and professional manner.

People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

People’s nutritional needs were being assessed and met. Where concerns were identified about a person’s food intake, appropriate referrals had been made for specialist advice and support.

A complaints procedure was in place. People’s concerns and complaints were listened to, addressed in a timely manner and used to improve the service.

Staff understood their roles and responsibilities in providing safe and good quality care to the people who used the service. The service had a quality assurance system and shortfalls were addressed promptly. As a result the quality of the service continued to improve.

We carried out this inspection in response to concerning information about poor staffing levels and medication practices that was impacting on care delivery. We also wanted to check to see if improvements had been carried out, following our last inspection of 30 April 2014 with regard to the care and welfare of people and the cleanliness of the service. We therefore focussed our activities on these three areas.

Further information not available on the day of our inspection was submitted and received on 26 September 2014.

During the inspection we spoke with 10 people using the service and four visiting relatives. We also spoke with the new manager, clinical lead nurse, two nurses, six care staff, catering staff, one domestic and the laundry staff.

We considered all the evidence we had gathered under the outcome’s we inspected. We have used the information to answer the five 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?

Many people accommodated at The Orwell had varying levels and complex needs. There were not sufficient staffing numbers to meet all the needs of people using the service.

There were appropriate arrangements in place to ensure people’s medicines were obtained, stored and administered safely.

Is the service caring?

People and visitors we spoke with all told us that staff were caring, kind and helpful. One visitor confirmed that they were regularly invited, and fully involved in the planning and review of care and support provided to their relative. We found the home provided a very happy, inclusive and homely environment that enabled people to live a normal lifestyle. Staff interacted with people living in the service in a caring, respectful and professional manner. Staff spoken with demonstrated a good understanding of people’s needs and were aware of their personal preferences, choices and behaviours.

Is the service effective?

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty safeguards (DoLS). We found the service was meeting the requirements. The service was aware of the changes in DoLS practice and was working with the local authority to ensure people who used the service were not unlawfully restricted and appropriate assessments were undertaken.

Improvements were needed in the assessments of capacity for people with dementia as individual circumstances and different capacities had not been taken into account when making a best interest decision.

Staff had regular contact with visiting health professionals to ensure people were able to access specialist advice and treatment when required. Two local GP surgeries provided primary care to people. People were referred to healthcare professionals as required. We saw evidence that staff had organised for people to be reviewed by their GP and specialists such as dieticians, chiropodists and experts from sensory organisations.

Is the service responsive?

Although people’s needs had been assessed and care plans developed these did not always adequately guide staff so that they could respond to people’s needs effectively. During our inspection we saw very little meaningful interaction and engagement with people, particularly those with dementia related needs.

Is the service well led?

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We met with the newly appointed manager who had only been in post three days prior to the day of our inspection. They had a lot of previous experience in managing various health and social care services and the provider had fully informed them of the challenges this service was facing. They were aware of where improvements were needed and they were being supported by the provider’s operational manager. An application to register with the Commission had not yet been submitted.

When we inspected the service it had 26 people living there who required personal or nursing care. We observed people moving freely around the home, taking part in activities and making choices about how and where they wanted to spend their time.

We spoke with an acting registered manager and two staff. We spoke with two people who used the service and one relative. We looked at records at the home. Below is a summary of what we found.

During our inspection we looked to see whether we could answer five key questions: is the service safe, effective, caring, responsive and well led?

Is the service safe?

The staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the correct steps to take if they were concerned that abuse had taken place.

Recruitment procedures were rigorous and thorough. We looked to see whether there were the right levels of staff working at the service. We looked at the staff rotas which showed there were enough staff to meet people's needs at all times.

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

During our inspection we noted some shortfalls in the way the service was maintained and cleaned. We have asked the provider to send us an action plan of how they intend to improve this and also noted that a full refurbishment of the service is planned for June 2014 which would address some of the soft furniture we saw that were not suitable for people to use.

Is the service effective?

People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.

People’s health and care needs had been assessed and care plans were in place. There was limited evidence of people being involved in assessments of their needs and planning their care, particularly people with dementia. In two of the three care plans we reviewed family members had consented to their relatives care as it was identified that their relatives were living with dementia. However there were no mental capacity assessment in place and no best interest decision meetings had taken place to show why the people's relatives made decisions on their behalf. This meant that people’s capacity to consent to their care had not been assessed before people made decisions on their behalf and they were not involved in the decisions about their care.

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate. However one of the three care plans contained a care plan regarding a person's skin care which indicated that they did not suffer from any skin problems but the accompanying assessment of their skin integrity stated that at each month's review that they had broken skin areas. This meant that we could not be assured that records were effectively being reviewed to ensure people's continued wellbeing.

People had access to a range of health care professionals some of which visited the home.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.

People and relatives we spoke with were positive about the care provided by staff. One person who used the service said the staff were, “very caring.”

Is the service responsive?

We saw people were able to access help and support from other health and social care professionals when necessary.

People were able to participate in a range of activities. During our inspection people were taking part in a flower arranging activity in the main living area of the service. People were engaged and interacted well with staff.

The service responded well to concerns about the safety of people who used the service. They worked with local healthcare professionals and safeguarding teams to ensure that any concerns were investigated and actions taken as needed to safeguard people from harm.

People told us that the service responded to their needs. One person told us that, “the night staff are very good and come when I need them” and “the call bells are always answered promptly.”

Is the service well-led?

The service had a quality assurance system in place to identify areas of improvement. There was regular audits on medication and the environment.

Records seen by us showed that identified repairs and maintenance were addressed promptly. As a result the quality of the service was continuously improving.

We found staff employed to work at the service had all the necessary skills to support the people who used the service. Staff told us that they felt well supported and were able to work towards additional qualifications in care and received regular training.

One person's relative told us that the “manager is very approachable.” They were included in the changes ongoing in the service and people were also involved in how the service was managed. For example one person told us that they were involved in the recruitment of new staff.

Our inspection of 5 April 2013 found areas of non-compliance. We completed a follow up inspection on 19 September 2013 to check that improvements had been made.

We found that the provider had made improvements to general environment and made reasonable repairs. We were satisfied that the provider had taken reasonable actions to meet with the regulations for safety and suitability of premises.

Our inspection of 19 November 2012 found areas of non compliance relating to the amount of staff on duty to safely care for people who used the service. We completed a follow up visit on 05 April 2013 to check that improvements had been made.

We found that people were cared for by a sufficient number of trained staff. People had their needs met as and when they requested support.

We found that the home required repairs and refurbishment in several areas. People, staff and visitors were not always safe because areas of the home were found to be hazardous and not fit for purpose.

The people using the service that we spoke with told us that they were well looked after. One person said, “They do look after me well, everything.” All the people we spoke with said that they chose to spend most of the day in their rooms. One person said, “I choose to eat all my meals here.”

Care plans showed that people were asked what they liked to do, and how they wished to be supported. People were encouraged to maintain their independence. People’s needs were properly assessed and reviewed to identify any changes required. One person told us, ”My ankles used to be swollen but they are not now.” A relative told us that, “We are always told of anything that happens (to our relative).”

Medications were given safely and with the correct controls to ensure people received the medication prescribed for them. Not all medicines were given at the time prescribed for them. Although people told us they were well looked after, the service had continuing problems in filling care staff vacancies. At times this meant that staffing levels were lower than required by the needs of people using the service.

The provider had a system of monthly reports from the manager, and reports by regional staff, to monitor the quality of service.

We did not talk with people about their medicines during this inspection visit.

Relatives told us that the staff were accommodating, and that action was taken if they raised concerns. One relative was concerned that medications were not always observed to have been taken.

That staff give them their medicines on time but they were not sure what they were prescribed for.