We inspected The Shires on 5 and 8 March 2018. The inspection was unannounced.

At the previous inspection of this service in December 2016 the overall rating was requires improvement because we found the provider in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not ensured staff had been supported through relevant training, supervision and appraisal of their practice and, the quality assurance and monitoring system was not robust; as it had not identified the areas where improvements were needed.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and confirm that the service now met legal requirements. We found improvements had been made, the provider had met the legal requirements and the overall rating had improved to Good. Although, we identified areas that needed further improvement and others needed time to be embedded into day to day practice.

The Shires 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.

The Shires is registered to provide personal care and accommodation for up to 27 older people with dementia and mental health needs. At the time of the inspection there were 21 people living there. They had range of health care needs including diabetes and mental health needs and some people were living with dementia. Accommodation was provided in a converted building on two floors, with lifts that enabled people to access all parts of the home.

The service is not required to have a registered manager in place. There is a registered provider, supported by two assistant managers. One was the designated 'care manager' and responsible for the provision of care for people on a day to day basis. The other was the 'general manager' responsible for recording and updating financial issues at the home. 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.

The quality assurance system had been reviewed and areas for change had been identified and an action plan had been produced to prioritise these and drive improvement. The management had carried out regular audits, including medicines, care plans, health and safety and infection control. However, some areas needed additional work, such as the maintenance records. These had not been consistently filled in and failed to evidence work that had been completed. Including the weekly fire alarm tests.

From August 2016 all organisations that provide NHS care or adult social care are legally required to follow the Accessible Information Standard. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand so that they can communicate effectively. The management had produced details of each person’s needs and these had been included in the care plans for people to take with them if they have appointments outside the home. However staff had not attended training in and we have made a recommendation that the provider seeks advice and guidance from a reputable source, about Accessible Information Standards (AIS) to ensure staff are aware of their responsibilities.

Staff had a good understanding of the Mental Capacity Act 2004 and Deprivation of Liberty Safeguards and, referrals had been made to the local authority as required to ensure restrictions were safe and appropriate. Staff had received essential training as well as training specific to people’s needs, such as dementia awaren

This unannounced inspection took place on 22 December 2016. The Shires is registered to provide personal care and accommodation for up to 27 people. At the time of the inspection, 24 people were using the service some of whom are living with dementia.

The previous inspection of The Shires took place on 17 April 2014. The service met all the regulations inspected at that time.

The service is not required to have a registered manager in place. There is a registered provider who is supported by a care manager responsible for the day to day management of 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.

At this inspection, we found that the registered provider was in breach of two regulations.

Regulation 18 (2) (a) of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. The breach of this regulations relate to staffing. The registered provider had not ensured staff received appropriate support and training to enable them to carry out their roles effectively. Staff had not received regular supervision and appraisal to monitor their performance and to reflect on their practice. The registered provider had not properly trained and prepared all staff in understanding the requirements of the Mental Capacity Act 2005 (MCA).

The registered provider was in breach of Regulation 17 (2) (a) of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. The systems in place to monitor the quality of the service were not fully effective and did not always result in improvements being made when necessary.

CQC is considering the appropriate regulatory response to resolve the problems we found in respect of these regulations. We will report on action we have taken in respect of the breaches when it is complete.

A range of activities were provided for people. However, some people who were unable to leave their rooms spent time in their rooms or lounge without any activity or stimulation.

We have made a recommendation about involving people in activities that meet their individual needs.

People received safe care and support. Staff understood the procedure of reporting concerns of abuse and knew how to help keep people safe. Staff assessed and managed risks to people’s safety and well-being effectively. Staff had up to date plans with adequate guidance on how to support people safely.

There were enough staff deployed to meet people’s needs. The provider followed robust recruitment procedures to ensure only suitable staff worked at the service.

People received support to take their medicines safely. There were effective systems on the managing, storage and administering people’s medicines.

Staff received on-going training and refresher courses in some areas, including safeguarding adults to update their knowledge and skills to meet people’s needs. People gave consent to the care and support they received. Staff promoted and upheld people’s rights under the Deprivation of Liberty Safeguards.

Fresh and nutritious home cooked meals were provided at the service and people could choose what they wanted to eat. People received support with their eating and drinking as required. People received appropriate care and treatment from health care professionals when needed.

People were happy to be living at The Shires and said staff delivered their care with kindness and compassion. People had developed positive relationships with staff. Staff respected people’s privacy and dignity. People received the support they required to communicate their views about how they wanted to be cared for. People were supported by staff who understood their needs.

Staff involved people, their relatives and healthcare professionals

We carried out this inspection to look at the care and treatment that people living at the home received. At the last inspection on 7 and 8 November 2013 we found that there were inconsistencies in the care plans and associated documentation, and that an effective system, which ensured that there was enough staff working at the home to support people, was not in place. We found at this inspection that these issues had been addressed.

We spoke with all of the people living at the home. However, most people were not able to tell us about their experiences of living at The Shires, because of their complex needs. People that did speak with us said, “I am comfortable living here”, “I can decide what I want to do”, and “The girls are very nice, they are always there if I need anything”.

We spoke with three care staff, the deputy manager and the assistant manager, and a relative. We reviewed four care plans and associated documentation; looked at staff rotas, training records and relevant policies and procedures.

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?

Is the service safe?

We found during our inspection that people were safe, their rights and dignity had been respected; staff had attended training and knew how and when to report safeguarding concerns.

Systems were in place for the management and staff to learn from accidents, events and safeguarding, and the concerns identified at the last inspection had been addressed. The home had polcies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, although no applications were in place at the time of the inspection.

Is the service effective?

We found during our inspection that the service was effective. Staff we spoke with demonstrated and understanding of people’s specific needs, and we observed staff supported people to maintain independence whenever possible.

People who spoke with us said the staff looked after them, and that they could decide how and where they spent their time.

Is the service caring?

We found during our inspection that the service was caring. We observed that people were supported by kind and attentive staff. Care staff were patient, they knelt or sat next to people and spoke in a respectful manner at all times. People were encouraged to participate in activities if they wished.

Is the service responsive?

We found during our inspection the service to be responsive. We saw evidence that when people’s needs had changed, the deputy manager had made appropriate referrals to outside agencies.

People who used the service and their relatives were encouraged to make their views known and raise any concerns if they arose.

Is the service well-led?

We found during our inspection that the service was well led. Staff we spoke with said the management were supportive and if they had any concerns they could raise them at any time.

We used a number of different methods to help us understand the experiences of people using the service, because some of the people had complex needs which meant that they were not always able to tell us their experiences. We observed staff supporting people living in The Shires, and we looked specifically at the systems in place for monitoring the quality of the support and care provided by the service.

We found that the service monitored quality in a number of ways. Audits had been introduced and these included the management of medicines, staff training, care plans and suitability of the environment. We found that the audits had been carried out regularly.

We spoke with the manager who said that the quality monitoring system enabled them to identify where changes were needed. There were records in place to support this.

The service had developed a questionnaire to obtain feedback about the support they offered. They had started to give them to relatives, and a system was in place to send them out with people's invoices.

We spoke with five people who used the service, and they told us the food was very good and they were comfortable. They made no specific comment about how the service monitored the quality of the care and support provided.

We used a number of different methods to help us understand the experiences of people using the service because some of the people using the service had complex needs, which meant that they were not able to tell us their experience.

We observed staff supporting people living in The Shires. We looked at documents and spoke to relatives, the care staff, manager and provider.

People who were able to speak with us told us that they were comfortable and liked the support they received.

We used a number of different methods to help us understand the experiences of people who used the service. People had complex needs, which meant they were not able to tell us their experiences. However, those who spoke with us said, “I like sitting here” and “The staff are very good.”

We saw that staff asked people for their consent when they assisted them with personal care and support. People were able to move around the lounge and dining area, and people were asked where they wanted to spend their time.

We examined four care plans. We found that there were inconsistencies in the information recorded, and the way records were kept.

We looked at the policies and procedures for the management of medicines, and how the home ensured people were safe.

We looked at the staff rota and noted the staffing levels. The home did not have an effective system for ensuring that a sufficient number of staff worked on each shift.

We found that the care plans and associated documentation needed to be reviewed and updated.