We carried out an unannounced comprehensive inspection of this service on 8 February 2018.

The home is registered to provide accommodation and personal care for adults and who may have a dementia related illness. A maximum of 28 people can live at the home. There were 27 people living at home on the day of the inspection.

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.

At the last inspection, the service was rated Requires Improvement overall with the rating of inadequate for safe. This was because the provider had failed to ensure systems and processes were in place to assess, monitor and mitigate risk to people living in the home. The rating for safe has been improved to Requires Improvement following this inspection as the provider will need to demonstrate that the changes made are effective and sustainability over time. At this inspection we found the service had improved and was now Good overall.

The provider was recruiting additional night staff to ensure there were enough staff at night to meet people’s needs. The new staff were planned to start within a few days. People told they felt safe living at the home and that staff supported them with maintaining their safety. Staff told us about how they minimised the risk to people’s safety and that they would report any suspected the risk of abuse to the management team. People got the help needed with staff offering guidance or support with their care that reduced their risk of harm.

There were staff available to meet people’s care needs or answer any requests for support in a timely way. People told us they received their medicines from senior care staff who managed their medicines in the right way. People also felt that if they needed extra pain relief or other medicines as needed these were provided. Staff wore protective gloves and aprons to reduce the risks of spreading infection within in the home.

People told us staff knew their care and support needs. Staff told us they understood the needs of people and their knowledge was supported by the training they were given. Staff knowledge reflected the needs of people who lived at the home. People told us staff acted on their wishes and their agreement had been sought before staff carried out a task. People were supported to have 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 who lack mental capacity to consent to arrangements for necessary care or treatment can only be deprived of their liberty when this is in their best interests and legally authorised under the MCA. The procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS).

People told us they enjoyed their meals, had a choice of the foods they enjoyed and we saw where needed people were supported to eat and drink enough to keep them healthy. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs.

People told us they enjoyed spending time with staff and spent time chatting and relaxing with them. We saw people’s privacy and dignity was maintained with staff supporting them to do this where needed. People’s day to day preferences were listened to by staff and those choices and decisions were respected. Staff told us it was important to promote a person’s independence and ensure people had as much involvement as possible in their care and support.

People were involved in planning their care and if requested their relatives were involved. The care plans reflected people’s life histories, prefe

Our inspection took place on 15 and 17 August 2017 and was unannounced.

The Shrubbery is registered to provide accommodation and personal care to a maximum of 28 people. People lived with dementia, mental health needs and/or needs relating to old age. On the day of our inspection 19 people lived at the home.

At our previous inspection of 07 March 2017 we rated three of the five questions we ask relating to the effectiveness, caring and responsiveness of the service, as requires improvement. The remaining two questions relating to safety and if the service was well-led we rated as inadequate. The overall rating for the service was inadequate and we placed the service into special measures. Special measures means that we monitor the service closely and if improvements are not sufficiently made in order to meet people’s needs and to keep them safe we would decide on the enforcement action we would need to take.

At our previous inspection we found that the provider was in breach of the law due to there not being adequate staff provided to meet people’s needs and keep them safe. During this inspection, we found that although staffing levels had not always been consistently adequate to meet people’s needs the provider had taken action to improve this.

At our previous inspection we found that the provider was in breach of the law because they had failed to assess, monitor and mitigate risks within the premises relating to the safety and welfare of people. During this inspection, we found that most safety issues had been addressed relating to the premises and fire safety issues. However, action relating to the poorly fitted first floor landing carpet was still outstanding. This meant that the flooring had remained as a potential trip hazard since March 2017. People had been placed at risk because staff did not follow instructions in people’s care plans to prevent them from choking. People were at risk of harm because staff were not always aware of their specific needs and care plans were not in place to instruct staff of those needs.

At our previous inspection we found that the provider was in breach of the law as they had failed to ensure that people were protected from harm, abuse and degrading treatment from other people who lived at the home. During this inspection, we found that further improvement was required to ensure that staff had the information they needed to keep people safe.

At our previous inspection we found that the provider was in breach of the law as they had not identified or taken action to identify or mitigate risks regarding people’s health and safety. During this inspection, we found that some action had been taken to mitigate risks to people’s health and welfare. However, staff had not ensured people’s safety at mealtimes and had not followed instructions to monitor people to prevent a risk of choking. The systems and processes in place to ensure that the provider and manager oversight, took responsibility and accountability were ineffective. They did not ensure that the service provided met people’s needs safely and in their preferred way, or that risks to people’s health and welfare were reduced.

At our previous inspection we found that the provider was in breach of the law as they had not notified us of safeguarding issues, serious injuries or Deprivation of Liberty Safeguarding [DoLS] as they are required to by law. During this inspection we found that the provider had met this requirement of the law.

The main meal time experience for people was not always efficient. It was disorganised and some people had to wait a long period of time for their meal. People were well informed of what food choices there were and enjoyed the food and drink offered. Staff received induction training and support mechanisms including supervision were provided. Staff confirmed that they had the training that they required. Staff asked people for their consent before they provided any care or support. Where restrictio

Our inspection took place on 07 March 2017 and was unannounced.

At our previous inspection of 16 March 2016 we found that the provider was not meeting regulation 18 HSCA 2008 (Regulated Activities) Regulations 2014 due to there not being adequate staff provided to meet people’s needs and keep them safe. During this, our most recent inspection, we found that staffing levels were still inadequate to meet people’s needs and to keep them safe.

The Shrubbery is registered to provide accommodation and personal care to a maximum of 28 older people and younger adults who may have Dementia or mental health needs. On the day of the inspection 22 people lived at the home.

There was no registered manager in post. It is a legal requirement that a manager is registered with us. 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.

Similar to our previous inspection we found that there were not sufficient numbers of staff available to meet people’s needs or to keep them safe. Risks to the premises had not been identified or managed. People had not been properly safeguarded from the risk of abuse and degrading treatment from other people. Medicine systems required some improvement to promote safety. Overall, safe recruitment processes were in place.

The provider had not ensured that the overall service was caring as they had not taken action to ensure that people were safe or lived in an environment that promoted people’s dignity. The individual staff who supported people had a kind and caring approach and treated people with dignity and respect. People were supported to maintain their independence where possible. Visiting times were flexible to enable people to have regular contact with their family and friends.

The main meal time was not a pleasant experience for people. Although there was a choice of meals people were not appropriately informed of what these choices were. Staff told us that they received an induction when they started to work at the home, on-going supervision and that they were supported well. Staff confirmed that they had the training that they required. Staff asked people for their consent before they provided any care or support. Where restrictions were used to keep people safe the provider had ensured that the actions taken had been approved by the local authority.

Complaints procedures were available but not in a user friendly format. Complaints received had not always been logged appropriately. We were unable to ascertain if people had been given the opportunity to feedback on the service they received. There was a lack of meaningful activities available for people. People and their relatives were involved in the planning and review of their care.

Quality monitoring and audits had failed to identify that a number of areas of service provision were not meeting the requirements of the law. People were at risk of harm and injury and no action had been taken to address this. The provider had failed to notify us of issues that they were required to by law.

You can see what action we told the provider to take at the back of this report.

The overall rating for this service is ‘Inadequate’ and the service therefore in ‘special measures’. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line wit

Our inspection took place on 16 March 2016 and was unannounced. Our last inspection took place on 19 September 2014 and we found that the provider was not meeting Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 due to people’s care records not being completed accurately where people’s needs had changed. Following the inspection we asked the provider to send us an action plan outlining how they would make improvements and we considered this when carrying out this inspection.

The Shrubbery is registered to provide accommodation and personal care to a maximum of 28 older people and younger adults who may have Dementia or mental health needs. At the time of the inspection, there were 26 people living at the home.

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. However, the registered manager was unavailable on the day of the inspection and so we were supported by the deputy manager and the provider.

Records kept on medication were not always accurate. Where people required medication on an ‘as and when required’ basis, there was no guidance for staff on when these should be given. The appropriate authorisations for people who had medication hidden in food had not been sought.

Strategies put into place to manage risks were not always implemented by staff. Records kept about how to manage risks were not always accurate.

People and staff told us that there were not always sufficient numbers of staff available to meet people’s needs. Where staff pre-recruitment checks had identified possible risk, these had not been assessed by the provider to ensure the person was safe to work.

People and their relatives were involved in the planning and review of their care. Staff had a good understanding of people’s needs and how these should be met although records held conflicting information about people’s current care needs.

There was a lack of meaningful activities available for people.

People had not been given the necessary information on how to make complaints. The complaints that had been made were investigated fully by management. People had not been given the opportunity to feedback on the service they were provided.

Quality assurance audits were completed but these had failed to identify issues in medication and care records.

Staff received training and adequate supervision to support them in their role.

Staff understood the importance of enabling people to make their own decisions in line with the Mental Capacity Act 2005 and ensured people’s rights were protected.

Staff supported people with their dietary needs and people had sufficient amounts to eat and drink. People were supported to access healthcare when needed.

People were supported by staff who had a kind and caring approach and treated them with dignity. People were supported to maintain their independence where possible.

People were involved and supported to make decisions about their care. Where people’s needs changed, their relatives were kept informed.

During our previous inspection of January 2014 we found non-compliance with the law concerning care and welfare, quality monitoring and safety, availability and suitability of equipment. The provider told us that they would take action to improve. We carried out this inspection to monitor the progress made on previous compliance actions. We only inspected for part of the day and we focused on the areas where improvements were needed.

No-one knew we would be visiting as our inspection was unannounced. During our inspection we spoke with seven people, three relatives, four staff, two visiting health professionals, the deputy and registered manager.

There were 27 people living at the home when we inspected. We saw that interactions between staff and people who lived at the home were friendly and relaxed.

The summary is based on our observations during the inspection, discussions with people who used the service, the staff supporting them, and by looking at records. If you wish to see the evidence supporting our summary please read the full report.

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

Is the service safe?

We found that where staff had identified concerns regarding risks associated with people’s health and welfare they had been referred to appropriate agencies.

We identified that arrangements were in place so that equipment was maintained and safe for people to use.

Records did not always accurately reflect the care given, which could lead to people not getting the care they needed to stay safe.

Is the service effective?

All people, relatives and staff we spoke with told us that people who used the service were safe and well cared for which gave assurance that an effective service was provided.

Staff received support from senior staff to ensure they carried out their role effectively. Staff we spoke with told us that they felt well supported.

Arrangements were in place to request heath, social and medical support to help keep people well.

Staff knew about people’s needs. However, records we looked at did not highlight all people's needs which meant that there was a potential that specific needs might not be met.

Is the service caring?

We saw that interactions between staff and people who lived at the home were friendly and relaxed.

The staff knew of people's care and support needs which ensured that individual personal care was provided in a way that people preferred.

Is the service responsive?

We found that the provider had taken note of our previous concerns and had learnt from past experiences. For example, improvements had been made regarding complaints processes and monitoring the service which would ensure that people’s needs were better met.

Is the service well led?

A registered manager was in post which meant that the provider was complying with the law, as it is a requirement to have a registered manager and consistency and familiarity was provided.

Staff were generally organised to ensure people’s needs were met and the required support was available.

At the time of the inspection 27 people lived at The Shrubbery. We spoke with eight people who lived at the home, three visitors, five care staff, the deputy manager, registered manager and the registered provider.

Interactions between staff and people who lived at the home were friendly and relaxed. One person told us, “I am really happy here, I have everything I need”. A visitor told us, “They look after X really well”.

Activities in the home to promote people's wellbeing were limited and people had not always received care in a way that met their individual needs.

People received a choice of food and drinks and were protected against the risks associated with poor nutrition and hydration.

People were not always protected from the risks of unsafe equipment and some equipment needed was not available.

Satisfactory recruitment procedures ensured that people were protected from the risk of unsuitable staff being employed.

There were systems in place to monitor the quality of the service. However these were not effective in identifying shortfalls and managing risks to people. This could place people at risk of harm.

There were 16 people living at the home when we visited. Nobody knew we would be visiting that day. We spoke with the manager, owner, deputy manager and spoke briefly with some of the people living there.

We inspected the home in July 2012 and found that improvements were needed with people’s care records so that it was clear that people had received the care they needed.

At this inspection we looked at the improvements that had been made in relation to this. We saw that record keeping had improved. People’s care records were well maintained and reflected that care had been given as detailed in their care plan, so people’s needs were being met.

There were 17 people living at the home on the day of our visit. No one knew we would be visiting. We spoke to eight people who lived at the home, one relative, one care professional, five members of staff and the provider.

We wanted to make sure that the manager and provider had met the compliance actions made at a previous visit to the home and we found progress had been made.

Some of the people who lived in the home had dementia care needs. Because people with dementia are not always able to tell us about their experiences, we used a formal way to observe people during this visit to help us understand. We call this a Short Observational Framework for Inspection (SOFI). We spent 30 minutes in a communal area and observed three people. We recorded their experiences at regular intervals. This included their state of well being, how they interacted with staff members, other people who live at the home and the environment.

We saw that interactions between people living in the home and staff were friendly and relaxed and we saw staff sit and talk to people.

Some activities were being offered to people and this was an area the home was trying to improve on so people have the opportunity to take part in meaningful activities.

Staff we spoke with knew about people's individual needs and personal wishes so they had cared for people in a way that they preferred.

Staff told us they knew what to do to keep people safe and told us what they would do if they saw poor practice.

Staff received training so they had up to date knowledge and skills so they knew how to meet people's needs.

There were some systems in place to monitor how the home was being run so it was safe for people.

People's care records did not always reflect the care given and poor recording could lead to needs not being met.

We carried out this review of compliance in response to concerns that we received about the quality and safety of the service provided to people living at the Shrubbery.

We visited the home on 2 December 2011 to observe what was happening in the home, talk with staff, managers and look at records. The provider was extending the home to provide additional bedrooms. We also visited again on 14 December 2011 in response to the provider requesting a variation of their conditions of registration; this was to increase the number of beds from 15 to 28. Since the time of this later visit we have approved the provider’s application to vary their registration.

At the time of our first visit there were 14 people living at the home.

Most people living at the home during our first visit had some difficulty expressing their views. We therefore observed interaction between staff and people living at the home during our visit to gain an impression of their life at the home. We also spoke to staff, management and looked at records.

We saw different staff talked to, and supported people living at the home. We observed some staff offered people choices and appropriate individual support. We also heard a staff member make an inappropriate statement in earshot of one person living at the home and other staff talking over people whilst they were eating their lunch later on the same day.

We have been told by visiting professionals who visited recently that they have witnessed a mixture of good and poor practice. They have reported seeing good interactions between staff and residents but also occasions when people did not get the attention they needed. Staff were observed to be “rushed and under pressure”. These comments, which suggest problems with either staffing levels or staff deployment, reflect concerns we received in November 2011.

A relative told us “The staff seemed very good in general with patients and understanding their needs and particular problems and coped considering they seemed very understaffed at times”.

We heard from staff prior to our visit that they were concerned about the health care of one person living at the home. We heard reasonable explanations from the manager why this person was encouraged to go to bed at night but the care plan records did not fully reflect what staff needed to do. We also saw other records where there was evidence that information was not always updated to reflect people’s current support arrangements.

When we visited in December 2011 we looked at some people’s medication records and found some gaps in the recording.

After our initial visit to the Shrubbery in December 2011 we asked the management to forward information to us about their system for assessing and monitoring the quality of the service. This was needed to ensure people who use services receive safe and appropriate care. This information was not supplied to us.

We identified a number of areas where the quality of the service needed to be improved, this supported by the experiences of other professionals.