This comprehensive inspection took place on 30 October 2018 and was unannounced.

At our last comprehensive inspection on 25 January 2018, we rated the service as requires improvement. This was because risk assessment lacked detail and sufficient guidance for staff to keep people safe, medicine records were not always completed accurately, staff did not always follow safe infection control, people did not receive consistent support with their meals, there were limited opportunities for hobbies and activities and systems for monitoring the quality of the service was not effective in bringing about improvements. At this inspection we found the provider had made significant improvements to address these shortfalls, although further improvements were needed to ensure people were consistently safe.

Vishram Ghar is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Vishram Ghar accommodates up to 44 older people across two separate units, each of which have separate adapted facilities. One of the units specialises in providing short term care to people who are under assessment following illness, injury or hospital discharge. The second unit support people who require long-term care, some of who were living with dementia. At the time of our inspection there were 39 people using the service.

A registered manager was in post at the time of the inspection. 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 meet people's needs. However, staff were not always deployed effectively to provide people with consistent support and engagement.

There were improvements to protect people from the risk of infections. However, these were not fully embedded into all staff working practices.

Staff understood how to protect people from the risk of abuse and procedures that should be followed to report suspected abuse. People had risk assessments in place to cover any risks that were present within their lives, whilst also enabling them to be as independent as possible.

There were safe systems in place for the administration of medicines and people received their medicines as prescribed.

Staff recruitment procedures ensured that appropriate pre-employment checks were carried out to ensure only suitable staff worked at the service.

People received effective care and support from staff that had the skills and knowledge to meet their needs. Staff attended training where they completed mandatory training and received on-going training to enable them to fulfil the requirements of the role. Staff felt well supported by the registered manager and deputy managers.

People were able to choose the food and drink they wanted and staff supported people with this. Further development of the meal service was planned to ensure the serving of meals was efficient. Staff supported people with health appointments where necessary. Health professionals were involved with people's care as and when required.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice. People were encouraged to make decisions about their care, daily routines and preferences. Staff worked within the principles of the Mental Capacity Act 2005.

People were cared for by a staff team who were friendly, caring and compassionate. Positive relationships had been developed between people and staff. People were treated with dignity, respect and kindness.

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This inspection visit was carried out on 25 January 2018 and was unannounced.

At the last comprehensive inspection on December 2016 the service was rated, 'Requires Improvement.' We found the service was not meeting regulations with regard to providing safe care and having systems in place to ensure quality services. We followed up these issues in a focussed inspection in August 2017 and found improvements had been made, though further improvements were needed to ensure people were always supplied with a safe, quality service. The service remained rated as, 'Requires Improvement.' The service has been rated as 'Requires Improvement' for over two consecutive comprehensive inspections.

At this inspection, we found the provider had continued to make improvements to the care provided. However, some improvements had yet to be embedded into staff working practices to ensure people received consistently good care. The provider had failed to make sufficient, sustainable improvements to the quality of the service. The overall rating for this service remained 'Requires Improvement.'

Vishram Ghar is a 'care home' without nursing. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Vishram Ghar accommodates up to 44 older people across two separate units, each of which have separate facilities. One of the unit specialises in providing assessment, care and support to people who are recovering from a health condition or injury and wish to return to their own homes. The second unit supports older people who require long-term care and support. The service primarily supports people from Asian communities. At the time of our inspection there were 40 people using the service.

The service had a registered manager. 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.

Staff had completed training to enable them to recognise signs and symptoms of abuse and felt confident in how to report concerns.

Staff demonstrated a good understanding of actions they needed to take to keep people safe. Records showed potential risks to people had been assessed, but did not always include the detail and guidance regarding the measures staff needed to take to reduce risks. People received the support they needed if they became distressed or were placing themselves and others at risk of harm.

Staff were protected from the risk of unsuitable staff because the provider followed safe recruitment procedures. There were enough staff available to meet people's needs as assessed in their care plans.

People were supported to take their medicines as prescribed. However further improvements were needed to ensure that medicines records were completed accurately and consistently.

Systems were in place to support staff to follow safe infection control procedures to prevent the risk of infection when providing care. Staff were observed not to follow safe procedures when supporting people during meal times.

There were arrangements in place for staff to make sure that action was taken and lessons learned when accidents or incidents occurred, to improve safety across the service.

Staff completed an induction process when they first started working in the service. They received on-going development training and supervision for their role. The registered manager reviewed and evaluated training to ensure it was effective. This supported staff to gain the skills and knowledge they needed to provide care based on current practice.

People did not always receive the consistent support and assistance they needed to enjoy

Vishram Ghar provides personal care and accommodation for up to 40 people. On the day of the inspection the manager informed us that 40 people were living at the home.

This inspection took place on 10 and 11 August 2017. The inspection was unannounced.

At our last inspection in December 2016 the service was not meeting regulations with regard to providing safe care and having systems in place to ensure quality services. We followed up these issues and found improvements had been made, though further improvements were needed to ensure people were always supplied with a safe quality service.

A manager was in place at the time of this inspection visit and had applied to CQC to become the registered manager. 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 and associated Regulations about how the service is run.

People using the service and their relatives said they thought the home was safe. Staff had been trained in safeguarding (protecting people from abuse) and generally understood their responsibilities in this area.

People's risk assessments have not always been comprehensively followed to ensure people received safe personal care.

Staffing levels were sufficient to ensure people were kept safe.

Medicines had not been supplied to fully protect people from the risk of cross infection.

Systems to ensure that the premises were safe for people to live in were, in the main, in place.

Staff had been subject to comprehensive checks to ensure they were appropriate to provide care to people who lived in the home.

People, their relatives and staff were, in the main, satisfied with how the home was run by the manager.

People and their relatives told us that staff were, in the main, friendly and caring. We saw examples of staff working with people in a kind and respectful way.

Management had carried out audits and checks to try to ensure the home was meeting people’s needs, though this system had not been comprehensively robust to ensure that people using the service had been fully supported.

Vishram Ghar provides personal care and accommodation for up to 40 people. On the day of the inspection the acting manager informed us that 35 people were living at the home.

This inspection took place on 6 and 7 December 2016. The inspection was unannounced and was carried out by one inspector and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. Our expert for this inspection had experience of the care of older people and older people living with dementia.

At our last inspection in September 2015 the service was not meeting the regulation we inspected with regard to keeping people safe. We followed up these issues and found some improvements had been made, though further improvements were needed to ensure people were supplied with a comprehensive service.

A registered manager was not in place. The previous registered manager had left their employment three months before the inspection. The acting manager stated that the recruitment process was in place and supplied us with information indicating this was the case. 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 and associated Regulations about how the service is run.

People using the service and their representatives we spoke with said they thought the home was safe. Staff had been trained in safeguarding (protecting people from abuse) and generally understood their responsibilities in this area.

People's risk assessments have not always been comprehensively followed to ensure people how to save care.

Staffing levels were not fully sufficient to ensure people were safe at all times.

People using the service told us they thought medicines were given safely and on time. We found in the main, medicines had been supplied to people as prescribed.

Systems to ensure that the premises were safe for people to live in were not fully in place.

Staff had not been subject to comprehensive checks to ensure they were appropriate to work with the people who used the service.

Most staff had been trained to ensure they had the skills and knowledge to meet people's needs, though more training was needed on relevant issues in order there was assurance they could meet all the needs of people.

Staff generally understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have an effective choice about how they lived their lives, and the service had obtained legal approval for limiting people's choices when necessary for their best interests.

People had plenty to eat and drink, most people told us they liked the food served, though some people wanted more choice and variety. People had been assisted to eat when they needed help.

People's health care needs had been, in the main, protected by referral to health care professionals when necessary.

People and their relatives told us that staff were friendly and caring and we saw many examples of staff working with people in a kind and compassionate way.

Evidence was not in place that people and their relatives were involved in making decisions about their care, treatment and support, though evidence was lacking in some care plans.

Care plans were individual to the people using the service and covered their health and social care needs.

There were not sufficient numbers of staff to ensure that people's needs were responded to in good time.

Activities were organised to provide stimulation for people, though activities tailored to people's needs had not been frequently provided.

People and relatives told us they would tell staff if they had any concerns and were confident they would be followed

We inspected Vishram Ghar on 28, 30 September and 1 October 2015. The inspection was unannounced. Vishram Ghar provides accommodation for people who require personal care and treatment of disease, disorder or injury.

On this inspection we found a breach of the Health and Social Care Act 2008 Regulated Activities Regulations 2014 with regard to protecting people from infections, fire risks, and not having staff in communal areas to meet people’s needs. You can see what action we have told the provider to take at the back of the full version of this report.

A registered manager was 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 and associated Regulations about how the service is run.

The home provides a service to older people from the Asian community. At the time of the inspection there were 36 people living in the home. According to the manager, approximately two thirds of people were living with dementia. People had a range of other disabilities and approximately half the people living there were wheelchair users.

People using the service and relatives we spoke with said they thought the home was safe. Staff were trained in safeguarding (protecting people from abuse) and understood their responsibilities in this area.

Fire safety measures had not been fully put into place to keep people safe.

The home was not kept fully clean which posed infection risks for people living there.

Relatives told us that on occasions they thought there were not enough staff on duty to meet people’s needs promptly. We found a lack of staff cover in communal lounges to prevent people from falling and ensure they were safe in each other's company.

People using the service and relatives told us they thought medicines were given safely and on time. Some improvements were needed to the way medicines were handled to ensure medicines were not an infection risk.

Staff were safety recruited to help ensure they were appropriate to work with the people who used the service.

People told us they thought staff had skills to be able to provide care to them. Records showed staff had an induction but needed more training when they commenced employment to ensure they had the skills and knowledge to be able to fully meet people's needs.

Staff were being trained to understand their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have an effective choice about how they lived their lives.

People had plenty to eat and drink and told us they liked the food served.

People's health care needs had been fully met by referral to health care professionals when necessary.

Most of the people we spoke with told us they liked the staff and got on well with them, and we saw many examples of staff working with people in a friendly and caring way. However we saw instances of staff not always engaging people in a friendly way[CK8] when they supplied care to people and one person told us staff had dealt with them in an abrupt way.

People and their relatives were involved in making decisions about care, treatment and support.

Care plans were not fully individual to the people using the service and did not fully cover their social care needs.

People were satisfied with the activities provided and there was an activities programme to ensure regular activities were provided, although activities were not supplied every day and outings were limited.

People and their relatives told us they would tell staff if they had any concerns. Records showed that complaints had been followed up.

People and staff said they were generally happy with how the home was run. People had the opportunity to share their views about the service at meetings.

Management carried out audits and checks to ensure the home was running smoothly. However, audits did not include all issues needed to provide a quality service, and did not always show that prompt action was taken if improvements were needed to the service.

This inspection took place on 23 October 2014 and was unannounced.

Vishram Ghar provides accommodation and personal care for up to 40 people accommodated over two floors. This includes care of people with mental health or physical health needs. On the day of the inspection 40 people were living in the home. 16 people had a diagnosis of dementia and seven people received nursing care in bed. The service primarily supports people from Asian communities.

A registered manager was 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 and associated Regulations about how the service is run.

People’s care and support was not always planned and delivered a way that met their individual needs. Risks associated with people’s care were not always assessed and action was not always taken to reduce these risks.

People told us that any complaints, concerns or issues they raised were not always dealt with, in order to improve the service they received.

Systems in place for checking the quality and safety of the service and the care people received had not identified a number of shortfalls in the care and service provided. This meant that a number of issues had not been addressed for the benefit of people who lived at the home.

Staffing levels had recently been increased and were under further review in order to ensure that staff were available at the times people needed them.

Staff had received training on how to protect people who used the service from abuse or harm. They demonstrated they were aware of their role and responsibilities in keeping people as safe as possible.

Satisfactory pre-employment checks had been carried out for most staff. This meant people were protected from the risk of unsuitable staff.

People were given sufficient food and drink to meet their dietary needs and had a choice of what food they were given.

Most people were supported to maintain their health needs. In most instances referrals were made to health care professionals for additional support or guidance if people’s health changed.

The Mental Capacity Act (MCA) is legislation that protects people who may lack capacity to consent to their care and treatment. Not all staff knew how to protect people under this legislation.

The provider supported staff by an induction and some on going support, training and development. However, comprehensive training had not been provided to staff. Plans were in place to address this. Staff told us that they were well supported by the registered manager and were able to put forward suggestions about how the service was run during staff meetings.

People who lived in the home and relatives told us they found staff to be caring, compassionate and respectful. Our observations found staff to be kind and attentive to people’s individual needs and preferences and ensured that their dignity was maintained.

People were supported to pursue their hobbies, interests and faith and maintain relationships with people important to them.

People who lived in the home and their relatives were encouraged to participate in discussions and decisions about the care and support provided. This also included sharing their views and experience of the service

People who lived in the home had been asked to share information that was important to them about how they wished to have their needs met. This included information about routines, preferences, interests and hobbies.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Our expert by experience observed the people who used the service were cheerful. He spoke with some people in English and Gujarati and they said they felt happy and well-cared for. One person said they thought the service had improved since our last inspection.

Lunch was served in the dining room during our inspection. This was a lively and sociable event. People sat at tables set for one to four so they could dine in company or alone depending on their preferences. A range of Gujarati, Punjabi, and Halal dishes were served. The dining room was well staffed and no-one had to wait long for their food, or for assistance with eating if they needed it.

People told us they liked the staff and though the care they provided was good. One person said, “The staff are very helpful. When I need them they come straight away. They talk to me when they have time and have made me welcome here. A relative told us, “The staff are good, caring and kind. They make a big fuss of the residents and treat them like family.”

The home was purpose-built and spacious with large communal rooms, wide corridors, and level access throughout. All areas inspected were clean, tidy and fresh. People said they were satisfied with how the home looked and thought it was well-cared for.

An expert by experience accompanied us on our visit to this service. This is a person who has personal experience of using, or caring for someone who uses a health or social care service.

The expert by experience observed that staff treated the residents with dignity and respect and people could spend their time in communal areas or in their rooms depending on their preferences. Care was provided discreetly and people were encouraged to be as independent as possible.

The expert by experience found that people at Vishram Ghar were generally satisfied with the care and support provided. They observed people being hoisted and saw that it was done appropriately. One person told the expert that they liked using the hoist.

The expert by experience talked to the people who used the service and their relatives about staffing in the home. People told him the staff were always polite but there weren’t always enough of them on duty. The expert observed lunch being served and reported that one person had to wait 20 minutes for assistance with their meal.

The expert by experience observed that the heating was not on for part of the inspection and some of the people who used the service were dressed in jackets, hats and shawls to keep warm. One person told the expert the heating wasn’t usually on during the day.

An expert by experience accompanied us on our visit to the service. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service.

The expert by experience found that people were satisfied with the care and support they received and that people felt they were well cared for by staff who understood their cultural and faith needs. However they found that people were not consulted or supported to access community events or activities which included visiting temples to enable them to meet their religious and faith needs.

We spoke with a relative of someone who lived at Vishram Ghar. They told us that they were in the main satisfied with the care provided however did have concerns as to the number of staff on duty and their ability to meet the needs of people well.

People living at Vishram Ghar were supported by staff who conversed with them in their first language. Meals were culturally appropriate.