The Firs

We carried out a focussed inspection on 2 February 2017 to follow up concerns about how the service was managed which we had found at the previous inspection on 13 February 2016. We found that whilst there had been improvements some concerns remained.

This unannounced inspection took place on 23 April 2018. At this inspection we found the service was Good overall. We found considerable improvements with the management of the home which had positively impacted on all aspects of the quality of the service provided.

Why the service is rated Good overall:

There is a registered manager running 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.

People’s safety was contributed to by staff who had been trained in safeguarding vulnerable adults and health and safety policies and procedures. Staff understood how to protect people and who to alert if they had any concerns. General operational risks and risks to individuals were identified and appropriate action was taken to eradicate or reduce them.

There were enough staff on duty at all times to meet people’s diverse, individual needs safely. The service now had a stable staff team. The provider had robust recruitment procedures. People were given their medicines safely, at the right times and in the right amounts by trained and competent staff.

The service remained effective. Staff were well-trained and able to meet people’s health and well-being needs. They were able to respond effectively to people’s current and changing needs. The service sought advice from and worked with health and other professionals to ensure they met people’s needs.

People were encouraged 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 practise.

The service continued to be caring and responsive. The committed, attentive and knowledgeable staff team provided care with kindness and respect. Individualised care planning ensured people’s equality and diversity was respected. People were provided with a range of activities, according to their needs, abilities, health and preferences. Care plans were reviewed by management regularly. Care plans contained up to date information and records demonstrated that risk assessments were usually reviewed within stated timescales.

The registered manager was well regarded and respected. The quality of care the service provided continued to be reviewed and improved, as necessary.

At the last inspection, the service was rated Good overall and Requires Improvement in the ‘Well led’ domain with a breach of Regulation 17.

This inspection took place on the 2 February 2017 and was unannounced. The visit was a focussed inspection to follow up a breach of regulations from the last inspection which took place on 13 February 2016. It was found at the last inspection that the provider and registered manager did not have effective systems in place to monitor the quality of service being delivered. Some internal audits had not been completed to identify any shortfalls within the service. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 17; good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

We found that improvements had been made with the provider oversight of the service and that there was no longer a breach of the regulations. However, we found that there were still improvements required with the day to day management of the service.

The service had an interim manager in post and recruitment for a permanent registered manager was being undertaken at the time of the inspection with a closing date for applications the day after the visit. 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 and staff felt that the interim manager was approachable and were confident action would be taken to address any concerns should they have raised them. The provider carried out regular quality checks on the manager. The service and had a range of audit systems in place to measure the quality and care delivered so that sustained improvements could be made. At this inspection we found the provider had made some of the required improvements. Whilst the provider had made provision for greater oversight of the service including the appointment of a mentor for the manager there were still areas identified by external audits which remained outstanding.

The inspection took place on 13 February 2016. This was an announced inspection which meant the provider knew we would be visiting. As we were visiting the service on a Saturday we rang the day before the inspection to ensure there would be someone at home on the day of our visit. We also wanted to make sure the manager would be available to support our inspection, or someone who could act on their behalf.

A registered manager was employed by 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.

The provider and registered manager did not have effective systems in place to monitor the quality of service being delivered. Some internal audits had not been completed to identify any shortfalls within the service.

People told us they liked living at The Firs and felt safe living at there. There were systems in place to protect people from the risk of abuse and potential harm. Staff were aware of their responsibility to report any concerns they had about people’s safety and welfare. Staff had received training in how to recognise and report abuse.

We observed staff showed concern for people’s wellbeing in a caring and compassionate way, and responded to people’s request for support and assistance promptly.

People’s needs were assessed and care plans were developed to support people with everyday living skills, support them to access their local and wider community and to help people live their lives as independently as they were able. Staff had knowledge of people’s preferences and needs. They received training and supervision to enable them to meet people’s needs.

There were enough staff deployed to fully meet people’s health and social care needs. Day to day staffing levels were varied and set to meet people’s needs. The registered manager and provider had systems in place to ensure safe recruitment practices were followed.

People had access to food and drink throughout the day and were encouraged to maintain a healthy diet.

Where required people were supported to access healthcare services to maintain and support good health. There were safe medication administration systems in place and people received their medicines when required.

Staff and the manager had an understanding of the Mental Capacity Act (2005). Staff were knowledgeable about the rights of people to make their own choices and decisions.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The Firs is one of a group of residential homes providing care and support to people within a village environment known as Ravenswood Village. It was run primarily for those of Jewish faith, but people and staff did not have to be Jewish to live or work there. People were supported to practice their faith, and the village celebrated Jewish rituals and festivals. People had the choice of whether they wished to attend the synagogue or follow Jewish rituals.

The location did not have a registered manager at the time of our inspection. This is a requirement for registration with the Care Quality Commission (CQC). We spoke with the person managing the service on the day of our inspection. They told us they had submitted their application for the role of registered manager to CQC. Our records confirmed this.

As part of this inspection we spoke with three of the ten people who use the service, four people's relatives, the manager, two deputy managers, three care workers and one volunteer. We also reviewed records relating to the management of the home, including five care plans and daily care records.

Below is a summary of what we found.

Is the service caring?

One person told us 'I like the staff'. We observed staff were patient and caring, and people sought their company. People and staff dined and chatted together. This indicated to us that people felt relaxed with and enjoyed the company of staff. All the relatives we talked with spoke positively about the care that staff provided.

One relative told us the service was a 'family unit', as the people had lived together for a long time. They said 'Those needing extra care get it. Care workers treat people respectfully. When X visits us they always ask when they can go back home. X is happy to be there'. Another relative said care was 'Very client led. They work carefully with people to ensure their wishes are considered'. They told us when they visited they saw that staff were attentive and respectful when interacting with people.

Is the service responsive?

We saw staff were responsive to people's needs and wishes. One relative told us staff were 'Committed to addressing X's [health problem]'. One care worker told us 'We work with rather than for the residents'. They understood people's anxieties, and took actions to promote people's wellbeing.

Care plans recorded people's support needs, and we saw this information was reviewed on a quarterly basis, and updated when it had been identified that people's needs changed. Care workers spent quality time with people, and were able to identify slight changes in people's facial features or gestures if people were unable to verbally communicate. This meant care workers were able to respond promptly to indicators of ill health, discomfort or dissatisfaction.

When people required health interventions, we saw records documented that staff ensured they attended health appointments and followed guidance from health professionals. This demonstrated that the service was responsive to people's needs.

Is the service safe?

We found the service followed safe practices. For example, assistive technology, such as sensors to detect seizures at night, had been used to promote people's safety when asleep. Risk assessments had been completed and reviewed to protect people and others from identified hazards. Accidents and incidents had been reviewed to reduce the risk of repetition.

The provider ensured essential checks and services had been completed in accordance with health and safety and manufacturers' guidance to maintain the safety of the service. For example, we saw gas safety certification, and noted the lift had been regularly serviced. Safety checks and regular maintenance protected people from potential harm.

We found there were sufficient staff to support people safely. People's needs were assessed, and the number of staff on duty was directed by this needs analysis. The manager ensured staffing levels were sufficient to support people with their planned activities.

Records were stored securely. This meant information about people and staff could only be accessed by those authorised to do so.

Is the service effective?

At our last inspection in September 2013 we did not find systems to monitor and assess the quality of the service had been effective. At this inspection we found actions had been implemented to provide assurance of an effective service delivery.

One relative told us 'Overall I am very happy X is there. Any problems are minor. X is safe, secure and well cared for'. All the relatives we spoke with told us that their loved ones were effectively cared for in accordance with their care plans.

Records demonstrated that information was documented, reviewed and analysed to ensure people were cared for appropriately. This showed us that the service monitored and assessed the care people received to ensure they were cared for effectively.

Is the service well led?

We found the service was well led. Relatives we spoke with told us the manager had implemented changes for the better. One relative told us 'We can see a big improvement since the manager's arrival'.

We saw evidence that feedback was sought from people, their families and staff, and issues identified were acted on. For example, we saw changes had been made to the menu to provide healthier options, and people chose where they wished to holiday.

We saw checks and audits ensured care worker's allocated roles and responsibilities had been completed. Where information required updating, we saw entries in the communication book, or discussion in team meetings, to remind staff to address identified issues. This meant that staff understood the procedures required to ensure people were appropriately care for.

We observed staff interacting with people in a friendly; calm; relaxed and courteous way and we observed personal care being given respectfully.

We saw that the environment was clean but there was some need of updating of some fittings and fixtures. We saw that people had personalised their rooms and there were photographs of people throughout the home. The outside areas were well maintained.

We saw that people were treated as individuals and there were opportunities for them to spend time pursuing leisure; educational or some work based activities.

We found that there was a lack of quality assurance processes to identify; monitor and address any findings; gaps and omissions.

We spoke with people living at the home. They told us they liked living at the home and were able to do things they enjoyed. One person told us, 'I like to see the trains and for my birthday next week, me and my friends are going on a train ride.'

We saw people making choices and being encouraged to be independent. Likes, dislikes, abilities and goals were considered in relation to the support people received and this was evidenced in their care plans.

Appropriate checks were undertaken by the home before staff began work.

The care workers we spoke with were confident to recognise and report abuse. They had training in safeguarding and knew of the home's policies and procedures in protecting people from abuse. Procedures were in place to support people and their families to make complaints.