The Firs

The Firs is a residential care home without nursing providing personal care and support to up 22 people. The service provides support to people who are frail and some who are living with dementia. At the time of our inspection there were 20 people using the service.

People’s experience of using this service and what we found

People told us they felt safe and well cared for. One person said “They (staff) are the best. They take good care of us.” Most people were unable to give their views, but we observed people looking relaxed and comfortable. There were good interactions between people and staff. Staff showed kindness and patience towards people, particularly when they became distressed or needed some support to understand their surroundings. Staff explained what was happening next and encouraged people to share a lunch time experience together.

Relatives said they were confident that staff understood people’s needs and supported people in a kind and caring way. One relative said “I have had personal experience of what a poor care home offers and I can honestly say The Firs offers the right care. Staff are very caring and are doing a great job.”

The staff team knew people well and spoke about people in a positive way. There was a good teamwork approach to delivering care. One relative commented on this, saying “They (staff) never say oh I will get someone to do that, or that’s not my job, whenever I ask them something. They say, yes I will get right onto that and they do!”

Care plans were detailed and personalised to enable staff to provide care and support in a way that ensured people’s preferred routines were honoured. Where known, people’s past history and things which were important to them were included within their plans. This helped staff to understand who each person was and what their experiences had been prior to coming into the service.

The provider had employed a well-being facilitator who supported the care team in developing activities and experiences for people which were meaningful and suited their interests. They had formed good links with the local community which continued through lockdown. For example, the local school children were not able to visit but became pen pals with people. People helped to make the garden look nice and the service won six awards as part of the local flower festival. They had more plans to develop these links further with a wildlife and wildflower section being developed in one part of the garden. They were redesigning one area of the home to be a vintage tearoom where people could meet with family and friends.

Systems and processes ensured quality outcomes were being measured, peoples’ views and those of their families and as well staff views were listened to.

Rating at last inspection-

The last rating for this service was requires improvement (Published 9 December 2020). The last inspection did not look at caring and responsive as there were no breaches or recommendations made. The inspection prior to this had rated both these areas as requiring improvement.

At this inspection we found improvements had been made and both caring and responsive have been rated as good.

Why we inspected-

This inspection was prompted by a review of the information we held about this service. We undertook this focused inspection to check on two areas which were rated requires improvement. This report only covers our findings in relation to the Key Questions caring, responsive and Well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Firs on our website at www.cqc.org.uk.

Follow up-

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The Firs is a residential care home that was providing personal care to 20 people aged 65 and over at the time of the inspection. Most of the people at the service were living with dementia.; The home is registered for 27 people. It is owned by South West Care Homes Ltd who own and manage eight other care homes in the South West.

People’s experience of using this service and what we found

Most people were unable to give their views about the service verbally. Two people said they enjoyed living at The Firs. One person said, “We are treated very well, its five star.” Another who was being cared for in their room said they were “Quite happy.” People were moving around freely and interactions between people and staff were relaxed and showed there was good rapport between them. One relative said “I find all the staff extremely competent, caring and lovely. The manager is very approachable, and I am kept well informed about my mums care.”

When we last inspected in October 2019, we found the environment was in need of repair and refurbishment to ensure the safety and comfort of people living there. Despite the pandemic meaning some essential work was delayed, most of the areas identified have been completed. This included rebuilding a new conservatory. This was in the final stages of being painted and plans were being looked at to use this as a visiting area during the pandemic. This area being out of action had not impacted on people as there were other communal spaces they could use.

Previously we had identified that poor lighting may contribute to the risk of falls. Lighting in people’s bedrooms had been improved using LED lighting which is brighter. Lighting checks were also now included as part of weekly checks of the environment.

At the last inspection we found checks concerning possible scalds from hot water was not robust and failed to show how people were being fully protected. At this inspection we found this had improved so where hot water was above the recommended temperature, maintenance adjusted the mixer valves. All radiators had fixed covers or were not accessible to people to help protect them from risks associated with hot surfaces.

The laundry area was in the process of being refurbished to move the sink to a better position to ensure good infection control. Where previously commode pans were being brought to the laundry area for cleaning, these had now been replaced with disposable bedpans, so the risk of cross infection was reduced.

There was a clear programme of refurbishment, some of which had been delayed due to the pandemic but was being monitored by the manager and provider quality assurance team. The provider had sent monthly quality assurance reports to CQC as part of the positive conditions we imposed following the previous inspection. These showed good oversight of the issues being addressed to ensure the environment was being maintained to a satisfactory and safe level. Some parts of the home remain in need of refurbishment, such as worn paintwork and stained carpets. However, this did not impact on people’s safety or well-being. Previously part of the home was malodourous. On this inspection we found the service was clean and fresh smelling.

At the last inspection we found training was not always up to date and staff lacked some of the essential skills to do their work effectively and safely. There had been clear improvements since the last inspection. Despite the need to reduce face to face learning due to the pandemic, staff reported their learning needs were being met. All of the 12 staff interviewed as part of this inspection said they had completed training in core areas such as infection control and Covid. One staff member said “I have done all my online training and am up-to-date with everything and all my mandatory which included infection control and safeguarding. We had a separate Covid-19 course and I just done my first-aid. We are always kept in the loop by the manager of any updates to guidance.” The provider had introduced a new training matrix which made it simpler to see which staff had completed or needed updates in core training. A provider wide training manager had been employed to oversee and coordinate company training.

The manager explained that at the last inspection one or two staff had been doing more than their core hours. Each staff member had been asked to complete a declaration stating whether they were happy to do above their core hours, but that this was checked so staff did not do too many hours. In the previous inspection this had been identified as an issue. Staffing rotas showed the providers preferred numbers were rostered each day and unless in exceptional circumstances such as sickness, staff did not do cover and above their core hours.

At the previous inspection we found people had not been involved in the development or review of their own care plans. The manager explained that most people did not have capacity to understand their care plans. She had been working through a list of relatives to share plans and get their agreement/signature. This was work in progress which had been slowed due to the home having to ‘lockdown.’ It was also noted at the previous inspection that Deprivation of Liberty Safeguard applications had not always been updated to include restrictions such as the use of a sensor mat. At this inspection we found improvements had been made to show these applications were regularly reviewed and where needed, updated.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was inadequate (report published 18 February 2020).

This service has been in Special Measures since February 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures

Why we inspected

We undertook this unannounced focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

We looked at infection prevention and control measures under the ‘Safe’ key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Inadequate to Requires improvement. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm . Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Firs on our website at www.cqc.org.uk

People’s experience of using this service:

Quality assurance arrangements were weak, and problems were not always identified or addressed in a timely manner. Since our last inspection, the standard of record keeping, auditing and the safe running of the home had declined. Staff said poor quality audits of the service, a lack of investment, a lack of office time for the manager and staff vacancies were contributing factors.

Some areas of the home were poorly maintained, unsafe and odorous. Staff practice showed a lack of understanding of good infection control measures. Systems had not been put in place to ensure commode pans were emptied and washed in a safe manner to prevent the risk of cross infection. Three bedrooms had an odour of urine. Cleaning fluids had been left in two communal bathrooms and the door to the laundry and the sluice area was left unlocked which put people living with dementia at potential risk of harm. A large sofa in the conservatory had stained seat cushions.

Checks to ensure people were protected from scalds from hot water were not meaningful. When the hot water was above the recommended temperature, there was a poor audit trail to show how the risk had been managed to protect people from harm. Radiators in two bedrooms were uncovered. One person’s heavy bedroom door shut so rapidly they were in danger in being knocked over; they were frail and used a frame to walk. Neither, the door opener system or the door closure fitting were working correctly.

There were areas of the home in a poor state of repair, for example worn carpets taped to prevent a trip hazard, loose cabling, as well as chipped paintwork. There were leaks in the conservatory roof, the water dripped onto the carpet in three places and the carpet was wet. Flooring was stained or ripped around some toilets. One person’s bedroom ceiling was heavily stained due to a leak from the room above. Some bedrooms were poorly lit, which could put people at increased risk of falling.

Following the outcome of an individual safeguarding concern, action to show lessons had been learnt had not been taken promptly.

Many areas relating to care needed to be improved, including people not signing their care plans to show their agreement. There were examples of poor moving and handling by some staff. There were gaps in staff training, including medicine administration and fire safety. There was poor oversight of staff hours; one staff member was working excessive hours which had not been addressed.

Care plans and risk assessments were reviewed on a regular basis. The quality of these reviews was variable, mistakes had been made in the completion of some assessments, so they were inaccurate. However, this had not impacted on how the risk was addressed by staff.

The organisation was reviewing how peoples’ well-being and interest were met. They recognised some elements of their current provision was not suitable and were expanding the quality and choices available to people.

Staff were not recording concerns formally and therefore the complaints process was not being followed. There had been a lack of effective oversight and governance of the service, which did not support the delivery of high-quality care. The culture of the provider was not always open and transparent. People living, working and visiting the home had not been formally told of changes to the way the organisation was being run.

The provider had recruited a new team of operational staff. It was too early to see the impact of this new approach. However, since the inspection we have received timely assurances regarding action taken to address concerns.

People were positive about their experience of living at the home. They looked relaxed and at ease with staff. Staff could explain how they supported people and understood how they contributed to their health and wellbeing. For example, “I have nothing but praise for the staff, they always keep half an eye open. I can’t complain. Sometimes I need to get up quickly to the toilet, they always respond.”

Staff relationships with the people they assisted continued to be caring and supportive. People's nutritional needs were met, and people praised the quality of the food. A visitor said, “I feel the atmosphere is pleasant, they care about people.” Staff spoke confidently about the care they delivered and affectionately about the people they supported. They understood how they contributed to both people’s physical health and mental wellbeing.

Staff praised the approachability of the manager and were happy with the level of team work. They said the manager was a good role model as they were “relaxed and happy with residents.” Other staff described the manager as “kind” and “compassionate.” Staff said they enjoyed working at the home.

Rating at last inspection: Requires Improvement (report published in April 2019).

Why we inspected: This inspection was scheduled for follow up based on the last report rating.

In November 2017, a focussed inspection was completed following a safeguarding concern. The service was rated as Requires Improvement. Two previous inspections in 2016 and 2017 had been rated as Good.

In July 2018, a comprehensive inspection took place following the service becoming part of a whole service safeguarding and an individual safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the previous registered manager had been part of these discussions. Both of these alerts were closed based on the improvements and actions taken to address concerns identified. CQC are continuing to look at the circumstances surrounding an incident involving one individual.

During the inspection in July 2018, we found staff spent time with people and there was a low risk of social isolation. However, people were not always enabled to take part in meaningful activities on a regular basis. The overall rating was Requires Improvement with one breach.

In April 2019, the service was rated as Requires Improvement for a third time but this time there were no breaches.

In September 2019, there was an individual safeguarding concern raised for a person living at the home. A multi-disciplinary meeting was held, and actions were agreed to address concerns arising from the investigation.

In September 2019, a new nominated individual began working for the provider. Their role includes Director of Operations; they have a team of four staff with their own quality assurance responsibilities. These include maintenance, care planning, activities and community involvement, training and overall quality assurance. CQC have met with this new team in October 2019 and will continue to meet with them every six to eight weeks to discuss the operation and regulation of the nine homes registered with the provider.

On this inspection, we judged there had been five breaches of regulation in relation to infection control, safe care and treatment, maintenance of the building, staff training and governance arrangements. We also made a recommendation as to how oral hygiene was provided.

Special Measures

The overall rating for this service is 'Inadequate' and the service is in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement

procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Action we have taken: CQC have taken enforcement action by imposing a condition on the provider's registration. This requires the provider to provide CQC with a monthly report outlining actions and progress in making the required improvements.

Follow up: We will continue to monitor the intelligence we receive about the service. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

There had been three managers in less than a year. However, staff and people living and visiting the home were positive about the new manager, who was already known to them. The new manager was praised by people, their relatives and staff, for their positive and supportive approach. They have not yet registered with the Care Quality Commission but have started the process.

Systems were in place to monitor the quality of care provided. Improvements had been put in place but needed time to be imbedded and sustained.

Communication within the staff group was improving, new systems had been introduced but needed to be embedded and sustained.

Work had started to improve meeting people’s individual interests and hobbies but this also needed to be embedded and sustained.

Improvements had been made to assessing the care needs and health risks for people who came to the home for a respite or short stay.

The manager worked closely with staff, spending time on the floor and ensuring the whole staff team was updated with people’s changing health and emotional needs. Staff commented on the improvements at the home in staffing levels and support to carry out their role. This included improved systems to update staff when people’s care needs changed.

People were cared for by staff who were kind and attentive. Staff were friendly and welcoming.

People's privacy was respected and their dignity maintained. Staff were responsive to people's individual needs and wishes and had an in-depth knowledge about each person.

People and their relatives were positive about their experiences and the care provided.

People were cared for by staff who knew how to keep them safe and protect them from avoidable harm.

Sufficient staff were available to meet people's needs and people told us they were generally available when they needed assistance, staff responded promptly. Care was delivered by staff who were trained and knowledgeable about people's care and support needs.

People received their medicines regularly. Systems were in place for the safe management and supply of medicines, although work was being instigated to address some areas of practice. For example, the time taken to administer medicines in the morning.

Incidents and accidents were investigated and actions were taken to prevent recurrence.

The premises were clean and staff followed infection control and prevention procedures. Work was planned to improve the layout of the laundry room and the downstairs toilet and shower room.

People's needs were assessed, including people receiving respite care. Care was planned and contained personalised information.

People were provided with a nutritious and varied diet. They were complimentary about the quality and choice of food offered.

Staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice. When people were unable to make decisions about their care and support, the principles of the Mental Capacity Act (2005) were followed.

Rating at last inspection: Requires Improvement (report published in September 2018).

In July 2018, a comprehensive inspection took place following the service becoming part of a whole service safeguarding and an individual safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the registered manager had been part of these discussions. Both of these alerts were closed based on the improvements and actions taken to address concerns identified. CQC are continuing to look at the circumstances surrounding an incident involving one individual.

In July 2018, we found staff spent time with people and there was a low risk of social isolation. However, people were not always enabled to take part in meaningful activities on a regular basis. There were no audits about how people were spending their day. Activities offered by staff and external entertainers, did not ensure each person had their social and leisure needs met. However, we found people's care plans were detailed and identified risks, safeguarding issues were identified and shared with the local authority, we received notifications as legally required and audits, other than for activities, were good. The overall rating was requires improvement with one breach.

On this inspection in March 2019, the service was rated as requires improvement for a second time but this time there were no breaches.

Why we inspected: This was a scheduled inspection based on the previous rating of requires improvement.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. As this is the second time the service has been rated as requires improvement we will meet with the provider.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

There was a registered manager at the service. A registered manager is a person who has registered with the 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. They were currently not working at the home which was being managed by the deputy operations manager and the operations manager on site. Both had worked for the provider for some time.

The last comprehensive inspection was in September 2016; at that inspection the overall rating for the service was good and we found that people were safe. A recommendation was made that the service sought advice and guidance on developing activities for people living with dementia. At this inspection in July 2018, we found that staff spent time with people and there was a low risk of social isolation. However, people were not always enabled to take part in meaningful activities on a regular basis. There were no audits about how people were spending their day. Activities offered by staff and external entertainers, did not ensure each person had their social and leisure needs met.

A focussed inspection was completed in February 2017 to look at safety issues at the service following some concerns about how risk was managed; at that inspection we found the service was safe. In November 2017 we found during a focussed inspection that the service had not submitted statutory notifications to the Care Quality Commission when particular events had occurred. Checks and audits were carried out routinely but these had not always identified issues that were found during the inspection. Care plans did not always fully reflect people's risks and needs when changes occurred. When incidents had happened, plans did not always take into full consideration how to reduce the risks of reoccurrence. During this inspection in July 2018 we found people’s care plans were detailed and identified risks, safeguarding issues were identified and shared with the local authority, we received notifications as legally required and audits, other than for activities were good.

This inspection was brought forward because of safeguarding concerns. Prior to our inspection, the service became part of a whole service safeguarding. An individual safeguarding process remains ongoing. This meant the local authority safeguarding team, commissioners, CQC inspectors , police and other professionals had met to discuss the safety and well-being of the people living at the service.

The provider, their operations team and the registered manager had been part of these discussions. Actions from this process included reviewing and monitoring people’s care as part of a whole home safeguarding process. The service has recently completed a number of improvements in response to the concerns raised as part of the safeguarding process. For example, in relation to health concern and documentation. We did not look at the specific concerns relating to the individual’s care but inspected to check if other people were at risk. The whole home safeguarding process has now closed with the service making good progress in embedding improvement. We found during this inspection that there were two areas requiring improvement in relation to a lack of consistent provision to meet people’s social and leisure needs and there were improvements needed to ensure medicine management was robust to keep people safe.

On the day of the inspection there was a calm and relaxed atmosphere in the home and staff interacted with people in a friendly and respectful way. People were able to choose what they wanted to do and where they wanted to spend their day and enjoyed spending time chatting with the staff who were visible and attentive. Most people were independently mobile and able to move towards staff in the communal areas if they wanted to engage with them. People looked comfortable and happy to spend time in the large lounge/conservatory or dining area or choose to spend time in their rooms.

Staff ensured they had identified those who could not use their call bells easily, and they were checked regularly. People were encouraged and supported to maintain their independence and risk and independence was well balanced in the least restrictive, safe way. Staff engaged with people in ways which reflected people's individual needs and understanding, ensuring people mobilised safely from a discreet distance.

People and relatives said the home was a safe place for them to live. Comments included, “I can leave here and know that my loved one is well looked after. They brought her flowers from the garden and pop in for a chat” and “He is very happy now. I think [the registered manager] is doing a wonderful job here. I am happy with the standard. They are safe, yes.”

Staff had received recent training in how to recognise and report abuse. Any safeguarding concerns had been managed well with provider involvement and they had listened to any advice, and the service worked openly with the local authority safeguarding team. Relatives said they would speak with staff if they had any concerns or complaints and issues would be addressed. Staff were vigilant about protecting each person from possible negative interactions with other people living at the home, recognising frustrations and misunderstandings between people due to them living with dementia. They used chatting and distraction techniques as they knew people well, showing patience and understanding. One person, for example, was having a walk with staff around the garden as they were becoming agitated. Staff knew what to chat about to help the person feel calmer.

People were well cared for, and people and relatives were involved in planning and reviewing their care as much as they wanted to be. Staff demonstrated kindness and compassion for people through their conversations and interactions. People's human rights were protected because the management team and staff had an understanding of the Mental Capacity Act 2005 (MCA).

There were regular reviews of people's health, and staff responded promptly to changes in need. For example, care records of people currently living at the home showed many examples of staff identifying changes in need and appropriate and timely referrals to health professionals. For example, one person was having regular appointments with a specialist dentist and another person had regular appointments to check their pacemaker. People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs.

Medicines were generally well managed and they were stored in line with national guidance. Records were completed with no gaps, and there were now regular audits of medication records and administration to help ensure the correct medication stock levels were in place. We made a recommendation to ensure all issues were identified robustly, although the monthly audit would have picked up these issues which were due to take place.

Staff were well trained and there were good opportunities for on-going training and obtaining additional qualifications. There was a comprehensive training programme covering a wide range of topics. The training matrix showed staff were up to date or booked on training. A comprehensive induction was completed by new staff and supervisions and appraisals were up to date and showed meaningful discussion. The staff team was stable and many care staff had worked at the home for some years as the service was in a rural location.

People's privacy was respected. Staff ensured people kept in touch with family and friends and there was open visiting with people made welcome. All people living at the service had family and friends able to visit.

The management team said they were keen to give people good care and valued their staff team. Staff said they enjoyed working at the home and it was seen as important in the local area as it was so rural and a small community. Staff had clearly adopted the same ethos and enthusiasm as the management team and this showed in the way they cared for people in individualised ways following the company ethos of promoting choice.

Observations of meal times showed these to be a positive experience, with most people choosing to join each other in the dining room. People were supported to eat a meal of their choice where they chose to eat it at times of the day to suit their appetite. People were supported discreetly to be as independent as possible, using adapted crockery, having finger food or snacks when they most had an appetite.

The premises were clean and smelt fresh. The building was an older style premises with a modern extension but had been well maintained and there was an ongoing maintenance programme. The staff and relatives said there had been a lot of work recently to improve the garden areas with new garden furniture and flowers. The décor was interesting for people living with dementia and promoted their independence with accessible signage.

Apart from relating to activities and improvements needed in the medicines audit, there were effec

The service provides care and support for up to 27 people; some of who may be living with dementia. There were 24 people living at the service at the time of the inspection.

This unannounced focussed inspection took place on 10 and 15 November 2017. The inspection was prompted in part by concerns received about the care provided to people at The Firs. The information shared with the Care Quality Commission (CQC) indicated potential concerns about the management of risk of someone leaving the home who may not have been safe to do so on their own; the management of some behaviours that were challenging to others; staffing levels, staff training with respect to management of risks as well as the management of people’s safety. Concerns had also been raised about the cleanliness of the home.

Some of these concerns were not substantiated as we found the home clean. Staff had supported with relevant training. At the time of inspection we found staffing levels were meeting the needs of the people living at the Firs. However there had been occurrences in the previous two months when staffing levels were below the provider’s preferred establishment as the number of people living at the Firs had increased.

We had been made aware of an incident where one person, who lacked capacity to go out alone, had left the home without staff being aware. We had not received information about this incident from the provider or registered manager. We found that this incident had occurred and not been reported to the Care Quality Commission or to the local authority safeguarding team.

We found, at the time of inspection, there were sufficient staff to keep people safe. However, there had been a number of days during the preceding months where staffing levels had fallen below the number identified as needed by the provider. Staff understood people’s risks and needs and were confident when dealing with the management of specific incidents. We found no evidence to support the concern regarding the cleanliness of the home. However, incidents where a person had shown aggression to another person had not been reported to the local authority safeguarding team or to the CQC as they should have been. Risk assessments had not been reviewed or updated following an incident or accident to reduce the risks of a recurrence.

New staff had been recruited using safe recruitment practices. Checks were made before staff were allowed to work with people.

The team inspected the service against two of the five questions we ask about services: Is the service well led? and Is the service safe?

A focussed inspection was previously completed in February 2017 to look at safety issues at the service; at that inspection we found the service was safe. The last comprehensive inspection was in September 2016; at that inspection the overall rating for the service was good; however we found that the service required improvement in relation to the question: Is the service responsive? This was because people were not always supported to undertake activities of their choice.

Through our on-going monitoring, and during this inspection, no risks, concerns or significant improvement were identified in the remaining Key Questions, so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The service had a registered manager, who was present during the inspection. A registered manager is a person who has registered with the 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. The registered manager was an experienced manager who was working to improve the service and make it more ‘dementia friendly’.

People, relatives and staff were all very positive about the registered manager and the improvements she had implemented since she had started in the home in July 2017. People and staff had been consulted about the improvements which had led to a more ‘dementia friendly’ environment. People were also being supported to have choice about meals, snacks and drinks.

The home was, clean, well maintained and generally safe. Staff followed good infection prevention and control practices.

Incidents and accidents were reviewed by the registered manager, but this had not always led to a full consideration of how to reduce the risks of recurrence. The registered manager had failed to notify us about significant incidents including safeguarding concerns.

We have made one recommendation in relation to the monitoring of safety at the service.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were occasions when people were not fully protected against the risk of abuse and people did not always receive safe care. We also found a breach of the Care Quality Commission (Registration) Regulations 2009 as the registered manager had not notified the CQC of incidents that had occurred.

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

The Firs is registered to provide accommodation for people who require personal care. The service provides care and support for 27 people; some people are living with dementia. There were 19 people living at the home at the time of the inspection.

We carried out an unannounced comprehensive inspection of this service on 2 and 6 September 2016. At that inspection we judged the service rating to be overall good, but required improvement in the responsive domain. All other domains were rated as good. We had made a recommendation that the service sought advice and guidance on developing activities for people living with dementia.

There was a manager at the service who had started the application process of registering with the Care Quality Commission (CQC) to become the registered manager at the service. A registered manager is a person who has registered with the 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.

The provider had considered on-going possible risks to people. At the inspection we were made aware by the director and through a statutory notification submitted to CQC, about the actions they had taken. These actions did not relate directly to the incident but had been identified as sensible safety enhancements.

Following the inspection the director confirmed that the actions had been carried out. They also confirmed alarm checks had been added to the weekly maintenance checks. The manager and deputy operations manager had been working on updating the service’s environmental risk assessment.

Accidents and incidents were safely managed. Staff had recorded incidents and accidents on the provider’s computerised system and the actions they had taken. The manager was well informed about incidents and accidents at the home and looked for trends and patterns.

People’s risk assessments and care plans were detailed and gave staff instructions about how to manage and reduce risks.

The director and the deputy operations manager had been at the service since the incident to liaise with all involved. They were also supporting the manager and staff to continue with their roles to provide a service to the other people at the home.

This report only covers our findings in relation to these topics. You can read the report from the last comprehensive inspection by selecting the 'all reports' link for The Firs on our website at www.cqc.org.uk

We last inspected The Firs on 20 and 24 February 2015; the overall rating for the service was ‘requires improvement’. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to medicines administration. In our inspection in September 2016, we judged this breach had been addressed; we found improvements had been made throughout the service.

The manager at the service was new in post. They showed us they were in the process of applying to be registered with CQC. 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 manager, the provider and operations team worked closely together. The manager had begun to make improvements within the home and staff were complimentary about their approach and the changes they were making.

People living at the home told us staff were kind and caring. However, several people mentioned there was not enough to do; there was not an established range of activities to meet the social needs of all the people living at the home. Improvements were being made to the garden and some areas of the home had been refurbished and updated. There was a commitment to making areas of home a more stimulating environment to create topics of conversation between people and staff. There were positive relationships between staff and people living at the home, and their visitors. There were systems in place to protect people from harm and abuse.

Improvements in communication ensured people were kept informed about changes within the home and plans to improve the service. People living at the home knew who the new manager was and spoke positively about his practice. People were confident their concerns or complaints would be listened to and acted upon. Since our inspection, a visitor has made a complaint about some aspects of their relative’s care. The provider has investigated and sent their response to the complainant. We have asked the provider to review their response to ensure all the concerns are answered.

Recruitment practices were well managed. There were sufficient numbers of suitable staff available to meet people's individual care needs. However, staff time to support people with individual and group activities to meet their social needs was not routinely available.

The manager was aware of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They demonstrated through their practice an understanding of how this impacted in the way they worked. People were offered a choice of meals. They were supported with their health and had access to health and social care professionals, when necessary.

The manager provided an approachable style of leadership . There were systems to monitor the quality of the service, including responding to suggestions for improvements. Work took place during our inspection to address areas of potential risk in the home’s environment. The manager took these concerns seriously and these were addressed immediately.

There were 17 people living at the home. We met a number of people living at the home and spoke with three people living at the home about their experiences. We spoke with five staff and the management team. Some people were not able to comment directly on their care so we also spent time with people in communal areas of the home so we could make a judgement about how well people were cared for.

The home does not currently have a manager registered with CQC as they resigned in April 2014. When we inspected in May 2014, an acting manager had been appointed; they left the service in August 2014. When we inspected in September 2014, the provider's operations manager had taken the role of manager to provide stability to the people living and working at the service. People confirmed they knew her well and felt confident in her management skills. The provider told us the post for a permanent manager was currently being advertised.

We looked at a selection of care records and staff communication records, as well as records relating to the management of staff, the environment and quality assurance.

Is the service safe?

Steps had begun to be taken to put safeguards in place for people who were assessed as being unable to make decisions about some aspects of their lives. The acting manager considered people's individual needs and observed their routines to establish care and support to keep them safe and help them to feel safe. People looked relaxed with staff. Work to improve care plans meant staff were being provided with greater guidance to help promote a consistent approach. Improvements to the environment, such as the garden, new flooring and fitting more thermostatic valves made the home a safer place to live.

Is the service effective?

Care planning was being improved but was still work in progress. Work had taken place to ensure records, such as food and fluid charts were completed appropriately but required more effective auditing. Staff told us the acting manager was approachable and she asked their opinions about how to care for people, which they valued. They felt there was good teamwork and information was shared appropriately, which helped them work effectively. However, further work was needed to ensure the quality assurance processes were effective. For example, to ensure care plan reviews, audits and supervisions were carried out in a timely manner.

Is the service caring?

Staff were kind and caring. They adapted their style of approach to people's changing moods and care needs. People responded well to staff and appeared at ease; we saw people cuddling staff or stroking their face or holding their hands. Some people enjoyed each other's company and friendship, which staff respected and supported. Updated care plans recognised people's individuality; this approach was reflected in our discussions with staff who knew people well and respected their individual personalities and backgrounds.

Is the service responsive?

Staff told us the acting manager was responsive to their concerns and looked for solutions to improve the lives of people living at the home. There were no current concerns regarding equipment not being fit for purpose and staff were confident maintenance issues would now be addressed quickly. Care records showed staff recognised changes to people's well-being and contacted health professionals promptly and appropriately.

Is the service well-led?

Staff had a good understanding of the ethos of the home and their role in promoting good practice and reporting concerns. This helped to ensure that people received a good quality service. They praised the role of the acting manager who they described as being approachable and compassionate in manner with people living at the home. They felt she provided a positive role model and provided the staff with stability.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare because identified risks such as weight loss and food/fluid intake were poorly managed.

The behaviour of two people living at the home impacted on other people's well-being but appropriate action had not been taken to manage their care needs in a planned manner.

Staff knew their responsibility to report concerns but did not feel these had always been acted upon in the past. However, we were reassured that a concern raised during the inspection was being addressed.

We founds risks related to the environment were not well managed, including a lack of accessible call bells, the temperature of hot water and the risk from freestanding heaters.

Is the service effective?

Despite the high level of mental health needs of the people living at the home, there was little written guidance in people's care plans to guide staff to respond in a consistent manner.

There was no record of how people's individual interests were met despite their interests and hobbies being recorded as part of their original assessment. Care plan reviews did not provide a meaningful oversight of how people's social and emotional needs were met. Therefore the service could not demonstrate how people's social and emotional needs were met on a regular basis.

There was not a robust quality assurance system in place, which was acknowledged by a senior management team and we were advised changes would take place to make sure systems were more effective.

Is the service caring?

Staff spoke about people in a respectful manner and recognised their different personalities and characteristics. There were experienced staff within the team who provided good role models and knew the people they cared for well. Throughout the inspection, staff were caring and kind to the people living at The Firs.

Most people were unable to comment directly on the care they received but five people were able to tell us they felt well cared for and were happy with how staff supported them with their care. One person said 'It's ever so nice, it really is'. From our observations, we saw people looked relaxed with staff and at ease with them. People joked with staff and also showed through their body language and conversations how they appreciated reassurance from staff.

However, people who lived at the home, their relatives, friends and visitors had not been given the opportunity to complete a recent satisfaction survey or attend a meeting to enable them to share their views on their care.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes but there was poor recording of how people's social and emotional needs were met.

Is the service responsive?

When shortfalls or concerns were raised directly to the provider these were taken on board and responded to appropriately. However, some repair issues had not been addressed in a timely manner and some maintenance issues had been allowed to escalate to become a significant problem.

A visiting professional told us the home contacted them appropriately and in a timely manner. They said staff followed their advice regarding treatment. We heard staff sharing information with each other and updating one another on people's well-being. Staff said they worked well as a team, which we could see throughout the inspection.

Is the service well-led?

There have been recent changes in the staff team and there was a temporary manager in place. In this report the name of a registered manager appears. However, they were not managing the regulatory activity at this location at the time of the inspection. Their name appears in the report because they were still a registered manager on our register at the time.

The service had a weak quality assurance system, and records showed that identified problems and opportunities to change things for the better had not always been addressed promptly.

Staff told us they were clear about their roles and responsibilities. Staff had a strong commitment to provide good quality but they said could not influence the quality assurance processes, although they were clear their role was to provide good quality care.

We looked at the care records of three people who lived at the home, and the recruitment records of two members of staff. We spoke with seven people who lived at the home, six staff who worked at the home the Manager and the home owner. We spoke with three health professionals who visit the home and two relatives of people who lived at the home. People were treated with dignity and respect and were involved in making decisions about their care. The care and welfare of people who lived there was well supported by staff.

Some aspects of the safety and suitability of the premises required some improvements on the day.

People expressed their views and were involved in making decisions about their care and treatment.

People who lived at the home were offered choices.

One member of staff told us they felt the most important thing in the home was respecting people's 'dignity and respect'.

We saw that proof of identity and necessary pre employment background checks had been completed prior to the staff working at the home. This helped to ensure the safety of people who lived at the home.

All of the people who lived at the home confirmed they knew how to complain if they had a problem and would feel comfortable in doing so.