The inspection took place on 16 October and was unannounced.

Blossom House 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.

Blossom House provides accommodation for up to 31 people. At the time of our inspection, there were 26 people living in the home. This home provides a service to older people, including people living with dementia, a physical disability or a mental health need. The service was arranged over three floors, with bedrooms on each floor. There was a mix of single and double bedrooms and communal bathrooms on each floor. The service had three lounge areas for people to use, a large dining room conservatory and an accessible garden.

There was a registered manager at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection of the service, in February 2018, the service was rated ‘Inadequate’ overall and we identified breaches of Regulations 9, 11, 12, 17 and 18 of the Health and Social Care Action 2008 (Regulated Activities) Regulations 2014. We found the following concerns; people did not receive person-centred care which met their needs, people’s rights had not being protected in line with the Mental Capacity Act 2005, risks to people’s health and safety had not always been identified and assessed, systems and processes to assess and monitor the service were not effective and there were insufficient levels of staff.

At this inspection, we found that significant action had been taken to address these issues and there were no longer any breaches of Regulation. However, some areas of further improvement were identified and there was a need for embedding of improvements to be sustained.

Quality assurance systems were in place, based on a range of audits. However, we found these were not always effective and had not identified the concerns raised during the inspection.

Staff did not have a clear understanding of legislation to protect people’s freedom and staff were not able to identify which people living at the service were subject to restrictions in law.

Information and guidance for staff about people’s nutritional and hydration needs was not always fully recorded in people’s care plans, which meant staff could not easily identify if people’s needs were being met.

People’s care plans had been completely re-written since the previous inspection, however we identified that information was not always consistent and further improvement was needed.

There were sufficient levels of staff available to ensure that people were cared for safely.

Individual and environmental risks to people were managed effectively. Risk assessments identified risks to people and provided clear guidance to staff on how risks should be managed and mitigated.

People felt safe living at Blossom House. Staff knew how to keep people safe and how to identify, prevent and report abuse. They engaged appropriately with the local safeguarding authority.

People received their medicines safely, as prescribed, by staff who were trained appropriately to do so. There were comprehensive systems in place to ensure the safe ordering, storage and disposal of medicines.

Staff received a variety of training and demonstrated knowledge, skill and competence to support people effectively. Staff were supported appropriately by the management of the service.

People were cared for with kindness and compassion. Staff had developed positive relationships with people and their relatives and knew what mattered most to them.

Staff took action

The first day of inspection took place on 15 February 2018 and was unannounced. On 16 February 2018 two inspectors undertook an announced further day of inspection. The inspection was prompted in part by concerns raised by whistle-blowing notifications alleging concerns about people’s care.

Blossom House provides accommodation and personal care for up to 31 people, the service does not provide nursing care. There were 28 people living at the home when we visited. The home had two floors with 19 ground floor bedrooms and five bedrooms on the first floor accessed by stairs and a stair lift. The ground floor comprised of seven double and 14 single bedrooms. There were communal areas on the ground floor and an accessible garden.

Blossom House 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. We found the home to be clean and tidy throughout the inspection.

The home 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.

Since 2015, all comprehensive inspections of the service had found regulatory breaches. The last comprehensive inspection of this service was in April 2016 when two regulatory breaches were found. The service was rated as Requires Improvement in Well Led and Good overall. In May 2017 we undertook a focused inspection to check on these breaches and found sufficient improvements had been made and there was no rating change.

At this comprehensive inspection we found five breaches of regulations. This was within nine months of the focused inspection in May 2017; this demonstrated that the provider of this service was unable to sustain improvement in the long term. There were systemic failings identified during this inspection which had already been identified at the last two comprehensive inspections of the service. All five regulatory breaches from the comprehensive inspection in January 2015 were repeated. Failures to provide safe care, treatment, person centred care, staff training, good governance and failing to act in accordance with the Mental Capacity Act 2005 were common themes. A further two breaches in respect of dignity and respect and premises were found.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Quality and safety monitoring systems were ineffective in identifying and directing the service to act upon and mitigate risks to people who used the service and ensure the quality of service provision.

Staffing was not planned effectively. There were not enough staff to meet more than people’s basic personal care needs; staff were task orientated and did not spend one to one time with people.

Care plans were not consistently person centred and lacked detailed guidance for staff to ensure people received care in a safe way. Risk assessments that related to people’s health and safety did not ensure that all risks were effectively assessed. Action had not always been taken to reduce identified risks to ensure the safety of people. This exposed people to a risk of neglect and unsafe or inappropriate care or treatment.

Records relating to the management of the service had not been effectively reviewed and assessed; we found errors, omissions and discrepancies that had not been identified by the registered manager’s quality assurance systems.

The administration, safe management and security of medicines were in line with best practice. Topical creams had not always been recorded as applied and had not been audited to highlight this.

Records of t

We carried out a comprehensive inspection of this service on 18 and 28 April 2016. We found two breaches of regulations relating to maintaining a safe environment for people and keeping accurate and up to date records. We gave the service an overall rating of good. The rating for the key area well-led was requires improvement. We told the provider to send us a report by 12 October 2016 of actions they proposed to take to make the necessary improvements. Their report stated they would complete their actions by the end of October 2016 with “ongoing assessments” of records by the registered manager.

We undertook this focused inspection as part of our regulatory functions under Section 60 of the Health and Social Care Act 2008 to check whether the provider’s actions had been sustained and to confirm whether they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the “all reports” link for Blossom House on our web site at www.cqc.org.uk.

This focused inspection took place on 31 May 2017. It was unannounced.

The previous comprehensive inspection in April 2016 found the provider was not meeting the requirements of regulations concerning the safe maintenance of premises and equipment and maintaining up to date and accurate records concerning people’s care and support. This inspection found that improvements had been made in both areas. The provider was now meeting the requirements of the regulations and showed the characteristics of a well led service.

Blossom House is registered to provide personal care and accommodation for a maximum of 31 older people. At the time of our inspection there were 29 people living at the home. Accommodation was on two floors in a mixture of single and shared rooms. Shared areas of the home included a lounge, dining room, conservatory, quiet lounge and an enclosed garden. Access to some of these areas was restricted as refurbishment and improvement works were in progress.

The service had a registered manager in place. A registered manager is a person who has registered with us 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 had started work since our last inspection when there was no registered manager in place.

The registered manager had taken steps to improve the consistency, accuracy and currency of records relating to people’s care and support. A computer based system for care planning was deployed and in use. This meant people could be confident their care and support met their needs and reflected their preferences.

The provider had completed actions required by Hampshire Fire and Rescue Service, and received confirmation from them that Blossom House was “broadly compliant” with the relevant fire safety regulations. This meant people could be reassured that risks associated with an emergency evacuation were reduced and managed.

The inspection took place on 18 April 2016 and 28 April 2016. It was unannounced. At our previous inspection in January 2015 we found breaches of five of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponded to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were to do with providing care and support that met people’s needs, meeting the requirements of the Mental Capacity Act 2005, managing risks to people’s safety and welfare, supporting staff and having effective systems to monitor service quality. We also made a recommendation about respecting people’s privacy and dignity. The provider sent us an action plan describing how they intended to meet the requirements of these regulations by 30 November 2015. At this inspection we found the provider had made sufficient improvements in these areas. However, we found new breaches of two regulations.

Blossom House is registered to provide personal care and accommodation for a maximum of 31 older people. At the time of our inspection there were 28 people living at the home. Accommodation was on two floors in a mixture of single and shared rooms. Shared areas of the home included a lounge, dining room, conservatory, quiet lounge and an enclosed garden.

At the time of our inspection there was no registered manager at Blossom House. 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.

Systems were in place to make sure the service was managed efficiently and to monitor and assess the quality of service provided. However the provider did not always make sure that required maintenance to the building and equipment was arranged in a timely manner. People’s care records were not always complete, accurate and up to date.

The provider had arrangements in place to protect people from risks to their safety and welfare, including the risks of avoidable harm and abuse. Staffing levels were sufficient to support people safely. Recruitment processes were in place to make sure only workers who were suitable to work in a care setting were employed. Arrangements were in place to store medicines safely.

Staff received appropriate training and supervision to maintain their skills and knowledge to support people according to their needs. Staff were aware of and put into practice the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were supported to eat and drink enough to maintain their health and welfare. People were supported to access healthcare services, such as GPs and community nurses.

People had caring relationships with their care workers. They were encouraged to take part in decisions about their care and support and their views were listened to. Staff respected people’s independence, privacy, and dignity.

Care and support were based on assessments and plans which took into account people’s needs and preferences. People were able to take part in leisure activities which reflected their interests if they wished to do so.

The home had an open, friendly atmosphere which encouraged people to make their views and opinions known.

We found two breaches 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 end of the full version of this report.

We carried out this inspection as part of our routine inspection programme to answer our five questions. Is the service safe, is it effective, is it caring, is it responsive and is it well led? The inspection was carried out by a single inspector. At the time of our inspection there were 25 people using the service. We spoke with five of them and three visitors in order to understand the service from their point of view. We observed the care and support people received in the shared areas of the home. We looked at records and files. We spoke with the registered provider, the registered manager and three members of staff.

This is a summary of what people told us and what we found.

Is the service safe?

People told us they felt safe and comfortable in the home. They said they had good relationships with staff. A visitor said the staff were “wonderful” and their loved one was “in safe hands”.

We found there were sufficient staff employed to support people safely. The provider had effective recruitment processes and undertook the necessary checks to ensure staff employed were suitable.

We saw staff were mindful of people’s welfare and safety. Appropriate risk assessments were in place. People were assisted to move around the home safely. If equipment used required two members of staff, two care workers were available.

Is the service effective?

People told us that they were satisfied with the care and support they received. One person said, “It’s very good. I have no complaints.” Visitors we spoke with were satisfied with the care their loved ones received.

We found people’s care and support were based on assessments of their needs. Care plans were detailed and personalised. Systems were in place to ensure care was delivered according to people’s plans.

We found day to day care was delivered with people’s consent. However the provider was not following legal guidance where people did not have the capacity to consent. We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to mental capacity assessments and best interests processes.

Is the service caring?

People using the service and their visitors told us they got on well with their care workers and other staff and had a good relationship with them.

Staff we spoke with were motivated to provide good care. They knew about people’s needs and how they preferred to have their care delivered.

We observed positive, friendly interactions between staff and people who used the service. Staff took time to make sure people understood, spoke clearly and made eye contact with the person they were talking to.

We found people were involved in decisions about their care and treatment. They were treated with dignity and respect, and their preferences were taken into account. People’s independence was promoted as much as possible.

Is the service responsive?

People told us staff listened to them. People’s care plans were individualised and amended as people's needs changed.

We found the service had systems in place to ensure the care provided was appropriate to people’s changing needs. People were supported by other healthcare providers as appropriate.

Is the service well-led?

Staff told us they were supported to deliver quality care. People who used the service were satisfied with the care and support they received.

We found risks were assessed and appropriate action plans were in place in people’s individual care plans. Effective systems were in place to regularly assess and monitor the quality of service provided. The provider sought the views of people using the service and others. Incidents, accidents and complaints were handled appropriately and lessons were learned.

At the time of the inspection 25 people lived at Pear Tree Lodge. We spoke with four people who used the service and relatives of three people who were visiting that day. One person who used the service said it “the staff are good. I wouldn’t change a thing”. A visiting relative said “I absolutely love it here – they are like my family. It is second to none.”

We spoke with three care staff on duty, the cook and kitchen assistant as well as the manager and the deputy manager. One member of staff said they particularly enjoyed the activities such as singing, both planned and impromptu. Another said “It is a good staff team. The management are supportive and always there when you need them”.

We also spoke with a Qualifications and Credit Framework (QCF) assessor. They told us “It’s a lovely friendly home. The managers are very supportive of staff training, and that enables me to do my job.”

We reviewed care records for three people who used the service. We found that people who lived at the home experienced safe and effective care because their needs were assessed and reviewed, and care plans kept current.

People were protected from the risks of unsafe use and management of medication because there were effective systems and processes in place.

People could choose from a varied menu and had the support they needed to help them eat and drink.

People using the service benefited from a staff team who were well trained and supported to do their job.

The focus of our visit was to follow up the improvements required on cleanliness and infection control identified as needed from our inspection in October 2012. At this visit (February 2013), we found that improvements in the service had been made, so that people who use the service were protected from the risk of infection because guidance had been followed. We spoke with three relatives and four people who use the service and they told us the home was clean and tidy.

We spoke with six people who used the service and observed people being supported by care staff. People using the service spoke positively about the care provided at the home. We spoke with three relatives who told us that members of staff were caring and kind. People’s records detailed the care and support individuals required. Care and support plans covered a range of topics and included how to continuously monitor people’s health. People we spoke with told us that there were enough staff at the home. Staff working at the home told us they were well supported and trained to meet the needs of people. The service had an effective quality assurance system which provided people using the service to comment on the service they received.

We spoke with three relatives who told us that they were “delighted” with the service provided by the home. Three relatives told us that members of staff were “helpful” and “spent time with people.” They also told us that there were activities for people to get involved in and that the home had a good atmosphere. We spoke with three relatives who told us that the home was clean and “spotless.”

This inspection took place on 28 and 29 January 2015. It was unannounced. At the time of our inspection the location was called Pear Tree Lodge. The provider has since changed its name to Blossom House.

At our previous inspection in July 2014 we found Pear Tree Lodge was not meeting minimum standards in relation to people who did not have capacity to make certain decisions about their care and support. On this occasion we found improvements had been made but the improvements were not sufficient to meet minimum standards according to the regulations.

Pear Tree Lodge provided personal care and accommodation for up to 31 older people. At the time of our inspection there were 28 people living at the home. The registered manager told us they were all living with dementia. Accommodation was arranged on two floors in a combination of single and shared rooms. Shared areas of the home included a lounge, dining room, quiet lounge, conservatory and enclosed garden.

Procedures for the storage and administration of prescribed creams and ointments did not make certain these medicines were kept safely and people received them as prescribed. Other medicines were stored, handled and recorded safely.

The provider had taken steps to make sure staff knew how to protect people against the risk of abuse and avoidable harm. Risk assessments were in place. They were designed to protect people without restricting their freedoms, but they were not always up to date and followed. People did not always receive care and support according to the plans designed to protect them against risks.

There were enough staff to care for people safely, and the provider carried out the required checks before staff started work.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. We found Pear Tree Lodge to be meeting the requirements of the DoLS. Where people lacked capacity to make certain decisions, staff were not guided by the principles of the Mental Capacity Act 2005 to ensure decisions were made in the person’s best interests.

People were supported by staff whose skills and knowledge were not kept up to date by timely and relevant training. Staff were not well supported by a system of supervision and appraisal, but informal support was available to them.

People were supported to maintain a healthy diet. They had access to healthcare services when they needed them.

People’s privacy and dignity were not always respected when they had a visit from a healthcare professional. Staff did not always make sure people had their own clothing in their wardrobe.

Staff engaged with people in a caring way, took time to engage with them and were attentive to their needs. Staff encouraged people to be involved in decisions about their care and support.

People did not always receive care that was responsive to their needs. Their care plans and assessments were not always complete and kept up to date when their needs changed.

People could take part in a variety of leisure activities and entertainments, but these did not always reflect their individual interests and hobbies.

The registered manager and staff listened when people raised concerns. The majority of people’s complaints were dealt with and improvements made to the service they received.

There was a homely, happy and informal atmosphere at Pear Tree Lodge. However the management style was informal and lacked structure. Processes to monitor and assess the quality of service provided were not effective.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see the action we told the provider to take at the end of the full version of this report. We also made a recommendation with respect to respecting people’s privacy and dignity.