About the service: Bluebell House is a residential care home that was personal to 26 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

People said they felt safe and well cared for by a staff team who understood their needs. Staff said they had sufficient training and support to do their job effectively. They knew people’s needs, wishes and what was important to them.

Most but not all risks had been assessed and plans in place to mitigate identified risks. Risks to some hot water outlets had not been fully risk assessed, although the provider was addressing this by installing mixer valves which would prevent hot water reaching a temperature which was a risk of scalding.

Care and support were well planned and there were enough staff to meet people’s assessed needs. People were treated with kindness and respect.

People benefitted from the food and fluid being carefully monitored and by being offered a variety of meals, snacks and drinks throughout the day.

People’s medicines were not always managed safely.

There were a range of activities which people enjoyed. This included regular visits from local school children, which people really enjoyed and looked forward to.

People were supported in the least restrictive way possible; the policies, systems and culture in the service supported this practice.

People said they were listened to and could make their concerns known, but these were not always recorded.

Rating at last inspection:

At the last inspection the service was rated as Requires Improvement (The last report was published January 2018). At this inspection the overall rating remained as Requires Improvement. This was the third time the service has been rated as requires improvement.

Why we inspected:

This was a planned inspection to look at improvements the service had made following the previous rating. At this inspection we found improvements had been made in the areas we identified previously. Care plans were now more detailed and contained more individualised content. There were more meaningful activities and people appeared engaged and well cared for. However, we found other areas which required improvement. Medicine management was not robust and placed people at risk. Following our initial feedback, the manager completed an audit of all medicine records and stock and had made some changes to systems. They had also addressed this with senior care staff. Hot water temperatures on some sinks were in excess of what is considered safe for vulnerable people. This had not been risk assessed. The service was in the process of fitting regulator valves to prevent water being too hot and therefore reduce the risk of possible scalding. However, at the time of the inspection, this risk remained.

Enforcement: Action we told the provider to take. We have made one requirement notice in relation to regulation 12- safe care and treatment. You can see this in full at the end of the report.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned based on the rating. If we receive any concerns, we may bring our inspection forward.

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

This focussed inspection took place on 7 February 2018 and was unannounced. When we completed their last comprehensive inspection on 19 September 2017 we found there were breaches of legal requirements in regulation 9 - person centred care, 12 -safe care and treatment and 18 of the Registration Regulations 2009 - notifications of other incidents. We issued requirement notices for these three breaches. We also found a repeated breach of regulation 17-good governance so we issued a warning notice. This sets out the evidence we found to show the breach and gave the provider a timeframe by which they needed to make improvements to meet this regulation. We are also met with the provider on 23 February 2018 to discuss their actions to improve this service and two other services they provide at other care home locations.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, responsive and well-led to at least good. During this inspection we found improvements had been made to the detail of care plans which enabled staff to provide more personalised and consistent care. We found health conditions and people’s preferred routines and likes and dislikes had been more clearly recorded. Risks were being clearly monitored and risk assessments detailed what staff should do to mitigate any risks identified. A new activities person had been employed who was providing a programme of activities throughout the week both in groups and to individuals, depending on their wishes and interests. We checked the accident and incident reports and found they linked to whether a notification had been sent to CQC. There were no gaps in reporting.

Where we had previously identified gaps in the quality assurance and audits to ensure people were kept safe, these had been rectified. Hot water was being regularly monitored to ensure it was not a risk of scalding people. The medicines storage areas were being more closely monitored to ensure the temperature did not rise above the recommended level. The provider had installed a cooling unit to the medicines storage room which helped to keep the temperature at a consistent level. The audits were being overseen by the manager and provider, who had increased their visits to the service.

No risks, concerns or significant improvement were identified in the remaining Key Question through our ongoing monitoring or during our inspection activity 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.

Donnington 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. Donnington House is registered to provide personal and nursing care for up to 36 people. They provide care and support for frail older people and those people living with dementia, but do not provide nursing care. On the day of the inspection there were 18 people living at the home.

Since the last inspection the registered manager has resigned. The provider’s compliance manager was providing management cover over four days per week, whilst they are recruiting a new 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.

Just prior to Christmas we received some information of concern about staffing levels and we asked the provider to send us some information. They staffing levels had fallen below their preferred levels but this was due to staff sickness

This inspection was a comprehensive inspection took place on 18 and 19 September 2017. At the last comprehensive inspection, completed in June 2016, we rated the service as overall requires improvement. We issued two requirements in relation to regulation 9, person centred care and regulation 17 – good governance. The service sent us an action plan to show how they intended to meet these requirements but did not give specific timescales.

At this inspection, we found there had been some improvements in relation to planned activities for people, but this was not consistent. We found people were still spending large parts of the first day without any engagement. In relation to regulation 17 we found little had improved and this continued to be a breach. This was because audits and systems for checking the quality of care and support delivered had not identified the number of issues we found, such as care plans not updated or missing important details and records of medicine storage showing medicines were being kept in temperatures above the recommended temperature.

Prior to completing this inspection we received some information of concern from the local safeguarding team who had collated a number of safeguarding alerts and concerns. These centred on healthcare professionals raising concerns about the service not requesting emergency medical assistance in a timely way and poor communication. There was also an alert raised by a relative about lack of stimulation for people.

Donnington House is registered to provide personal and nursing care for up to 36 people. They provide care and support for frail older people and those people living with dementia, but do not provide nursing care. On the day of the inspection there were 18 people living at the home, including one person who was having a short break there.

There was a registered manager who has been in post for a number of years. They are also the registered manager for the providers other home situated next door. 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 were at risk of receiving inconsistent or inappropriate care. This was because not everyone had a care plan covering all aspects of their needs. This meant staff did not always have a guide about how best to plan and deliver people’s care and support. For example in working with people living with dementia and associated agitation. Care plans were not person centred and did not always reflect people’s needs, preferences, interests, hobbies or past lives. This meant staff would have limited knowledge about people and events that were important to them, and would limit what staff could talk to people about.

Healthcare needs were not always being well planned for. Care plans lacked detail about how staff should respond to someone with epilepsy for example. One person’s plan had not been updated in respect of their wound care and pressure sore, which had in fact healed but their plan did not reflect this.

One of the medicine trolleys was situated in a space which was too warm to be able to ensure that effectiveness of medicines would not be compromised. Despite the service regularly monitoring, the temperatures in the trolley being above the recommended temperature no action had been taken. We had identified a similar issue in the inspection completed in June 2016. Once we fed this back, the trolley was moved to a cooler area downstairs, next to another medicines trolley. However this also had high temperature reading in the warmer months.

Risks of scalds from hot water outlets had not been checked, to ensure hot water temperatures were maintained with recommended safe limits.

People, relatives and staff felt their views wer

This inspection was unannounced and took place on 22 and 23 June 2016. Donnington House is registered to provide care and support, which does not include nursing, for up to 36 people. At the time of this inspection there were 27 people living at the service.

When we last inspected this service in May 2015 it was rated overall requires improvement. We issued a requirement notice cause we found there were not sufficient staff available at key times to meet people’s needs. We also highlighted that their mental capacity assessments were not decision specific. Care plans did not show how people were involved in the development and review of their plans. Following the inspection, the registered manager sent us an action plan to show how she would address the requirement relating to staffing.

At this inspection we saw there had been a small increase and changes in rota patterns to ensure there were sufficient staff available at lunch times. They had also purchased a hot trolley to ensure food would be kept warm if people needed to wait for assistance with eating their meal. Improvements had also been made in respect of ensuring mental capacity assessments were decision specific. Where possible they had made sure people or their relaitves had signed to show they were involved in the review of their care plan.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2014 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection, applications had been had been made to the local authority in relation to people who lived at the service. The registered manager told us these were waiting to be approved. We saw that where mental capacity assessments had been completed, these were now more decision specific.

Recruitment processes showed only staff were employed who were suitable to work with vulnerable people. Staff understood how to keep people safe following risk assessments, using the right equipment and reporting any concerns.

People’s medicines were being well managed, which included written guidance to tell staff when they should consider an as needed medicine (PRN) for people who lacked capacity. The room medicines were stored in was too hot to ensure medicines were fully effective. Following our feedback the medicines were moved to a cooler room.

Staff received training in all aspects of health and safety as well as understanding the needs of older people and dementia. Staff had support and supervision to help them understand their role and do their job effectively. Staff said they felt valued and listened to.

People said they felt safe and well cared for. Staff knew people’s needs and preferences. One person said ‘‘Staff have been very kind to me. They are lovely.’’ Another reported, ‘‘I can’t fault the staff who work here, all very good.’’ One relative said they were always made welcome and that they believed staff were kind to their relative. They said ‘‘I do believe (name of relative) does get good care. The staff are always caring when I visit.’’

Staff knew how to protect people from potential risk of harm and who they should report any concerns to. They also understood how to ensure people’s human rights were being considered and how to work in a way which respected people’s diversity.

Care and support was being well planned for people’s health and pers

We met and spoke with most of the 28 people who used services, spoke with seven relatives, talked with the staff on duty and checked the provider's records. One person using the service said “They (staff) are very kind”.

Before people living in the home received any care or treatment they were asked for their consent and staff acted in accordance with their wishes. Throughout our visit we saw staff involving people in their care.

We saw people’s privacy and dignity being respected at all times. We saw and heard staff speak to people living in the home in a way that demonstrated a good understanding by staff of people’s choices and preferences. When asked, one person living in the home confirmed that the staff “always asks me if I am ready to get up and if I want a cup of tea”.

Staff we spoke with were clear about the actions they would take should they have any concerns about people's welfare.

We looked at care records for four people living in Donnington House. We spoke with staff about the care given, looked at records relating to them, met with them and observed staff working with them.

We saw that people's care records described their needs and how those needs were met. We saw that people's mental capacity was assessed to determine whether they were able to make particular decisions about their lives.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. We spoke with most of the staff working during our visit. Many of the staff had worked at the home for a number of years with one saying "we are like a family here".

As part of the quality monitoring system people who lived in the home and their relatives were sent surveys to complete. These surveys asked their views of the home. Improvements were made in the home following the results received.

We visited Donnington having received some information of concern. We looked at outcomes relating to the information we received.

Many people at the home lived with dementia. People who were able to tell us their experiences, and two people's families, spoke highly of the service. Comments included, "The staff are brilliant. You can't fault them" ; "(The manager) would deal with any problem" and "Xxx is lovely. She seems to be very patient with people". We observed care workers providing sensitive and respectful care to people who were confused and anxious.

Two health care professionals said they had no concerns and people's health was promoted. They said that the standards of personal care people received ensured their hygiene and dignity. However, one person's nails had not been kept at a safe length, which had caused a minor injury.

Comments about the food provided were varied and included, "Cannot be faulted" and "Passable". We found that people received adequate amounts of food and liquids, that there was a varied diet provided for them and dietary needs were monitored.

People said that the manager would deal with any concerns. However, there was almost no understanding amongst staff of the safeguards which should protect people who lack the mental abilities to make decisions about their welfare and staff lacked knowledge of local arrangements to protect people from abuse. This meant that people might not be protected or their rights upheld.

We carried out a review with an inspection to Donnington House

on 26th March 2012 and we looked the key outcomes covering respect and involvement, care and welfare, safeguarding people from abuse, staff support and assessing and monitoring the quality of the service. The purpose of this review was to check compliance in these key outcome groups for people currently living in the home.

Some of the people that use the service at Donnington House have dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us about their experiences and we also spoke with visitors to the service and other health professionals.

We spoke to five people who were able to give us feedback. They told us that their needs were being met, with comments like “You couldn’t find a better place”. Care workers are described as “kind” and “very caring”.

We met four visitors. Families of people living in the home said that they feel very involved and “always made welcome”. They also said that the care workers “are so nice and have so much patience with people” and “it’s always lovely no matter what time we come”. One relative remarked that they had seen a huge improvement in the running of the home and commented “it’s much better than when he first moved in”.

A professional told us that the team were “very helpful and made sure I had everything I needed” as they were visiting a person. They also told us that there were “plenty of staff” at the home.

Overall, we found that Donnington House is a well run home that is constantly improving the quality of service that people experience.

This inspection was unannounced and took place on 11 and 15 May 2015. The inspection was brought forward in response to some information of concern the Care Quality Commission (CQC) received in relation to staffing levels being low.

Donnington House is registered to provide accommodation for up to 36 people requiring personal care. They do not provide nursing care. There is a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People living at the home felt safe and well cared for, although there were periods of time where people were left unattended and may not have been fully protected. At lunchtimes there were not always sufficient staff to meet everyone’s needs. For example some people needed additional support and encouragement to eat their meals. This support was not always available in a timely way.

Activities had started to be planned around people’s interests where possible. For example they had recently started a weekly knitting group. There were some paid entertainers who visited the home on a regular basis and staff tried to fit in activities during quieter periods, but this was ad hoc and needed more structure.

Care was planned and being delivered by a staff group who understood people’s needs but there were key times when there was not sufficient staff to meet people needs in a timely way.

Risks were being managed and reviewed in line with people’s changing needs. For newer people to the service, care planning was taking place over a period of a few weeks. In the interim, staff had the person’s pre admission assessment and any care plans and assessments from the funding authority.

Staff understood people’s needs and could describe their preferred routines. Health care needs were being monitored and advice sought from GPs, community psychiatric nurses and other health care professionals when needed. One healthcare professional described the service as being ‘‘Receptive to training’’ another said ‘‘We are often called in for falls and traumatic skin flaps.’’

Medicines were managed appropriately and people received their medicines appropriately and pain relief when required. Staff reported that they felt well supported and had confidence in the management team. Staff felt their concerns, ideas and suggestions were listened to and acted upon. There was a planned training programme covering all aspects of health and safety and some more specialised areas such as working with people with dementia care needs and care of the dying. Staff had regular opportunities to discuss their work and receive support and supervision.

Systems were in place to ensure people and their family had opportunities to have their views heard both formally and informally. Relatives reported they were made to feel welcome and had opportunities to talk to staff and management about concerns or ideas

We found one breach of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report