We inspected Borrage House on 18 and 26 May 2017. The first day was unannounced and we told the provider we would be visiting on the second day.

At the last inspection in May 2016 we found the provider had breached three regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to ineffective staff deployment, deprivation of liberty applications had not been managed well and evidence that people were not treated with dignity. We asked for and received an action plan telling us what the provider was going to do to ensure they were meeting regulations. At this inspection we found improvements had been made in all areas and the provider was no longer in breach of regulations.

Borrage House is a large property which consists of a Victorian main building with modern extensions. The service provides care and support for up to 40 older people, some of who may be living with dementia.

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 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 in place for the management of medicines had been developed. Staff who used them had been supported to understand how to better manage the system to enable safety.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

Risks to people’s safety had been assessed by staff and regularly reviewed to ensure they contained the most up to date information. Care plans contained information about how people preferred to be supported. This enabled staff to have the guidance they needed to help people to remain safe and receive the care they chose. People’s independence was encouraged and their hobbies and leisure interests were individually assessed. We saw there was a plentiful supply of activities and outings.

We saw staff had received training and supervision to enable them to perform their role. Some staff had received an appraisal to review their overall performance. A plan was in place to ensure each staff member received this.

People told us there were enough staff on duty to meet their needs. We found safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

There were positive interactions between people and staff. We saw staff treated people with dignity and respect. Staff were attentive and observation of the staff showed they knew people very well and could anticipate their needs. People told us they were happy and felt well cared for.

We saw people were provided with a choice of healthy food and drinks which helped to ensure their nutritional needs were met. People were supported to maintain good health and had access to healthcare professionals and services.

The provider had a system in place for responding to people’s concerns and complaints. People were regularly asked for their views. There were effective systems in place to monitor and improve the quality of the service provided.

We undertook this inspection on 25 May 2016. At the previous inspection, which took place on 25 September 2014, the provider met all of the regulations that we assessed.

Borrage House provides accommodation and care for up to 40 people, with the user bands of 'older people' and 'dementia'. Nursing care is not provided. At the time of this inspection the service was providing care for 36 people. Borrage House is close to the centre of Ripon and is owned by Anchor Trust.

There was a new manager who had been in post for two months. They were not yet registered with the Commission, but had submitted an application to register and were going through the registration process. 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 service had experienced a period of time when it lacked consistent leadership and management. However, during this inspection people were positive about the new manager and their impact so far.

Governance systems were in place to monitor service safety and quality. However, some areas needing improvement had not effectively been recognised or addressed. The new manager showed us that an action plan was now in place, with evidence that the they had identified the home's priorities and was making progress.

The service had not effectively implemented the Deprivation of Liberty Safeguards (DoLS). This meant that some people had been deprived of their liberty without the required authorisations being in place. The new manager had recognised this and was in the process of taking action to put things right.

Although most people spoke well of individual staff and told us that staff usually treated people well, we observed two occasions when people’s privacy and dignity was not maintained during manual handling procedures.

Processes were in place to assess the staffing levels that were needed, based on people’s dependency and the lay out of the building. However, people told us that there had been occasions when they had to wait for staff assistance and our observations showed that the deployment of staff was not always effective.

The service recruited staff in a safe way making sure all necessary background checks had been carried out. Records showed staff received the training they needed to keep people safe and the new manager had taken action to ensure that any additional training and support staff needed had been planned.

The service was generally well maintained, clean and comfortable. However, there were some on-going issues with the fire alarm panel and door closures that the provider was working to rectify. Temporary safety measures had been put in place while this was done.

People told us they felt safe. Staff knew the correct procedures to follow if they considered someone was at risk of harm or abuse. They received appropriate safeguarding training and there were policies and procedures to support them in their role. Risk assessments were in place to identify risks due to people’s health or mobility and to make sure these were minimised.

Medicines of people living at the service were managed safely. Staff had received the appropriate training and checks took place to make sure medicines were given safely. However, more written guidance information about medicines prescribed 'as required' would help to ensure that these were managed consistently.

People had their care needs assessed and planned, and reviews took place to make sure people received the right care and support. However, the information in people’s care plans was not as person centred and detailed as it should be.

We received positive feedback from healthcare professionals who worked with people who lived at the home.

People told us the food

At the time of our inspection 36 people were using the service. Below is a summary of what we found.

We spent time speaking with people who lived at Borrage House as well as speaking with relatives and staff. We spoke with the provider/manager and we reviewed records and spent time observing people in the home. If you want to see the evidence that supports our summary please read the full report.

We considered all the evidence we had gathered under the regulations we inspected. We used the evidence to answer the five questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people who lived there. We spent time observing people and noticed that they were cared for safely. Every member of staff we spoke with said that they were happy with staffing levels and said that these helped to provide safe and appropriate care.

Staff records demonstrated that mandatory training was up to date and that staff were trained to meet the needs of people. Staff were trained in the care of people with dementia, moving and handling and safeguarding.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

During our visit we spent time observing people and staff. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well. For example, we noted that staff were able to tailor the way they spoke to each person, particularly their sense of humour and speech, to be able to make each person feel listened to and important.

People were cared for by staff who were supported to deliver care safely and to an appropriate standard. Staff had received training to meet the needs of the people living at the home and told us that they were able to put their training into practice.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people, especially when they needed help moving around and to eat. Staff took into account the needs of people when planning activities so that they could take part in these safely. Staff told us that they worked hard to make sure their training was applied to the individual needs of people so that they could be supported to take part in activities important to them.

Staff said that they were very happy with the level of professional and emotional support they received from the management team.

Is the service responsive?

People's needs had been assessed before they moved into the home and these were checked by regular reviews, in which they were involved. People's needs assessments included an assessment of their capacity to make decisions as well as consideration of their dietary and nutrition requirements.

People's preferences and interests were acted on by staff who used monthly meetings to support people to meet their needs and goals. People had access to activities that were designed to stimulate them and they were able to influence the running of the home.

Is the service well led?

There was a manager in place who was registered with the Commission as the manager of this location, in line with the requirements of the registration of the service.

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us that they were clear about their roles and responsibilities and that management support helped them to do their job effectively. One person spent time talking with us and told us how supported they had felt by staff. The person said, "[Staff] talk to me nicely and I always feel like I'm important to them."

Our inspection of 16 May 2013 found that people did not always experience care and support that met their needs. For example, weight loss had not been followed up for two people and we found examples of care records not being kept up to date and accurate. We also found that people were not protected against the risks associated with medication because safe arrangements were not in place.

At this inspection we found that improvements had been made and this was confirmed by the people we spoke with. We also saw written evidence that action had been taken to address the shortfalls previously identified.

Therefore, people were receiving care and attention which met their needs and people were protected against the risks associated with medicines, because the provider had appropriate arrangements in place to manage the administration of medicines safely.

One person who used the service told us, “It is lovely here. We are taken care of very well.” Another person told us how the staff made sure they received their medication on time and that they thought ‘care was very well organised.’ We observed staff supporting people and offering assistance as needed. This was done in a calm, professional and organised way.

Staff were spoken about in a positive way by people who used the service. They were described as kind and thoughtful. Without exception, people gave us the impression that their experiences at Borrage House were positive and that they received a good standard of care.

We visited the home during the early hours to gain a wider view of the service provided, we arrived at 04:15am. This was part of an out of normal hour’s pilot project being undertaken in the North East region.

Some people were not able to tell us about their experiences. We therefore used a number of different methods to help us to understand the experiences of people. We spoke with six people who used the service and two visitors. Everyone we spoke with told us the care and support at the home was good. However, people were not protected against the risks associated with medicines because appropriate arrangements were not in place to manage the administration of medicines safely.

Overall people’s care plans contained a level of information that ensured their needs were being met. However, not all information was being followed up. For example where people who had lost weight and records did not accurately reflect the care being given. This meant that peoples care needs could be overlooked and we could not be assured that proper care was being given.

We saw records that showed people were involved in developing their care plans and that relatives or their representatives had been involved, where necessary.

There were enough qualified, skilled and experienced staff to meet people’s needs. We saw how staff supported people, at their own pace, to make sure they knew how best to meet a person's need.

There was an effective complaints system in place.

We engaged in conversation with 15 people and one visitor. Everyone said they were satisfied and happy at Borrage House. One person said; "We get excellent care here, we are very well looked after.” Other comments included; “The staff are sensitive when they help me dress and undress, they try to look away or make sure I am covered up.” Nine people said they were involved in their care, with their preferences being sought and taken into consideration. This included being enabled and supported to live their lives as independently as they wished.

People who were able to comment told us that they were happy with the care and treatment they received. One person said; "When I need attention I use my alarm, a red light comes on outside and they come straight away. ”Another person said; “I am truly happy here. The care is very good.” One person said; “I want for nothing, it is all here.” A visitor told us; “They are in good hands here, it is well run.”

People told us that they found staff to be 'kind, appropriately trained and competent.'