This unannounced comprehensive inspection took place on 29 May and 7 June 2018.

Chelfam 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.

Chelfam House accommodates to a maximum of 41 people, the majority of whom are living with dementia. There are 38 bedrooms, mostly single rooms many with en-suite facilities, over three floors. The main premises was not purpose built but there is a purpose built extension added. There were 38 people using the service at the time of the inspection.

There is 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.

At our last inspection in October 2015 we found the service was meeting the required standards and was rated Good. At this inspection we found the service was not meeting all the required standards.

The audit and monitoring systems in place did not always ensure people receive a safe, effective, responsive and caring service. People were put at risk because staff were not always available to support and care for them. The premises was not always clean, fresh and hygienic. However, this was improved during the inspection. Staff put people at risk by giving them very hot food and drink. People were found in undignified situations, such as left in wet clothing. Unclaimed or no longer needed underclothes were kept for other people to wear. One staff member ignored a call bell that had been ringing for a long time. We found that people had their liberty deprived without lawful authorisation.

We have made recommendations in relation to looking at improvements relating to medicines management, the layout and use of the premises and providing a dignified and respectful service. Recruitment was not fully robust as one check had not been completed.

Staff struggled to understand the full concept of person centred care. Activities were not always meaningful to the person as an individual although there was a range of shared activities and events.

Care plans did not always provide clarity on how staff should deliver care. Fire safety had been compromised, but this was also addressed prior to the end of this inspection.

Staff had a good understanding of how to protect people from abuse and people were protected from discrimination. People’s nutritional needs were fully met and there was a varied menu available to them.

People’s physical care needs were fully met. No agency connected with the service had concerns about the service. The community nursing team praised the care provided. A district nurse said “The care is very good. Staff are alerted to the slightest concern. I have no concerns. Staff knowledge is good and staff are really good at contacting the surgery.” Staff praised their training, which was broad and at times innovative in its approach. Care workers received supervision of their work and felt supported. The registered manager said they needed to address the training and supervision of ancillary staff.

The registered manager had been progressive in finding ways to improve the service. They used training, research and meetings with other professionals toward this end. Care workers talked with passion about the people they cared for, wanting to do their best for the people in their care. They said they were well supported and the registered manager was always available, would listen and act on their suggestions. The provider constantly updated plans to maintain the premises, worked in partnership with, and supported, the registered manager.

We found four breaches of Regulatio

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 35 people living at Chelfham House. The summary is based on conversations with five people living at the service, three relatives, five staff and the registered manager. We looked at records of people's care and quality monitoring systems used with the home. We also spent time observing how care and support was being delivered to people. Following the inspection we spoke with the community nurse team who make regular visits to the home.

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

Is it safe?

We found the service was not always safe because there were not enough staff on at all times to meet the complex needs of people living at the service. We have made this judgement based on our observations of how people were supported during the inspection visit, looking at staff rotas and by talking to staff about people's needs. We found that on the day of our inspection, some people did not get their medication until 11.30 am. We have been assured however that this was unusual.

We saw people had to wait for staff to assist them with eating their meal. We found staff were rushed and could not always provide quality time to people. The provider did not have a tool to assess the dependency needs of people therefore we were unclear about how they had decided on the levels of staffing.

We found some areas of the home posed a potential risk to people, which meant they could be unsafe. For example we saw not all windows had been restricted. Some vanity units were chipped and would not be able to be cleaned in a way which would ensure against infection control. We found wardrobes had not been secured to walls and could easily be pulled over and cause an injury to people. The registered manager said she would address the environmental issues as a matter of urgency.

Is the service caring?

We found people were being supported by a staff group who showed a great deal of caring. Our observations showed although staff were busy, they provided people's care in a respectful and dignified way. Relatives we spoke with were very complimentary, one said ''I am so grateful, this home is very, very good. I feel they have given me my mother back.'' They explained their relative had been very sick prior to coming to the home and over time has improved, put on weight and ''getting back to being more contented and settled.'' Another relative we spoke with said '' You could not wish for better care, the staff are all very caring, they work very hard and they always put on a lot of entertainment.''

Is the service responsive?

The service was responsive to people's needs and wishes. For example where people's needs had changed, care plan information had been updated and equipment had been considered. Where people had injured themselves following a fall, medications reviews had been considered and well as ensuring the environment was safe, free from clutter and pressure mats being used to alert staff if people got up unaided from their bed for example.

Is the service effective?

The service was effective because it was clear from the discussions we had with visiting relative and the community nurse team, that staff knew and understood people's needs. When needs had changed healthcare teams were consulted and the approach appeared proactive in seeking the least restrictive way of supporting people. The Deprivation of Liberty safeguards had been appropriately used to ensure people's rights were upheld, but that the service continued to meet people's needs.

Is the service well led?

The service was well led by a manager and team of staff who have continued to develop their knowledge and skills with ongoing training.

Systems were in place to ensure people's views were listened to and where possible relatives were included in the running of the service as there was an active relatives association, which met with the manager monthly.

We brought forward this planned inspection as we had received some information of concern about staffing levels and people's personal care needs not being met. We had also been made aware of a safeguarding alert in respect of one person not receiving their medications.

During this inspection we spent time talking to seven people who live at the service. We also observed care and support and spoke with four staff. We looked at some key documents, including care plans, risk assessments, medication records and complaints. This helped us to understand how well the home was being run. Prior to the inspection we spoke to two health care professionals. We also spoke with one visiting relative.

People said they were well cared for by staff who understood their needs. Comments included ''I don't know how long I have been here, but it's very good'' and ''Staff are lovely.''

We found that on the day of this inspection there were 35 people living at the home. There were six care staff on duty and this was sufficient to meet the needs of the current people. Although staff were busy throughout the day, they provided support in a kind and respectful way.

We checked how medication was stored, recorded and administered. We found that robust systems were in place, but audits needed to be documented to demonstrate that this was being monitored.

We found that the home were fully compliant with all five outcomes we inspected during this inspection.

We carried out this unannounced inspection on 19 April 2012 as part of our planned inspection programme. We spent time talking to eight people who currently live there, as well as six members of staff. We also observed how care and support was delivered throughout different times of the day. Most people that live at this service have dementia and therefore not everyone was able to tell us about their experiences. To help us understand the experiences of people, we used our SOFI (Short Observational Framework for Inspection). This tool allows us to spent time watching what is going on in a service and helps us 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 their views. We also spoke with two visiting relatives and two visiting health care professionals.

We looked at some of the key records kept by the home. These included care plans, risk assessments and staff training records. This helps us to better understand how well the home is run. Following the inspection we asked the registered manager to send us some additional information in respect of how they monitor and review the quality of care and support provided.

People we spoke with who were able to share their experiences of living at the service were very positive. Comments included ‘‘we are very well looked after” and ‘‘I have no complaints, everything is good’’. One visiting relative stated, “you only have to mention an issue and it gets dealt with. Staff are very respectful and make sure people’s privacy is maintained.’’

We looked at how well care and support was planned and reviewed. The plans contained good basic information about what personal, health and emotional care needs people had and how staff should meet these needs. Risk assessments were in place to show how the home identified, managed and minimised any risks for people.

We observed staff providing care and support in a kind and sensitive manner and we were told by staff that they felt well trained and supported to do their jobs. We observed people experiencing positive interactions with staff who tried hard to engage people. There were good systems in place that ensured people’s views were listened to and acted upon.

This inspection was unannounced and took place on the 6 and 8 October 2015. Chelfham House is registered to provide care and support for up to 41 people. Most people living at this service are living with a form of dementia At the time of the inspection there were 37 people living at the home.

There was a registered manager 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 2008 and associated regulations about how the service is run.

When we last inspected this service on 14 May 2014 we found improvements were needed in the staffing levels to ensure people were safe and their needs could be met in a timely way. We also found there were some areas of the home which needed to be made safe for people. These included ensuring wardrobes could not fall on people if pulled and that all windows were fitted with restrictors to keep people safe. Following the inspection the provider and registered manager sent us an action plan to show how they intended to make improvements.

During this inspection, it was clear the registered manager was using a dependency tool to help determine the right levels of staff needed to meet people’s changing needs. Staffing levels had increased and the deployment of staff had been considered. This was to ensure there were enough staff at meal times to assist people when they needed it.

We had received some information from the local safeguarding team which suggested that there had been a high incident of falls resulting in a high number of people sustaining serious injuries. The service is required to report this type of incident to CQC. Our records showed incidents were reported, but they were not unusually high for the number and needs of people living at the service.

The environment had been made safe. Any large furniture such as wardrobes had been secured to the wall, and all windows had been fitted with restrictors. Previously there had been some vanity units which were chipped and would have been hard to clean. These had been replaced.

The registered manager had attended a dementia course which had helped her and the staff team to think about the environment and how to make it dementia friendly. They had changed rooms around so that there were now more spaces for sitting in small groups. Dining areas were created in lounges so there was no longer one big dining area. Staff reported this had been working well, as people found small groups with less noise more enjoyable. Consideration had been given to colours and making the environment a more stimulating place. There were lots of pictures and features for people to look at. For people who were spending most of their days in their bed due to their poor health, coloured mobiles and pictures had been put up. Colourful garden ornaments had been put outside bedroom windows. There was clear signage with photos to help people orientate themselves around the building.

Care and support was being planned by staff who understood the needs of people who lived at the home. Staff had regular training and support to do their job safely and effectively.

People and their relatives were complimentary about the caring approach of staff. One person said ‘‘I really like the staff, they are caring.’’ One relative commented that they felt the staff group had showed a caring approach to them as well as their relative. They said ‘‘Staff here are very friendly and welcoming, they make it easier for me to visit and they listen to me.’’ Our observations supported the opinions we heard about staff. We saw examples of staff providing care and support ensuring people’s dignity and respect were upheld.

People’s rights had been considered and the service operated in line with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). This ensured people’s rights were protected and the service worked in the least restrictive way.