Clair Francis Retirement Home is registered to provide accommodation for up to 28 people who require personal care. The service does not provide nursing care. The service provides support for older people, some of whom are living with dementia. At the time of the inspection there were 17 people living at the service.

This comprehensive inspection took place on 2 March 2017 and was unannounced.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

Systems were in place to assess and manage risks to people using the service. Staff understood the risks for people and their responsibilities within the home. Information about emergencies was available for staff.

People’s capacity to make decisions for themselves had been assessed. Staff were trained and understood the principles of the MCA and DoLS and were able to describe how people were supported to make decisions if they lacked capacity. We saw that appropriate DoLS authorisations were in place to lawfully deprive people of their liberty. Authorisations in place were for people’s own safety because they were unable to make decisions on where they should live safely.

People were kept safe because there was a sufficient number of staff on duty to meet people’s needs. The provider had a recruitment process in place and staff were only employed within the service after all essential safety checks had been satisfactorily completed. Staff received an induction when they started work and further training was available for all staff which provided them with the skills they needed to meet people’s needs.

Staff knew how to support and meet people’s needs. People were involved in how their care and support was provided. People had access to health care professionals when they needed them. Staff treated people with care and respect and made sure that their privacy and dignity was respected all the time.

People and staff were able to provide feedback and information so that the provider could monitor and improve the quality of the service. The registered manager was open and available for people, their relatives, staff and professionals to discuss concerns or make comments to improve the service.

We carried out an unannounced comprehensive inspection of this service on 03 November 2014. A breach of two legal requirements was found. This was because people’s medicines were not always managed in a safe manner and there were not always sufficient staff on duty to meet the needs of the people living in the home.

After the comprehensive inspection the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this unannounced focused inspection on 13 July 2015 to check that the provider had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Clair Francis Retirement Home on our website at www.cqc.org.uk.

Clair Francis Retirement Home is a registered care home which provides accommodation, support and non-nursing care for up to 28 people, some of whom live with dementia. There were 22 people in the home at the time of the inspection. Accommodation is provided on two floors and there are gardens and internal communal areas, including dining rooms and lounges, for people and their visitors. The home is located in a residential area on the outskirts of Peterborough.

The home had a registered manager in post at the time of the inspection. 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.

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 Clair Francis Retirement Home on our website at www.cqc.org.uk.

At our focussed inspection on 13 July 2015 we found that the provider had followed their plan which they told us would be completed by 31 March 2015 and legal requirements had been met.

People told us they were supported to take their prescribed medicines. Staff understood their responsibilities in the management and recording of medicines. People had all their prescribed medicines available because there was sufficient stock in the home. Medicine audits had taken place each month and actions had been taken as a result of any issues identified. There was some information for staff so that medicine, prescribed ‘when required’, was administered in a consistent way.

There was evidence that people were supported by sufficient numbers of staff to meet their needs. Staffing levels had been assessed in relation to the dependency levels of people who lived in the home. People were supported with their individual interests and activities.

Clair Francis Retirement Home is a registered care home which provides accommodation, support and non-nursing care for up to 28 people, some of whom live with dementia. At the time of our inspection there were 22 people living at the home. Accommodation is provided on 2 floors and there are gardens and internal communal areas, including dining rooms and lounges, for people and their visitors. The home is located in a residential area on the outskirts of Peterborough.

This unannounced inspection took place on 3 November 2014 and was undertaken by two inspectors.

The last inspection took place on 31 October 2013 where we found the provider was meeting the regulations.

The home has 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.

People’s medication was not always available when they needed it, and the recording, handling and administration of medication did not keep people safe.

Satisfactory checks were completed during the recruitment of new staff so that only suitable staff worked at the home. Staff had a formal induction and ongoing training relative to their roles.

People were cared for by staff who understood them as individuals and supported them to maintain their dignity and respect. People were treated well and they and their relatives were actively involved in the review of people’s individual care plans.

Staff ensured that people had access to a range of health care services so that their individual health needs were maintained and improved where possible.

People’s rights in making decisions and suggestions in relation to their support and care were valued and acted on. Where people were unable to make these decisions, they were supported with this decision making process. Individual social interests and hobbies were sometimes provided, which helped people to maintain and promote their wellbeing.

People’s rights in relation to their care and welfare were known by staff and acted upon. Where people were unable to make decisions there had been best interest assessments. The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. We found that people’s rights were being protected as DoLS applications were in progress and some had been submitted to the authorising agencies.

People received care that was responsive to their individual needs and they were supported to maintain contact with their relatives. There were some community links and people were also supported to visit local amenities. Complaints and concerns made to the registered manager were acted upon and used to improve the service.

The care home was well-led and staff felt they were supported and managed to look after people in a caring and safe way. People, relatives and staff were very positive about the registered manager and felt they had opportunities at meetings to discuss the service and that actions were taken as a result. Quality monitoring questionnaires were in the process of being sent out so that improvements could be identified.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

During our inspection on 31 May 2013 we found that the provider had not undertaken a documented risk based assessment which looked at the individual needs of people using the service; as well as the number of people living at the home to determine appropriate staff numbers.

During this inspection on 31 October 2013 we found that the provider had now undertaken a documented dependency and risk based assessment on each person’s individual care and support needs. The provider told us that this analysis helped determine the number of staff needed to deliver safe and effective care and support to people using the service.

People we spoke with during our inspection raised no concerns around the current level of staffing within the home. One person went on to tell us that, "Staff are available to help."

During our inspection on 16 April 2013 we found that the Medication Administration Records (MARS) we saw did not evidence accurate documentation to ensure that people were protected against the misuse of medication. During this inspection on 31 May 2013, we found that the provider had made the required improvements to the recording of medication administration.

We found that there were no effective systems in place to make certain that staff levels ensured the safety and well-being of people who lived at the home. The provider was unable to evidence a risk based assessment which demonstrated to us that safe staffing levels were determined from both service user’s numbers and their individual needs. A person who used the service told us that, "We sometimes have to wait for help when staff are busy." Another person told us that, "I do have to often wait for help because staff are busy."

Adequate staff training was in place to make sure that people who used the service received safe support and care from suitable, skilled, and knowledgeable staff.

The name of a registered manager appears in this report who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We used a number of different methods to help us understand the experience of people using the service. This was because most of the people using the service had complex needs which meant they were not able to tell us their experiences. We used the Short Observational Framework for Inspection (SOFI) as this is a specific way of observing care to help us understand the experience of people who could not talk with us.

We saw documented evidence where people did not have capacity to consent to safe care and treatment. This meant that the provider acted in accordance with legal requirements.

People's standard of care and welfare was maintained. Staff had access to detailed care records to ensure that they provided care and support to people.

When reviewing Medication Administration Records we did not see evidence of accurate documentation to ensure that people were protected against the misuse of medication.

There were effective staffing levels in place to ensure the safety and well-being of people who lived at the home.

We saw an effective quality assurance system was in place as the provider generated action plans using the results from surveys and audit to improve the quality of the service delivered.

The name of a registered manager appears in this report who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We used a number of different methods to help us understand the experiences of people using the service, because most of the people currently using the service are living with dementia. This meant they were not able to fully tell us their experiences. We spoke with a relative of a person who lived in the home and two professionals to gather further evidence. We also used the Short Observational Framework for Inspection (SOFI) and general observation. SOFI is a specific way of observing people who could not talk with us.

The professionals we spoke with raised no concerns over the care and support people received within the home. One told us that the people they placed there seemed, "Settled and happy". This was because people received safe and appropriate care.

Care records were maintained to ensure that people received safe and appropriate care in a consistent way. A relative told us that they were, "Confident to raise a concern with management or staff". They went on to say that staff would "listen to it (a concern) and it would be taken seriously".

People were protected from the risk of infection spreading as there were effective systems in place to reduce the risk.

Effective staff recruitment were in place to ensure that people who used the service received safe and appropriate care from suitable staff.

There was an effective system in place for people to make a complaint.