The inspection took place on 8 and 9 May 2018 and the first day was unannounced.

Douglas 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.

The provider is registered to accommodate up to 30 people. People living in the home have a range of needs which include complex physical nursing needs and learning disabilities. At the time of the inspection 27 people were living at the service.

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.

At the last inspection on 24 November 2015 we rated the service Good.

At this inspection on the 8 and 9 May 2018 we found the service remained Good.

This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection. There was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns.

Douglas House had been developed and designed prior to Building the Right Support and Registering the Right Support guidance being published. We found the home followed some of these values and principles. These values relate to people with learning disabilities living at the service being able to live an ordinary life.

People and relatives we spoke with told us the home was safe and they trusted the managers and staff. When we asked people if they felt safe at Douglas House comments included, “Oh yes I think so”, “Yes, without a doubt” and "It’s a very good care home. I’m very safe."

People and relatives told us staff were kind and caring. During the inspection there was a very happy, relaxed and pleasant atmosphere in the home. We observed the staff being kind and polite towards people. They were attentive when people asked for assistance and they addressed people in a caring way.

People's privacy and dignity was respected and staff ensured people were encouraged to maintain their independence and were involved and in control of their care.

People were protected from abuse and neglect. We found staff knew about risks to people and how to avoid potential harm. Risks related to people's care were assessed, recorded and reviewed. The management of risks from the building were also satisfactorily managed. Medicines were stored and administered safely.

We found appropriate numbers of staff were deployed to meet people's needs and had been recruited properly to make sure they were suitable to work with people.

The staff told us they felt well supported. They had the information and training they needed to care for people. The staff felt the service was well managed and had opportunities to discuss their work and any concerns they had with the registered manager and other senior staff.

People received care and support based around their individual needs and requirements. Care plans were person-centred and reviewed regularly. People were able to make choices about their day to day lives. There was a variety of activities for people to do and take part in and people were supported to pursue their own hobbies and interests. Complaints were fully investigated and responded to.

The home continued to be well led. The management team promoted open communication with people, their relatives and healthcare professionals involved in their care. Staff were clear what was expected of them, and expressed enthusiasm for their work at the home. The management team completed audits and checks to assess and improve the quality of the service people received at Douglas House.

Douglas House is registered to provide nursing care and support to 29 people. People living in the home have a range of needs which include complex physical nursing needs and learning disabilities.

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.

This inspection took place on 24 November 2015 and was unannounced. There were 27 people living at the service at the time of the inspection. The service was last inspected in February 2014, when it met the regulations we looked at.

The service had a new registered manager. Staff told us “She’s done really well” and “(Registered manager’s name) knows what goes on”. People, a relative, and staff told us the registered manager was approachable. Comments included “It’s never an issue to approach her” and “I feel very happy I can talk to her”. The registered manager had taken steps to ensure there was an open culture. They told us they had recently faced challenges as they did not have a full permanent staff team. They had identified this had impacted on people through use of agency staff, reduced key working time (a key worker is a staff member who is allocated to a person and supports them in their daily life at the service), and not as many activities as they would have liked. They were trying to recruit and retain the right staff, were keen to provide a good service and committed to making improvements. We found a number of changes to people’s needs had not been updated in the care and support plans. This may have placed people at risk of inconsistent care. The registered manager had identified that care and support plans needed updating, before our inspection. They told us they had organised additional support until all plans were reviewed and updated.

People told us they were happy with the care and support they received. Comments included “The staff are very caring” and “I’ve always found them very helpful, nothing could be better”. Staff spoke passionately about people they supported and wanted to achieve the best outcomes for them. People told us if they needed help, staff always came. Comments included “They attend to me quickly” and “I only have to ring my bell and they’re here”. During our inspection, staff responded to people’s needs and requests in good time.

Staff knew people well and respected their wishes. Staff recognised when people were not feeling well and responded to this. Care plans contained some very personalised information. For example, how to meet personal hygiene by preparing washing items in a particular way. ‘One page profiles’ and personal histories were also available, to help staff know what was important to or about the individuals they supported. For example, what family they had, what their interests were, and what particularly mattered to them regarding any support they received from staff.

We saw people had friendships with others living at the home and were actively involved in making decisions within the service. For example, people had been involved in choices about the re-decoration of the dining room. The service had a day centre on the top floor that people could attend. On the day of our visit some people had gone swimming. Three people felt there were not enough person-centred activities and told us they would like more time with their key worker. Another three people told us they were happy they had enough to do. We saw a notice on the board in the corridor telling people about a planned meeting to discuss activities. People were supported to achieve their goals. For example, one person told us how staff had supported them to arrange a holiday and made sure all the proper arrangements were in place.

People were protected by staff who knew how to recognise signs of possible abuse. Where safeguarding concerns had been raised, the registered manager had worked with the local authority safeguarding team and taken appropriate action. Safe staff recruitment procedures were in place. This helped reduce the risk of the provider employing a person who may be a risk to vulnerable people. Staff told us they were happy with the training they had received and felt skilled to meet the needs of the people in their care. People told us staff knew how to meet their needs effectively. Comments included “They know what they’re doing, they really make an effort” and “They’re continually training”.

Where people lacked mental capacity to take particular decisions, these were made on their behalf, in their best interests and were as least restrictive as possible. Mental capacity assessments were in place. Staff gave examples of best interest decision-making they had been involved with, such as when one person wanted to remain in one place for a long time, causing risks to their health. One person was being deprived of their liberty as they were not able to leave the service on their own. The provider had made the appropriate application which had been authorised and they were meeting the conditions applied to the authorisation. Staff supported the person to access the local community and pursue their interests. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Risk had been assessed for each person. For example, risk assessments were in place after a person had a serious accident, to safeguard them yet allow them to continue a lifestyle choice. Premises and equipment were maintained to ensure people were kept safe and there were arrangements in place to deal with foreseeable emergencies.

The service had systems in place to assess, monitor, and improve the quality and safety of care. The local authority’s quality team had recently carried out an audit at the service. They had not identified any areas that needed action. People told us they felt able to make a complaint. The provider had a free phone helpline for people to make complaints, suggestions and compliments about the service. Where complaints had been received, the registered manager had investigated and responded to these. There was evidence that learning had taken place as a result of complaints. For example, staff had been spoken with in supervision to make sure an issue did not happen again. The quality team at the service’s head office reviewed complaints to ensure they were managed appropriately.

We, the Care Quality Commission visited Douglas House to follow up enforcement action we had taken in November 2013. During the inspection on 19 November 2014 we had seen that care files and records had not been accurately maintained since a previous inspection in September 2012 where the home had also been non complaint in regard to their record keeping.

At the inspection in November 2013 we had found that people's personal records including medical records were still not accurate or fit for purpose. This meant that people had not been protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had not been maintained for people who lived at the home or for staff who worked at the home.

We issued the provider a warning notice in December 2013 with a timescale of 11 January 2014 to put things right.

Following the issue of the warning notice the provider sent us an action plan detailing how they were going to become compliant. At this inspection we found that this action plan had been completed and the home were compliant with regard to their record keeping.

For those people who were able to express their views they told us they liked living at the home and felt in control. For those people who were not able to communicate their wishes, systems were in place which ensured decisions were made in their best interest. However, records did not always reflect this practice.

People received a good level of care. Staff knowledge of peoples complex needs was good. There was a varied activities programme and people were able to maintain links with the community where possible.

The home was clean and we saw systems in place to ensure that people living at the home, staff and visitors were protected from the risk of infection.

There were sufficient numbers of staff to meet the care needs of people. Recent staff shortages were being addressed.

During this inspection we saw that care files and records had not been accurately maintained since our previous inspection in August 2013. We found that people's personal records including medical records were not accurate or fit for purpose. However, we found other records in the home were well maintained.

During our visit to the home we spoke with seven people who lived there and with a relative who was visiting the home. We also spoke in depth with the registered manager, with a member of nursing staff and with two members of support staff. We observed staff interacting with and supporting people. We looked at all the communal areas of the building and in some bedrooms. After our visit the registered manager invited people living there, and visiting professionals, to send in their comments about Douglas House to CQC. We received feedback from the relative of one person who lived at the service.

People told us that they were involved in decisions made about their health and social care, and had their preferences taken into account. One person said “The majority of staff explain what they are doing and why they are doing it, before they do it”. People told us they made daily choices such as when to go to bed, when to get up, the clothes they bought and what they wore.

A relative said “The staff don’t see someone with a disability, they see the person. That’s who they relate to”. We observed staff being respectful in their interactions and in their conversations with people. For example, we saw that staff spoke with people who used wheelchairs at the person’s eye level. We heard staff giving information to people so they could make their own choices, for example about what to do and when and where to eat.

People with very complex needs told us that staff were competent, caring and quick to ask for advice and support if needed. People had high levels of immobility and complex nursing needs and one person had a pressure sore. This was a long standing problem which was being managed. Records showed that people had been assessed to determine their risk of becoming malnourished, developing pressure sores and falling. Where risk had been identified we found that there was plan to manage this risk in place. This information was contained in each person’s person centred plan.

Records demonstrated that people had their health promoted through referrals to the doctor, specialist healthcare professionals, chiropodist and dentist.

People told us that they enjoyed the social activities they took part in. For example, some people enjoyed trips out, the most recent outing being to the Eden Project in Cornwall. The manager reported that everyone was given the opportunity to go. One person told us they went swimming, fishing and to a pottery class. People said that there was easy access to the grounds and balcony, which had sea views. The home had a computer suite and one person told us they enjoyed using the internet. We saw when we visited with people in their bedrooms that they had items such as phones, TV’s and DVD/video players and music players. People told us they went out in one of the minibus for trips.

People told us that staff were kind and helpful. They knew what action to take if staff did not behave in this way because they had received safeguarding training. Staff told us they had also received training in safeguarding adults. They were familiar with the different types of abuse and knew how to escalate concerns within the organisation, and how to escalate their concerns outside the organisation.

Recruitment records showed that appropriate pre employment checks had been undertaken before staff starting to work at the service, including checking that nurses were registered with the Nursing and Midwifery Council annually.

People told us about the different opportunities they had to have their views heard and to influence the service. For example they attended resident only meetings and could give their views to the local representative for the Leonard Cheshire Customer Action Network (CAN). They showed us the poster detailing how to contact the helpline. One member of staff told us that service users were involved in selecting staff and that their interview panel had included people living at Douglas House.

The service conducted annual surveys to gain feedback from residents. This was written in words and in pictorial form to aid people’s understanding. The most recent survey (conducted in Feb – April 2012 and collated in June 2012) showed a high level of satisfaction. The provider may find it useful to note that some suggestions for improvement had not been followed up.

We saw evidence that risk was being managed through the use of risk assessments and action plans. For example, people at most risk from the effects of a fire had been identified and plans had been put in place to manage this. Risk assessments in relation to people going swimming were in place and staff demonstrated a good understanding of these.

We found that some personal care plans (PCP’s) we looked at were not always accurate or detailed enough. They were hard to navigate and did not always contain all the information needed.