We carried out this inspection over three days on the 5, 6 and 11 March 2017. The first day of the inspection was unannounced. During our last inspection on 15 and 17 December 2015, we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with a requirement notice to ensure improvements were made. At this inspection, action had been taken and improvements had been made in relation to the cleanliness of the home, staff interactions and the analysis of accidents.

Downs View Care Centre provides accommodation and personal care to up to 51 people, some of whom have dementia. At the time of our inspection, there were 42 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. The registered manager was available throughout our inspection.

There were sufficient staff to support people effectively. Staff spent time with people and were able to undertake tasks in a relaxed manner, without rushing. New staff had been recruited using safe recruitment practice.

Improvements had been made to the cleanliness of the home. All areas, including those less visible, were clean. Cleaning schedules had been reviewed and a new post of head housekeeper had been introduced.

People felt safe and potential risks had been identified and addressed. Staff were aware of their responsibilities to identify and report any suspicion or allegation of abuse.

Medicines were safely managed and regularly audited to minimise the risk of error. People received good support from a range of health care professionals. Specialist services were requested as required.

Clear focus was given to food and its impact on wellbeing. Meals looked appetising and were based on people’s needs and preferences. People received frequent drinks and snacks throughout the day. Potential risks of malnutrition and dehydration were well managed.

Staff supported people in a caring, friendly and attentive manner. Frequent interactions demonstrated the positive relationships which had been established. People clearly benefited from the attention shown to them.

People were involved in a range of meaningful activity which was arranged in accordance with their ability and personal interests. There was a positive, stimulating environment within the home.

Staff were responsive to people’s needs and rights to privacy, dignity and choice were promoted.

People had a plan of their care, which was up to date and regularly reviewed. Whilst care plans, demonstrated the support people required, some areas lacked detail. Terms such as “regularly” were used, which did not provide staff with clear guidance to ensure the timing of care, met people’s needs.

People and their relatives felt listened to and were encouraged to give their views about the service. They were aware of how to make a complaint and were confident any issues would be properly addressed.

Staff received a range of training and felt well supported. There was a willingness to learn, develop and further improve the service people received.

Improvements had been made to the environment. Corridors were now more attractive due to sensory items and people’s artwork. People’s outdoor space was being extensively developed.

The home benefitted from clear leadership and organisational systems were well managed. Comprehensive auditing ensured any shortfalls were quickly identified and resolved.

One inspector visited the home and answered our five questions, is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with three people using the service, their relatives, seven staff, the manager and the operations manager. We reviewed five care plans and other relevant records. Additionally we used the Short Observational Framework for Inspection (SOFI) observation for a forty minute period. SOFI is a specific way of observing care to help us to understand the experience of people who could not, clearly, tell us about it.

Is the service safe?

Care plans instructed staff how to meet people’s needs in a way which minimised risk for the individual. They were detailed and ensured staff cared for people in a safe way.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home liaised effectively with the local authority DoLS team and had made applications as appropriate. The home had made eight DoLS referrals and extension applications in 2014.

We found that medication was administered and recorded in a way which kept people as safe as possible. Staff were properly trained and their competence to administer medicines was checked regularly.

The home trained and supported staff to enable them to work effectively with vulnerable people. People told us they had never experienced any poor treatment and felt safe in the home. The home referred staff to the appropriate bodies if they were not fit to work with vulnerable people.

Systems were in place to make sure that the manager and staff continually monitored the quality and safety of care offered to people.

Health and safety was taken seriously by the home and all the appropriate safety checks had been completed. This reduced the risks to the people who lived in the home, staff and visitors.

People told us they felt very safe in the home. One person said: ‘‘there’s no abuse here, I’ve seen the films and it wouldn’t happen here’’. Families told us that they had: ‘‘absolutely no concerns’’ (In regard to people’s safety).

Effective?

People’s health and care needs were assessed with them, and/or their relatives, as appropriate. Care plans were detailed and clearly identified people’s needs and how they should be met. They were reviewed regularly and changes were made to meet people’s changing needs. We saw that staff gave support as described in individual’s care plans.

We observed staff meeting people’s needs in an effective way and people told us they felt the home met their needs. Relatives said that the home met their family member's needs.

Caring?

People were supported by kind, caring and patient staff. We saw that care were attentive, encouraging and positive. One person described staff as: ‘‘kindness itself’’. They responded appropriately to people’s needs. Staff communicated with people at all times and encouraged interactions between people using the service.

People's diversity, values and human rights were respected. Care plans were individualised and person –centred. We saw that people were treated with respect and dignity by the staff.

Responsive?

We saw that health care was sought in a timely way and the home co-operated with other health care professionals to make sure their health care needs were met.

The home had made changes and improvements as a result of ideas and discussions with people who lived in the home and their relatives.

Well led?

We saw that staff were supported to do their job and meeting the needs of the people who lived in the home was the priority.

The service had an effective quality assurance system. We saw records which showed that identified shortfalls and ideas people put forward were addressed. Several examples of changes made as a result of the regular satisfaction surveys were provided by relatives and the manager. As a result the quality of the service was being maintained or improved.

At our previous visit to the home in July 2013 we had found shortfalls and had required that improvements were made. The service had supplied an action plan explaining the changes and improvements that were being made to ensure compliance. At this visit we found that improvements had been made.

People who lived in the home we spoke with told us they were well treated by the staff and were happy with the care and support that was provided. We observed staff interacting positively with people in a caring and professional manner.

The senior staff had undertaken training around the positive management of challenging behaviours. We were told how this input would be cascaded through the staff team.

The home had introduced improvements to the management of infection control. Additional auditing and checks had been introduced of the cleaning that was completed. The home had also sought advice and guidance from outside agencies. The latest appropriate formal guidance from the Department of Health was in place for staff to reference. There were plans to identify a staff member to take a lead role for infection control.

We found that the home was clean and mainly free form odours. The individual rooms appeared clean and hygienic and people who lived in the home we spoke with told us they were happy with the way their bedrooms were maintained and cleaned. We found that some improvements could still be made to parts of the communal areas.

People who lived in the home we spoke with told us they were well treated by the staff who were caring and friendly. We found that some improvements were required with regards to the meeting of some peoples care and welfare needs.

We found that people were provided with a varied choice of food and that nutritional needs were being monitored. People who lived in the home we spoke with told us they enjoyed the food.

We found that people enjoyed the activities that were organised

We found that while the home was generally clean and well maintained improvements were needed to the management of infection control.

The home had sufficient care and ancillary staff on duty to meet the needs of the people living in the home.

We saw that improvements had been made to the management of records.

People we spoke with told us that they were satisfied with the quality of care and support that was provided in the home. We were told that people felt safe living at Downs View and that they were treated with dignity and respect.

People who lived in the home told us that they were given choices about their treatment or care. The home had a range of activities which people could join in with. People told us that they were given a choice of food at each meal time.

People told us they felt safe when staff needed to use equipment when assisting with their care.

Staff had completed regular training appropriate to their roles. Staff told us they were well supported by their manager and colleagues.

We found that the records kept by the provider were not always up to date.

One person commented “the staff are very good to me, they look after me well”. A regular visitor to the home described the staff as “heroic”. We saw staff treating people with respect and helping people to make choices and decisions in their lives.

People appreciated the care that they received from staff. They had care plans which helped to ensure that staff provided support in a consistent way.

Relatives said that they were made to feel welcome and could pass on their views to the manager. A newsletter was produced which helped to keep people up to date and informed of new developments. We were told that one priority was to increase the support that people received with activities during the day.

We carried out this inspection over two days on the 15 and 17 December 2015. The first day of the inspection was unannounced. During our last inspection on 18 July 2014, we found the provider satisfied the legal requirements in the areas we looked at.

Downs View Care Centre provides accommodation and personal care to up to 51 people, some of whom have dementia. At the time of our inspection, there were 45 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. The registered manager was available throughout our inspection.

There were some concerns about some aspects of care people received. A night monitoring visit had identified some people were supported to get up very early and did not have access to a drink. This poor practice was appropriately addressed by the registered manager. Further monitoring visits identified no concerns although records had not been completed to evidence this. The registered manager told us further consideration would be given to ensure staff were more proactive, to minimise potential issues.

More intricate, less visible areas of the home were not clean. Such areas included the frames of wheelchairs, the beading on over-bed tables and the hinges of toilet seats. Records showed cleaning schedules were in place and being monitored.

Staffing levels were sufficient to meet people’s needs. However, there was often staff sickness which made shifts difficult to cover. Various initiatives had been implemented to improve staff attendance but these had not been as efficient as expected. Agency staff were being used and there was ongoing recruitment to increase the flexibility of covering for staff absences.

There were many positive interactions between staff and people who used the service. However, there were some interactions which could be improved upon. Some people received little interaction and stimulation from staff. Improving social activity provision was an area the registered manager was looking to develop.

The environment was in the process of being developed. This included a large lounge extension and office area, leading to a newly developed secure, sensory garden. Another lounge had been decorated with new furniture. There were plans to develop those areas, which provided a lack of sensory stimulation. This included the corridors, within one area of the home.

Staff responded quickly to people’s call bells and specific issues such as an altercation between two people who used the service. People looked well supported and their rights to privacy and choice were promoted. People’s needs were appropriately assessed and any potential risks were identified and minimised. Each person had an up to date care plan, which informed staff of individual wishes and the support required. There were management plans in place to help staff support those people who had behaviours that challenged.

People were offered a variety of choice at meal times. The lunch time meal looked appetising and was well presented. Individual preferences and specialised diets were provided. Those people at risk of malnutrition were appropriately assessed and monitored. People were regularly weighed and given increased calorie intake if required.

People had access to a range of services to meet their health care needs. This included regular visits from the GP, district nurse and community matron. People received support to attend hospital appointments, as required. People received their medicines in a safe and person centred way. Staff received training in the management of medicines and had their competency regularly assessed. This ensured staff were competent in their role.

Staff were well supported by managers and each other. They received regular meetings with their supervisor, to discuss their performance and any concerns they might have. Staff undertook regular training to ensure they had the knowledge and skills to do their job effectively. However, housekeeping staff had not received training in dementia care. This training would increase staff’s knowledge and therefore enhance people’s experiences.

People were supported by staff who had undertaken a thorough recruitment process. This ensured all staff were suitable to work with vulnerable people. Staff had received safeguarding training and were aware of their responsibilities to recognise and report abuse.

There was an effective auditing system to assess and monitor the quality and safety of the service. The registered manager submitted a monthly report to senior managers to ensure further monitoring. People were encouraged to give their views about the service. This was informally, at meetings or by using questionnaires. The feedback received was used to help improve service provision. People knew how to make a complaint and were confident any issues would be properly addressed.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.