We inspected Fordingbridge Care Home on 29 and 31 March 2017. This was an unannounced inspection.

Fordingbridge Care Home is registered to provide nursing care for up to 60 older people, some of whom live with dementia. There were 53 people living at the home at the time of our inspection. Accommodation is provided over three floors. The lower ground floor supports people who are more independent. The ground floor provides care for people with more complex cognitive needs. The first floor cares for people who are more physically frail. Each floor has a lounge, other communal areas, a dining room and a number of spacious bathrooms, in addition to en-suite bathrooms in all bedrooms.

The service had a registered manager in place. 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 were protected from abuse. Staff had received training in safeguarding people and were knowledgeable about the home’s safeguarding processes and procedures. Staff knew how to report any concerns.

People received their medicines safely and systems were in place to manage the ordering, storage and disposal of medicines effectively.

Robust recruitment procedures were in place and appropriate checks were carried out before staff were employed to ensure they were suitable to work in adult social care.

Risks to people had been assessed and measures put in place to mitigate the risks. Incidents and accidents were recorded and analysed to learn from them and reduce the likelihood of them happening again.

Staff received training, supervision and appraisal to support them in their role.

Staff were knowledgeable about the requirements of the Mental Capacity Act 2005. People’s capacity was appropriately assessed and any decisions made in people’s best interests were documented appropriately.

Staff were knowledgeable about the deprivation of liberty safeguards (DoLS). The registered manager had applied for appropriate authorisation where people needed to be deprived of their liberty.

Staff were kind and caring and showed compassion when people became upset or anxious. Staff respected people’s privacy, dignity and wishes about how they received their care.

People received the health care they needed. Staff organised visits from their GP, hospital appointments and other assessments to support their care, such as speech and language assessments when required.

People and the relatives were involved in reviewing their care. Records showed reviews took place on a regular basis or when someone’s needs changed.

The service had an open culture. People and their relatives told us they felt able to discuss any concerns with senior staff, nurses or the registered manager.

A range of audits and quality assurance systems were in place to drive improvements within the home. Surveys were sent out to people and relatives to obtain feedback and the results were analysed to assess their satisfaction.

The management team was visible and staff told us they were given opportunities to participate in developing the service.

Health and safety within the home was managed effectively. Regular maintenance around the home and servicing of equipment was carried out by maintenance staff.

We inspected Fordingbridge Care Home due to some concerns we had received. We found that not everyone who lived at the home was able to tell us verbally what they thought about living there. However, we were able to speak with eight people who used the service and three friends and relatives who visited during the day. We also spoke to one visiting volunteer. We spoke with ten members of staff, as well as the registered manager and the owner. We gathered evidence against the outcomes we inspected to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe and their friends and relatives had no concerns about safety. However, we found some practices within the home to be unsafe.

Staff understood how to safeguard people they supported. However, the provider’s safeguarding policy did not include details of how to contact external agencies if they had concerns about people. This meant there was a risk that safeguarding referrals would not be made or investigated appropriately to keep people safe.

Arrangements for the management of medicines were not safe and people were not protected against the risks associated with poor medicine handling practices.

Systems were in place to make sure that managers and staff reviewed events such as accidents and incidents, complaints and concerns. However, there was not always evidence to show that actions were always carried through. This increased the risk of harm to people and failed to ensure that lessons were learned from investigations.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events, safeguarding and medication that affect people’s safety.

Risk assessments had been completed to guide staff in managing and minimising risks to people.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Applications to restrict people’s liberty had been made where appropriate but the registered manager told us there was a delay with receiving authorisation from the local authority. The manager was aware of recent changes to the legislation and relevant policies and procedures were in place.

Is the service effective?

The service was not always effective. People’s health care needs were assessed but not all care plans had information to guide staff in how to support people appropriately. Most care plans and risk assessments were updated to reflect people’s changing needs. However, we could not find always find evidence that people had been involved in this. The provider referred people to other health care professionals, when necessary, for specialist advice and treatment.

Where people did not have capacity to consent the provider had not always acted in accordance with legal requirements. For example, best interest decisions had not always been carried out in line with the Mental Capacity Act 2005. This meant there was a risk that decisions were made about people’s care without appropriate involvement of people, their relatives or representatives.

Is the service caring?

The service was not always caring. We observed that most staff spoke to people with kindness and respect. However, we found that not all staff were caring and compassionate, and saw that sometimes there was very little interaction by some staff with people they supported. This meant people’s care and support was not always provided in accordance with people’s wishes. We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in their care.

We spoke with two people being supported by the service and asked their opinions about the staff who supported them. Feedback was positive. One person told us that staff “Treat me well” and another said “Staff are wonderful.”

Is the service responsive?

We did not always find staff to be responsive. We saw on two occasions during our inspection that people were in pain or distress and required assistance and re-assurance. We saw that staff did not respond in a timely way.

People told us they knew how to make a complaint if they were unhappy. We saw that the service had logged nine complaints in the past twelve months. These had been responded to but it was not always clear how these had been investigated. In all but one case, the outcomes had been recorded in the complaint file.

Is the service well led?

We found the service was not always well led. There was a quality assurance system in place to identify and address issues and inform improvements. However, actions were not always followed up. For example, on the day of inspection we found that issues identified by our inspector with medication had been identified eight weeks previously during an internal audit. These had still not been addressed and were identified again during our inspection.

The registered manager and senior staff held supervision meetings with care staff to identify training needs and monitor staff performance. Staff told us that they were clear about their roles and responsibilities. They told us that they received training which supported them to carry out their roles. Staff meetings took place which enabled staff to discuss and plan improvements within the service.

People's care was planned and delivered to meet their needs. Staff were aware of people's needs and were able to tell us about people's likes, dislikes and preferred routines. Where people who lived in the home had dementia, staff were aware of how this impacted on their health and well-being. Staff communicated effectively with relevant health care professionals about people's physical and mental health needs and risks to their welfare.

We spoke with five relatives of people who lived in the home. Most of the comments we received were positive about the care provided. For example, one relative told us they had confidence that staff understood their family member's needs and were responsive to changes in their health. Another relative told us that staff looked after their family member "very well" and they felt assured of their safety.

A programme of activities was in place to help ensure people's social and emotional needs were met.

We found that there were arrangements in place to provide training and support to staff. Staff told us they felt supported in their work and received enough training to be able to carry out their work effectively. Relatives of people who lived in the home told us that staff were kind and caring. Most of the relatives we spoke with told us that they felt staff were well-trained and competent in providing care for their family members.

The home had records about people's needs and the care they received. These were stored securely and were located promptly when needed. However, we found that some records were not fully completed which potentially put people at risk of not receiving appropriate care.

We carried out this inspection to check that the provider had made improvements in relation to the care for people who required physical intervention when they became distressed. We found that the provider had arranged training for staff in safe holding techniques to ensure people's safety and care records had been updated to reflect these arrangements. People who lived in the home, and their relatives, were satisfied that Fordingbridge Care Home provided a safe place to live.

We also looked at staffing arrangements in the home to ensure there were enough qualified, skilled and experienced staff to provide care. We found that there were enough staff to meet people's needs and staff worked in a flexible way to ensure that people received the support they required. Arrangements were in place to ensure that staffing levels were kept under review.

We found that staff demonstrated a good understanding of people's needs and were able to tell us how these were met. A training programme was in place to support staff with developing the necessary knowledge and skills for their role.

People who lived in the home, and their relatives, told us that they felt there were enough staff available and that staff had the right knowledge, skills and experience to help them.

We inspected Fordingbridge Care Home on 21 and 29 January 2015. This was an unannounced inspection to check the provider had made the improvements necessary to meet the breaches of regulations we had previously identified.

At our inspection in June 2014 we found the provider to be in breach of a number of the regulations. These were regulations relating to; Respecting and involving people; Consent to care and treatment; Care and welfare of people who use services; Safeguarding people who use services from abuse; Cleanliness and infection control; Management of medicines; Staffing; Supporting workers; Assessing and monitoring the quality of services and records. We issued enforcement notices against the provider in relation to respecting and involving people who use services and the management of medicines and made compliance actions for the remaining areas of non-compliance.

We carried out a follow up inspection in August 2014 to check the provider had made improvements to comply with the enforcement notices we had issued. We found they had met the enforcement notices. However they remained in breach of the regulation for the management of medicines.

At our inspection in January 2015, we found the provider had made improvements in all areas.

Fordingbridge Care Home is registered to provide nursing care for up to 60 older people, some of whom live with dementia. There were 41 people living at the home at the time of our inspection. The home has three floors but the top floor had not yet opened.

The service had a registered manager in place. 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.

Staff were knowledgeable about the requirements of the Mental Capacity Act 2005 and worked with advocacy agencies, healthcare professionals and family members to ensure decisions made in people’s best interests were reached and appropriately documented.

Staff were knowledgeable about the deprivation of liberty safeguards (DoLS). People were not unlawfully deprived of their liberty without authorisation from the local authority.

People were protected from possible harm. Staff were able to identify the different signs of abuse and were knowledgeable about the home’s safeguarding processes and procedures. They consistently told us they would contact CQC and the local authority if they felt someone was at risk of abuse. Information and contact details were available for people and relatives to use if they wanted to raise a concern outside of the home.

Staff received training appropriate to people’s needs and were regularly monitored by a senior member of staff to ensure they delivered effective care. Where people displayed physical behaviours that challenged others, staff responded appropriately by using redirection techniques and only used physical intervention as a last resort.

Staff interacted positively with people and showed respect and compassion when they delivered care and people’s privacy and dignity was respected. Relatives told us staff engaged with people effectively and encouraged people to participate in activities. People’s records documented their hobbies, interests and described what they enjoyed doing in their spare time.

Records showed staff supported people regularly to attend various health related appointments. For example to visit their GP or attend hospital appointments and to have other assessments to support their care, such as speech and language assessments.

People received support that met their needs because staff regularly involved them, or their relatives in reviewing their care plans. Records showed reviews took place on a regular basis or when someone’s needs changed.

The service had an open culture where people and their relatives told us they were encouraged to discuss what was important to them. Surveys were sent out every year to people and relatives to obtain feedback and the results were analysed to form an annual service development plan which we saw was a working document.

The management team was visible and encouraged staff to participate in developing the service. Changes to staff routines had been implemented by the registered manager as a direct result of staff feedback and we were told this had improved the way in which care was provided to people.

Audits were undertaken across a range of areas such as infection control, medication and support plan documentation. However, these audits were not always effective as they did not consistently identify issues of concern. When we raised this with the registered manager and director of care they acted immediately to address the specific issues and told us they would put measures in place to ensure future audits were effective.

We have made a recommendation that the provider reviews and monitors their auditing processes.