This inspection took place on 21 February 2017 and was unannounced. When we last inspected this service in April 2016 we identified breaches of regulations in relation to medicines management, staff training, supervisions and appraisals, and managerial oversight of the service.

Fouracres is a care home which has been registered to accommodate a maximum of four people with mental health issues and learning disabilities. Fouracres also provides permanent, as well as long-term and short-term respite care to people. On the day of our inspection there was one person using the service.

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. During the inspection the registered manager was not present. The registered provider and an interim manager were present.

Medicines were now safely managed. At the time of the inspection, medicines were not in use at the service, however all staff had received training, and systems were in place to commence staff competency checks when medicines were next in use at the home. Medicines audits now formed part of the overall quality assurance systems in place at the home.

Staff were now receiving regular supervisions and an annual appraisal with the interim manager. Where a new member of staff had been recruited, they had completed a comprehensive induction which had been signed as completed.

There was now increased managerial oversight of the service. Regular weekly and monthly audits were completed on all aspects of the service.

Detailed current risk assessments were in place for the person who used the service. Risk assessments in place were reviewed and updated regularly. The risk assessments explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person.

Care planning were person centred and reflected what was important to the person. Care needs were regularly reviewed and updated to meet the changing needs of people who use the service.

We saw friendly, caring and supportive interactions between staff and people and staff knew the needs and preferences of the person using the service.

People were supported to maintain good health and had access to healthcare services.

The service regularly requested feedback from people who used the service, their relatives and professionals involved with the service.

The person was encouraged and supported to access the community and engage in a wide range of activities of their choosing.

This inspection took place on 19 and 20 April 2016 and was unannounced. When we last inspected this service in May 2014 we found the service met all the regulations we looked at.

Fouracres is a care home which has been registered to accommodate a maximum of four people with mental health issues and learning disabilities. Fouracres also provides short-term respite care to people. On the day of our inspection there was one person using the service.

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. During the inspection the registered manager was not present. The registered provider and an interim manager were present.

We found three breaches of regulations. Medicines were not always managed safely. Medicines were not stored in the correct way and the home did not have arrangements in place to store controlled drugs. The administration of medicines to people who use the service were appropriately recorded by staff. The home had a clear medicines policy in place which was accessible to staff. A medicines audit had not been carried out since 2014. Staff had not received recent medicines training.

We saw evidence of a comprehensive staff induction programme. However the induction programme had not been completed by staff prior to sign off. Staff did not receive regular documented supervision or appraisals.

No recent audits were carried out for any part of the service. The service had system in place auditing for health and safety and medicines, however, this had not been completed since August 2015.

People were supported to eat and drink. People were consulted about menu choices. However, during the inspection we found out of date dairy produce and food was not always correctly stored or labelled once opened.

Statutory notifications were not submitted to CQC when required.

Systems were not in place to ensure the quality of the service people received was assessed and monitored. Audits had not been recently carried out.

Staff were safely recruited and the necessary pre-employment checks were completed. Staff also had regular criminal records checks.

Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of types of abuse to look out for and how to raise safeguarding concerns.

A detailed current risk assessment was in place for the person using the service. The risk assessment explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person.

The home maintained adequate staffing levels to support people both in the home and the community which supported people wishes to increase their independence.

We saw friendly, caring and supportive interactions between staff and the person using the service and staff knew their needs and preferences.

The care plan was person centred, although key working sessions were not regular.

All staff had received training on the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and staff understood what to do if they had concerns as regards people’s mental capacity.

People are supported to maintain good health and have access to healthcare services. Referrals are made appropriately when concerns are noted as regards people’s health.

The provider and interim manager were accessible to people and staff who spoke positively about them and felt confident about raising concerns.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

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

Is the service safe?

Our inspection of 27 January 2014 found that people were at risk as there were not enough staff available to meet their needs and respond in the event of an emergency to maintain their safety. On the day of our inspection one person was using the service. We saw that the person received one to one care from a member of staff. The rota showed that the manager and two members of staff were on duty throughout the day. Risk assessments were in place to ensure that person's safety and well-being was maintained when receiving care. Risk assessments provided guidance for staff on how to minimise risks to people.

The person's records including their care plans were accurate, and had been reviewed and updated at regular intervals. Care records gave an explanation of how the person's needs were to be met. This meant that care records supported staff to provide safe and appropriate care to the person who used the service. Personal records including medical records were accurate and fit for purpose.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Our inspection of 27 January 2014 found that staff had not completed all the relevant training they needed to meet people's needs safely, and the provider did not have a training matrix that showed when staff would receive this training. At this inspection we found that a training matrix outlining what training was needed had been put in place.

Staff received appropriate professional development. We spoke with one member of staff who told us they had recently received training in challenging behaviour, epilepsy, first aid, and breakaway and restraint techniques. We looked at the training records for three staff and saw that they all had received this training recently. Staff understood how to apply what they had learnt to their work with the person who used the service.

We looked at the care plan for the person who used the service. This provided information about the person’s needs and gave guidance for staff about how they should be met. People’s health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. The records of the person using the service showed that they were supported to have regular health checks with their general practitioner, psychiatrist and other care professionals.

Is the service caring?

We observed that the person’s changing behaviour was responded to sensitively in a manner that enhanced their well-being. Where necessary the appropriate professionals had been consulted for advice regarding person’s behaviour. Staff explained that the person using the service often found it difficult to go to the surgery or to hospital appointments as this made them anxious. Staff told us that they had spent time taking the person to the surgery and the hospital so that they overcame their anxieties about seeing health professionals. This was documented in their care plan and the care plan gave staff guidance on how they were to respond to the person's anxieties when accessing healthcare. This meant that the person was supported to meet their health needs in a way that maintained their well-being.

Is the service responsive?

Care plans identified the person's needs resulting from their cultural background. Daily notes showed that the person who used the service had taken part in activities and were supported to access their local community. For example, the person was supported to go to the park and to do their shopping.

Staff knew how the person communicated and responded to the person’s requests. The person’s views were recorded in one-to-one meetings, and when their care plan was reviewed. Staff explained that regular key worker discussions were used to help the person to be involved in decisions about their care. Staff listened to people and acted on their views.

Is the service well-led?

People who used the service, their representatives and staff were asked for their views about their care and treatment and these were acted on. An annual quality survey had been carried out. The manager explained that a report had been produced, and any suggestions to improve the service were addressed. Peoples' suggestions were used as the basis to improve the care provided by the home.

Staff told us they were able to make suggestions to improve the home. Staff said the manager was supportive. They felt that staff meetings provided them with a way to raise issues. Staff were supported by the manager to take an active role in improving the care of people.

We received information of concern that people's care needs were not being met as staff were not always available and were not trained to meet their needs. On arriving at the service we found one member of care staff and the manager working at the home. Two people were using the service. One person came out of their bedroom and appeared to be distressed. Although staff were aware of this they did not come and support the person.

We looked at one person's care plan and found that it did not show how the service would support them to develop their independent living skills. Apart from attending a work placement each week there was no other evidence his care plan that showed how the person's skills would be further developed. Staff spoken to could not tell us how they would work with the person to enable them to be more independent. We asked both staff and the manager how an emergency situation would be handled when only one member of staff was working in the service. They could not tell us how they would respond to a medical emergency.

We looked at the training records for the four staff currently working at the service. These showed that there were number of areas where all staff had not completed the relevant training. We saw that one person needed specific support in developing their independent living skills. Records showed that no staff had received this training.

We observed that people were involved in and consulted about decisions affecting their care. One person said, "I can do the things I like." There were effective recruitment and selection processes in place. Staff told us that they had been through a detailed recruitment process. Staff had the skills and support necessary to met people's needs safely.

The provider explained that she had carried out a survey of people, their relatives and professionals to obtain their views of the quality of the service. The quality of service provision was assessed and monitored. For example, there is now a training and supervision plan to make sure that staff receive the training and support they need. People's personal records, including their care plans, were accurate, and had been reviewed and updated at regular intervals.

We observed that people were involved and consulted about decisions affecting their care. We saw that staff understood people’s needs. Staff spoke with people in a manner that showed respect and met their individual needs.

Staff spent time talking with people and engaging in one to one activities with them. Staff said that sufficient staff were available to meet people’s needs throughout the day. We looked at the files for the three new staff. There were no skills for care induction records to show this induction process had been completed. Staff had not received all of the training and support they needed to care for people safely.

We were told that there had not been a formal survey of people, relatives and other stakeholders about how the service could be improved. The provider could not show us how the delivery of care and management of the service were monitored, but said that there had been some consultation with relatives about care and support needs.

We observed that staff knew how to care for people. People said to us that staff were generally available to help them. However, it was not possible to confirm that sufficient staff were always available to meet the needs of people do use the service. We saw staff knew how to meet people’s needs.

People were treated well by staff. We saw that staff understood their needs. People may not be safe and might be at risk of being abused as staff had not received up-to-date safeguarding training.

We observed that people were involved and consulted about decisions affecting their care.