The inspection took place on 7 and 8 February and was unannounced.

We previously inspected the service on 5 and 6 September 2016. The service was not meeting the requirements of the regulations at that time. We found breaches of regulations in relation to meeting people’s nutritional and hydration needs, not submitting notifications regarding outcomes to deprive people of their liberty and not ensuring recruitment procedures were operated effectively. During this inspection we found the provider was in continued breach of one of these regulations. However, recruitment procedures and submitting notifications had improved and the provider was now meeting these regulations.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in safe, effective and well led to at least good.

We found during this inspection the provider did not have systems in place to manage medicines effectively and people at risk of dehydration, did not receive adequate fluids.

There was a registered manager in post at the time of our 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.’

Fremantle Court 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 care home accommodates 90 people in one adapted building. At the time of our inspection there were 85 people using the service.

The care home accommodates 15 people in six separate units, each of which have separate adapted facilities. Two of the units specialises in providing care to people living with dementia. The service referred to the units as ‘wings’.

On arrival at the service we were ‘let in’ by a member of staff who did not ask us who we were or who we had come to see. The member of staff opened the door for us and walked off leaving us standing in the main foyer for several minutes until a senior member of staff arrived and asked us who we were. We pointed this out to the registered manager who said they will investigate this.

In general people reported that they felt safe and reasonably well cared for living at the service. We received comments such as, “Overall there is not a problem living here, the staff are caring.” “Oh yes, I feel safe here and I know my [family member] is living just up the road, not far away.” “They are trained, but not on attitude and respect.” Relatives we spoke with reported they felt their family member was well cared for, we received comments such as. “[Relative] is happy, they (staff) are all helpful and it certainly saves me the hassle.”

Medicines were not managed effectively. Some people did not receive their medicines as the prescriber intended. We saw occasions where stock was not available and people did not receive their medicines. We saw on one occasion staff signed medicine records without administering the medicine.

Risk assessments had been completed for people with an identified risk. However, we found some records relating to the risks were not always completed.

We could not be sure people who had been identified as at risk of dehydration did not always receive sufficient fluids, due to poor recording of fluid intake. Air flow mattress checks were not always completed to ensure the mattress was at the correct setting.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; policies and systems in the service did not support this practice.

Safeguarding adults’ proced

This inspection took place on 5 and 6 September 2016. It was an unannounced visit to the service.

We previously inspected the service on 4 March 2015. The service was meeting the requirements of the regulations at that time.

Fremantle Court provides residential and nursing care for up to 90 people. This includes care of people with dementia. The home was full at the time of our visit.

The service did not have 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. A new manager had been in post for six weeks and would be submitting an application for registration in due course.

We received positive feedback about the service. People said they were treated with kindness and compassion and staff were respectful towards them. Comments included "The staff are kind and caring," “All the staff are lovely and very caring” and "I find the care very good and the staff very caring."

Healthcare professionals expressed positive views of the service. One told us said “Everyone I have dealt with has been helpful and with regards to watching them interact and care for residents, this has been with respect and with their best interests at the centre of their care. I always find Fremantle welcoming, clean and a pleasure to visit.” Another healthcare professional told us "It's really clean and people are friendly there. I'd be quite happy for my relative to be there." A third healthcare professional said people were consulted and staff “Checked with residents to see what they wanted,” in terms of options for treatment. They added "They speak to people like equals."

People were protected from the risk of harm. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Risk assessments had been written and were followed, to reduce the likelihood of injury or harm to people during the provision of their care.

The service did not always carry out appropriate checks to make sure relatives had the legal authority to make decisions on behalf of people who lacked capacity. We have made a recommendation about checking who can legally make decisions on people’s behalf. People who did have capacity told us staff asked for their permission before they carried out tasks. The Care Quality Commission had not been informed about the outcome of applications to the local authority to deprive people of their liberty. This meant we were unable to evaluate what restrictions were placed upon people and how the service managed these.

We received mixed responses to whether there were enough staff to meet people’s needs. Some people felt weekends were more stretched. However, we found people received the care they required whilst we were at the service. Staff received appropriate support through a structured induction, supervision and training. There were good communication systems at the home to make sure information about people’s health and welfare was documented and shared with staff. Robust recruitment procedures had not been carried out when recruiting nurses. Checks had not been made of their nursing qualifications and registration with the Nursing and Midwifery Council, to ensure they had the appropriate qualifications to provide care and treatment.

People were supported with their healthcare needs and were referred to external healthcare professionals as required. We found people’s nutrition and hydration needs were not always met effectively by staff. This meant some people were at risk of weight loss or dehydration. We found people’s medicines were not always given to them in accordance with their prescriptions. Medicines were not always promptly

When we visited the service on 16 January 2015, we asked the provider to make improvements to how it monitored the quality of people’s care and the management of people’s care and welfare. The provider sent us an action plan which outlined the changes they would make to become compliant.

We returned to the service on 4 March 2015 to check whether improvements had been made. This was after the date the provider told us all actions to improve the service would be completed.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service effective?

• Is the service well-led?

This is a summary of what we found -

Is the service effective?

We found Fremantle Court provided an effective service.

Improvements had been made to the personal information in people’s care plans. This included details about their histories, interests, families and what was important to them. This helped staff provide personalised care, especially where people have dementia and may not be able to express their needs.

Is the service well-led?

We found Fremantle Court provided a well-led service.

Improvements had been made to monitoring of the service. We spoke with the registered manager and their line manager about how the service was monitored now. They told us they had learned from the findings of the last inspection. Systems had been put in place to ensure actions were completed to improve the service. This included a weekly heads of department meeting and checking progress with meeting targets. This helped ensure the service had effective measures in place to assess the quality of people’s care.

When we visited the service on 23 and 25 September 2014, we had concerns about how people’s care and welfare was being managed. We set a compliance action for the provider to improve practice. We returned to the service on 16 January 2015 to check whether improvements had been made.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the questions we always ask:

• Is the service effective?

• Is the service well-led?

This is a summary of what we found -

Is the service effective?

We found Fremantle Court needed to take action to become an effective service.

There were some improvements to how people’s care and welfare was managed. Each care plan now contained an assessment of the person’s risk of developing malnutrition and plans were in place to minimise high risks. People’s weights were now being recorded and we could see people had been referred to their GP or dietitian where weight loss was noted. This helped ensure people received appropriate treatment to keep them healthy and well.

At the last inspection, we asked the provider to take action to include information in people’s care plans about their backgrounds and histories. This was to help staff provide personalised care, especially where people have dementia and may not be able to express their needs. We found there was a template on which to record personal information but these had not been fully completed. Other information in the care plans we read was not sufficient in documenting people’s preferences and what was significant to them. This meant there was a risk of people not receiving support that was sensitive to their needs.

Is the service well-led?

We found Fremantle Court needed to take action to become a well-led service.

Following the last inspection, the provider sent us an action plan which outlined the changes they would make to become compliant. They told us all actions would be completed by 30 October 2014.

During this inspection, we found the registered manager and provider had not ensured all the actions had been completed.

The provider had a system to monitor the service, including regular visits by a senior manager to assess the quality of care. The findings of our inspection show monitoring had not been effective in checking progress with completing the action plan to improve the quality of people's care. This meant that improvements had not been made in a timely manner.

The inspection was carried out by one inspector over the course of two days. We spoke with a range of staff during the visit, including the registered manager, the head of nursing, head of care, nurses, care workers and the activity organiser. We spoke with two relatives who were visiting the home and with 10 people living at the home. This was the first inspection of the service since it was registered in March 2014.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found Fremantle Court provided a safe service.

There were policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Managers had been trained to understand when an application should be made and in how to submit one. This ensured there were proper safeguards in place.

We observed there were adequate staff to meet the needs of people living at the home. Relatives we spoke with confirmed there were always plenty of staff around. Staff were friendly and courteous when speaking with people and used people’s preferred form of address. They answered people's questions patiently and politely and offered reassurance where people were anxious. We saw staff carried out their duties in an unhurried manner, giving time to people and answering call bells promptly.

The building was bright, spacious and well-designed. Accommodation was spread across two floors and divided into six groups. Each group had its own lounge, dining and kitchenette areas with additional quiet areas where people could sit or see their visitors. People had single occupancy bedrooms with en-suite facilities. They were encouraged to personalise their rooms according to their interests and tastes, to make them homely. The premises were accessible to people with disabilities throughout. For example, corridors and doorways were wide enough to accommodate wheelchair users.

People were protected from hazards at the service. For example, sluice areas were kept locked to prevent people coming into contact with contaminated material. We saw certification to show the gas and electrical installations at the home met approved safety standards. There were regular checks of the fire alarm and emergency lighting. This ensured they were fully operational and could be relied upon, when needed.

Is the service effective?

We found Fremantle Court needed to take action to become an effective service.

Care plans were in place for each person. We read six people’s care plans. These provided assessments of people’s care needs and the support they required. Risk assessments had been written for a range of activities and situations. For example, the likelihood of developing pressure damage and falling. Care plans had been written where people were assessed as being at risk. This helped reduce or control the potential for people to experience harm. However, we noted there was no nutritional risk assessment for one person whose records showed they may have been at risk of malnutrition. Additionally, there was only one record of them being weighed. This meant any potential weight loss may have gone unnoticed.

Care plans contained a section to record a personal profile of the person, such as their interests and hobbies, special memories and people and places that were important to them. The information was intended to help staff provide person-centred care for people with dementia. We found the profiles had not been filled in for three people’s care plans and in another three they were only partially completed. This meant staff were not always aware of important information about people’s backgrounds.

Activities were held in the home throughout the week. The people we spoke with said there was always something they could take part in. For example, during the week of our visit there was tai chi, watercolour painting, cake making and gardening. There was also a cinema room for people who liked watching films.

Is the service caring?

We found Fremantle Court provided a caring service.

People we spoke with were positive about standards of care at the home. Comments included “I’m very happy here, I’d give it top marks,” “The staff are all nice and it’s kept clean,” “It’s very nice here and I’ve got no complaints. The staff are very good and there’s a good choice of meals.”

There was good regard for people’s privacy and dignity and they were supported to be independent. People were able to express their views and they were involved in making decisions about their care and treatment. People told us they made decisions such as when to get up and go to bed. They said they could spend time in their rooms or the lounges as they wished. We heard staff offered people choices at meal times and afternoon tea. They were then provided with what they had requested. The home involved people in staff recruitment interviews. The manager and other staff told us there were several people who were keen to be on the interview panels and they had provided helpful feedback about the suitability of candidates.

Is the service responsive?

We found Fremantle Court provided a responsive service.

People had access to external healthcare professionals, such as GPs and specialist nurses. Notes were kept of these visits to record any advice or recommended treatment. We saw the home facilitated a busy doctor’s round and worked in partnership with the surgery to promote people’s health.

There were arrangements in place to deal with foreseeable emergencies. Personal emergency evacuation plans had been written for each person. Staff were trained in fire safety and a range of fire safety checks was carried out at the home. For example, checks of alarm activation points and the emergency lighting. These measures helped to protect people's safety and welfare.

Is the service well-led?

We found Fremantle Court provided a well-led service.

The provider had an effective system to regularly assess and monitor the quality of service that people received. We read reports which showed the home’s external line manager had visited on at least five occasions to assess care at the home. This included sampling care plan files, observing practice and checking whether there had been any safeguarding incidents, complaints or applications to deprive people of their liberty. Additionally, there had been audits such as an annual audit for nursing services. The report highlighted a need to improve clinical practice at the home. In response to this, the provider’s specialist nurse advisor was working at the home to look at and improve practice.

The provider sought people’s views through residents’ meetings and surveys. We found changes were made to practice as a result of complaints / comments and incidents at the home. For example, closed circuit television was installed after someone had set fire to a skip in the car park earlier in the year.