The inspection took place on 5 December 2017 and was unannounced. At our last inspection we found three breaches of regulation in relation to protecting people’s rights in relation to the Mental Capacity Act 2005, meeting the conditions placed on people’s DoLS authorisations and safety relating to medicine administration. At this inspection we found that improvements had been made. The rating for the service has improved to Good.

Humphry Repton provides nursing care and accommodation for up to 44 people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection there were 42 people living at the home. The home is split in to two areas. The ‘Green Wing’ has space for 13 people. The remaining rooms are in the main building. People who used the service had dementia.

There was 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 and their relatives were all happy with the service they received. Family told us they were informed and involved in decisions about their loved ones care. Our observations showed that staff were kind and caring in their approach and understood the needs of people they supported.

The service had experienced some difficulties recently in relation to staff vacancies and this had led to a high reliance on agency staff. However, the situation had been managed through using regular agency staff so that as far as possible people received continuity of care from staff who understood their needs. The service had also successfully recruited to carer roles through targeted local recruitment such as advertising in local shops.

People received safe support with their medicines. Medicines were stored safely and the temperatures of these areas were checked regularly. If people needed to have their medicines crushed in order to be able to take them safely, this was done following advice from the GP and pharmacist.

People received effective care that met their needs. Staff worked with community healthcare professionals such as speech and language therapists, occupational therapists, psychiatric nurses and GPs to ensure that people had the right health support in place.

People’s rights were protected in line with the mental capacity act 2005 (MCA). If people did not have capacity to make decisions, family were consulted and involved in making decisions about their care and support. As a result of findings at our last inspection, new systems had been implemented to ensure that the conditions on people’s DoLS authorisations were being met.

People received their meals in accordance with their needs. People were able to be seated where they wished at mealtimes. Some chose to be at the table and others chose to be in armchairs around the room. Meal textures were modified for those people that required it in order to be able to eat safely.

All staff were positive about the training and support they received. On the day of our inspection, staff were receiving dementia training. Staff also received regular supervision as a means of monitoring their performance and development. All staff were positive about working in the home and told us morale was good amongst the team.

Staff were responsive to people’s individual needs and preferences. A pre admission assessment was carried out which helped staff create person centred care plans. There was a range of activities in place for people to be involved in if they wished. This included visits from outside organisations and entertainers. During our inspection we

We undertook an unannounced inspection of Humphry Repton House on 22 and 28 November 2016. When the home was last inspected in April 2015 and March 2016 no breaches of the legal requirements were identified.

Humphry Repton House provides nursing and personal care for up to 45 older people. At the time of our inspection there were 33 people living at the home.

A registered manager was 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 home. 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 home is run.

The home was not always safe as medicines were not always stored or administered safely. Systems to check that medicines were safe were not always effective and documentation in regards to people’s medicines had not always been fully completed. Risk assessments were in place and had guidance in place for staff on how to support people in a way that minimised risks. Staff were knowledgeable in how to protect people from abuse. Incident and accidents were reported.

Staffing levels were at the home’s assessed level but still depended on a high number of non permanent staff members. This impacted on the individual care and support that was needed and the ability of the home to implement effective changes. Staff were supported through regular supervisions and a formal induction programme had been introduced. Staff had training specific to the needs of people. However, we found that not all necessary training was completed regularly.

The home was not always effective as consent to care and treatment was not always sought in line with the Mental Capacity Act (MCA) 2005. Mental capacity assessments and best interest decisions had not always been completed where appropriate. The registered manager was aware of their responsibilities in regards to (DoLS). DoLS is a framework to assess if the deprivation of liberty for a person when they lack the capacity to consent to care or treatment or need protecting from harm is required. The registered manager kept clear records of the steps taken in the DoLS process. However, we found that conditions attached to the authorisations of people’s DoLS were not always being met.

The home was caring as people were supported by staff that were kind and respectful. We observed positive interactions and relationships between staff and people living at the home. Staff knew people well and their personal preferences. Staff responded to people’s changing needs and were flexible in their approach.

The home was responsive. Care plans were person centred and gave clear guidance to staff as to how people wished for their care and support to be delivered. People were supported to engage in activities and outings. The environment , décor and items within it had been considered in response to people’s care and support needs.

The home was not always well-led. There were systems in place to monitor and review the quality of care and support. However, the systems in place were not always effective in identifying areas that required improvement or instigating the necessary changes. We received positive feedback in regards to the registered manager and the changes being made to improve the home. Staff told us they felt valued supported and involved. Information was communicated effectively to staff and relatives. Staff could contribute their feedback and ideas through meetings.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made one recommendation in relation to improving the effectiveness of audits. You can see what action we told the provider to take at the back of this report.

We carried out an unannounced comprehensive inspection of Humphry Repton House on 6 April 2015. At which there were a number of areas identified that required improvement. We had found that staffing levels were not assessed in a way that ensured the numbers were always correct to meet people’s needs. This meant there was not enough staff on duty at certain times.

We had also found that people were supported by staff who had a varied understanding of the Mental Capacity Act 2005. Some staff clearly understood what their legal responsibilities were while other staff were not sure. The provider had a quality monitoring system in place to ensure checks were undertaken on the service people received. However, audits and checks that the registered manager was required to do were not done as often as the provider’s policy required. This meant there were risks that people could receive unsafe and unsuitable care.

After the comprehensive inspection, the provider wrote to us to say what they would do to improve the service. We undertook a focused inspection on 4 March 2016 to check that they had followed their plan and to confirm that they had taken action to improve the service.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Humphry Repton House’ on our website at www.cqc.org.uk.

At our focused inspection on 4 March 2016, we found that the provider had not fully implemented their plan which they had told us would be completed by October 2015.

The way that staffing was deployed across the home did not always fully meet people’s needs. This meant there was not enough competent staff on duty at all times who knew people well to meet their needs.

People were still supported by staff who had a varied understanding of the Mental Capacity Act 2005. Some staff knew what their legal responsibilities were while other staff did not have the same level of understanding.

The management audits and checks were not done as often as the provider’s policy required. This meant there were risks that people could receive unsafe and unsuitable care.

The inspection took place on 07 April 2015 and was unannounced. At our last inspection in January 2014, the service was meeting the requirements of the regulations.

Humphry Repton House is registered to provide accommodation for persons who require nursing or personal care for up to 45 people. On the day of our visit there were 44 people at the home.

There was a registered manager for the service. 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.

Staffing levels were not assessed in a way that ensured the numbers were always correct to meet people’s needs. This meant there was not enough staff on duty at certain times. Staff expressed concerns about the numbers of staff and the mealtime experience for some people on the day of our visit was disorganised. Some individuals were not receiving their care at the time they needed it.

We have made a recommendation around staffing levels for people with dementia.

There was a system in place to try and ensure that the requirements of the Mental Capacity Act 2005 was followed when people were identified as requiring their medicines given to them covertly. Best interest meetings were being carried out. However the system was not fully effective as information from these meetings was not communicated effectively to the staff who needed to know it. This meant there was a risk peoples legal rights were not protected.

People were supported by staff who had a varied understanding of the Mental Capacity Act 2005. Some staff clearly understood what their legal responsibilities were while other staff were not sure.

We have made a recommendation around  implementing the requirements of the Mental Capacity Act 2005.

We found there was a lack of documented evidence to show that care plans had been fully evaluated. This meant information about how to meet people needs may not have been up to date

The provider had a quality monitoring system in place to ensure checks were undertaken on the service people received. However, the audits and checks that the registered manager was required to do were not done as often as the provider’s policy required. This meant there were risks that people could receive unsafe and unsuitable care.

There were safe systems when new staff were recruited. All new staff completed thorough training before working in the home. Staff were aware of their responsibility to protect people from harm or abuse. They knew the action to take if they were concerned about the safety or welfare of an individual.

People had an individual plan of care in place that set out what support they needed and how they wanted this to be provided. The staff understood people well and knew how to support them to make choices about the care they received.

People were treated with kindness and care by the staff who supported them. The staff engaged positively with the people they assisted. Staff were able to communicate effectively with people who were not able to verbally express their needs.

People were supported to eat a choice of meals, snacks and drinks to stay healthy. Care plans included guidance to support people with complex nutritional needs to ensure they stayed healthy. Care plans were reviewed regularly but the information recorded lacked detail.

Consideration was given to ensuring stimulating activities were available that were relevant to people’s needs. A lively gardening group took place on the day of our visit. There were also a variety of other groups and sessions suited to the needs of people living with dementia.

People were able to see their friends and families whenever they wanted. There were no restrictions on when people could visit the home. All the relatives we spoke with told us they were made welcome by the staff.

People were supported to make a complaint and where people could not make their views known their relatives or representatives knew how to raise concerns.

You can see what action we told the provider to take at the back of the full version of the report.

At our inspection on 30 August 2013 we had found that care and treatment had not been planned and delivered in a way that ensured people's safety. Nor did care plans demonstrate that people’s needs were met effectively.

We had also found that the provider had not responded appropriately to incidents of possible abuse. There were a number of incidents of aggression between people at the home. Some of these incidents had not been responded to in a way that aimed to keep people safe.

The staffing levels were inadequate to ensure that people received the care and support they needed.

We also found that quality checks on the suitability of staffing arrangements were not in place. This had meant that people were at risk of receiving unsafe care.

Humphry Repton House is registered for up to 44 people. When we carried out our inspection there were 36 people in the home.

At this inspection we saw that action had been taken that demonstrated that the provider responded appropriately to incidents of possible abuse. We saw that when there were incidents of aggression between people at the home there were risk assessments and strategies in place. These were to support staff to respond in a way that aimed to keep people safe.

The provider had put in place a quality checking system on the effectiveness of the staffing arrangements to ensure there were enough staff on duty to meet people’s needs.

The home is registered for up to 44 people. On the day of our inspection we were told there were 42 people in the home.

We observed staff were friendly when they assisted people with their needs. When people were not able to make their views known we saw that the staff communicated by facial expressions, body language, and gentle humour.

People had positive views of the meals at the home. People who used the service were provided with a varied and nutritious diet. Where needed the advice of dieticians was sought to support people with nutritional needs.

We found that staffing levels were inadequate to ensure that people received the care and support they needed. For example, people who needed supervision were not receiving this; and certain people’s care needs were not being met because they were not getting sufficient support. Also a person was not being helped to have a shower on a weekly basis as their care plan stated they required.

The quality of care was monitored however quality checks of the suitability of staffing arrangements were not in place. There was evidence that some shortfalls in the service were acted upon. For example a carer’s’ support group had given feedback about shortfalls in staffing and an excessive use of agency staff. A consultant had been employed to implement a staff recruitment and retention strategy for the home.

We carried out this inspection following information we received that raised concerns around nutrition and the level of nursing input people received in one area of the home known as 'green wing'.

During our inspection we were unable to speak to people living in the home as the people had complex needs and were living with dementia. However, we spoke with staff and relatives of people living at the home. We also observed people living at the home to gain an insight into people's experiences of living at the home.

People’s needs were assessed and care plans developed and agreed with people or their representatives. We saw that when a risk was identified a care plan was put in place which contained guidance for staff on how to ensure that these needs were met.

Staff were knowledgeable about the needs of people in relation to eating and drinking. We observed staff assisting people with eating and drinking, respectfully and appropriately. We saw that where people had been assessed as at risk of becoming dehydrated or malnourished priority measures had been taken.

We found that the people living on green wing did not have regular input from qualified nursing staff. The home did not have formal procedures in place for when staff working on green wing should contact the nursing staff for advice on people's health needs.

We found that staff at the home received support appropriate to their role.

Our inspection of 4 April 2012 found that the provider was not meeting six essential standards and compliance actions were set. During this visit we reviewed the actions that the provider had taken to meet the compliance actions set. We also looked at staffing levels in the home as we had concerns raised to us in this area.

The people in this home were all living with dementia. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed staff supporting people in a dignified and respectful manner. Throughout the day we observed good interactions between staff and people who used the service. For example a member of staff was talking with a person who was becoming anxious. The member of staff was very calm and reassuring and held their hand to comfort them.

The home had made changes to the way in which mealtimes were organised. We observed that people were supported appropriately to meet their needs at lunchtime.

We saw that people were involved in making decisions about the care and support they received. We also saw that relatives and relevant professionals were invited to best interest meetings, held for people who did not have the capacity to make their own decisions.

We did not discuss the outcomes with the people who live in the home as their dementia did not give them sufficient understanding of the questions we would have asked, therefore, in view of the communication difficulties of people who use the service, we relied on observations between the staff and people who use the service in order to understand their views of the service.

We also spoke with three relatives during our visit, one relative told us “I’m very pleased with the care received my relative has improved since being here”. Another relative said “the staff are very caring I have no complaints, they consult me first now before any changes are made to my relatives care”.

Three relatives did say the constant changing of staff from wing to wing was not helpful for people with dementia living in Humphry Repton, as they have to remember who the staff were. All relatives spoken to during and following the inspection, felt it would be good to maintain the same staff team in each wing wherever possible for consistency. This concern was echoed to us by two members of staff.

One relative felt the TV in the green wing could be moved to the lounge and have chairs around it, as it would feel safer and more like home. One person told us that relative meetings do take place at the home but often no feedback is given at a later date on points raised so they were unsure if their ideas or concerns were acted upon.

We observed staff offering people choices about how and where they wanted to spend their time and what food and drinks they wanted.

Staff we spoke to believed that people were treated well by the team and they had no concerns about the safety of people living in the home. On the whole staff were motivated, caring and positive about working in the home. However, we also observed some poor practices that put people at risk of injury. This included a person being wheeled in a chair with no foot rests and a second person that also had no footrests on the wheelchair they were being moved about in. We saw one person with their dignity compromised due to their catheter bag which was half filled with urine being in full view.

During our visit we asked the a senior member of staff to tell us about the people that live at the home, we asked them to tell us about the types of support that people needed and to explain to us how people were supported by staff. We were concerned that this member of staff made disrespectful comments when describing people that live at the home and used inappropriate language when describing the way that some people behaved. This showed a lack of respect and concerned us that this use of language could be adopted by other staff employed in the home. Although no further evidence of this was found during our inspection visit.