We visited the home on 27 & 28 October 2016 and carried out an unannounced inspection visit. This meant the provider did not know we were coming. At the last inspection on the 17 September 2015, we had asked the provider to make improvements in meeting people's health and welfare needs. We found that other improvements were needed around record keeping, safeguarding procedures and about people being supported to make decisions. This led to improvements being necessary in the overall running and monitoring of the quality of service by the provider. We received an action plan from the provider detailing how these improvements would be made.

At this inspection we looked at all the areas where the home had breached the regulations described above, and other areas to ensure that we carried out a fully comprehensive inspection of the services provided. We found that there had been significant improvements across all areas and the home was no longer in breach of the regulations.

Throughout this period the provider worked closely and co-operatively with CQC and the local county council commissioning and adult social care teams.

Little Acre Care Home is registered to provide accommodation for people who require personal care. The home can accommodate up to 14 older people, some of whom may have dementia. Accommodation is provided on the ground floor of a bungalow style property. All of the rooms are for single occupancy; 13 of the rooms provide en-suite facilities with the remaining room having close access to a communal bathroom. The home had one vacancy at the time of our inspection.

There was a new registered manager employed at the service since the last 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.

All of the people we spoke with during our visit to the home told us that they were “very happy” with the home and the support they received from staff. Everyone, including visitors and staff said they really liked the new registered manager. They found him “a breath of fresh air” and also said that both he and the owners were very approachable.

One person said; “I think it is excellent here, I looked at a few homes before I came here and I can’t fault it. This really is my home now.” Another said, ”The girls are very nice. I am safe and I comfortable and all my needs are catered for. What more can you wish for.” A third person said, “I’m very content. I couldn’t wish for better. I go to bed when I like and have a sleep in if I want. I can have cooked breakfast and the food is beautiful.”

Healthcare professionals told us of the staff, "They worked beyond the duty of care and always go the extra mile." Another said, "Definitely one of the best groups of staff I have ever worked with, they all really care, and the place is very person centred."

The ethos of the home was one of an extended family. Staff valued each person as an individual, people mattered and staff developed exceptionally positive, kind, and compassionate relationships with the people they supported.

Staff were very knowledgeable about people’s needs and about them as a person. This was a real feature of the home. One person said, “I love this home because its small and you get the personal touch. All the staff know me so well. I’ve known some of them and their families for years. This keeps me in touch with what’s going on. You can't buy that!” Another said, “This place really is my home. I do what I want as if I was at home.”

Training was now a positive feature of the home and staff were very upbeat about increased opportunities for learning. Staff were well supervised and supported to ensure they provided high quality care that was tailored to each person in

We visited the home on 17 September 2015. The inspection was an unannounced scheduled inspection visit.

Little Acre Care Home is registered to provide accommodation for people who require personal care. The home can accommodate up to 14 older people, some of whom may have mild dementia.

Accommodation is provided on the ground floor of a bungalow style property. All of the rooms are for single occupancy, 13 of the rooms provide en-suite facilities with the remaining room having close access to a communal bathroom.

There is a registered manager in post at the home. 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.

All of the people we spoke to during our visit to the home told us that they were “very happy” with the home and the support they received from staff.

One person said; “I cannot imagine that staff would not be supportive. They are respectful and helpful.” Another person told us; “I have never had to complain about anything here. The staff are very, very nice and friendly. I have never seen anyone being unkind here.”

We were also told by a person who had not been at the home for very long; “I have really settled in here. The staff are excellent and very obliging. The food is great and I think I eat too much now.”

A relative said; “It is a relief to know that there is someone here to care about my relative. The staff do try to find out about people who live here, what their interests are for example.”

When we looked at people’s care records, we found that people who used this service were not always involved in decision making and giving consent for their care and treatment. There was little evidence to confirm that decisions had been made in people’s best interests because they did not have the capacity to make those decisions themselves. We found that the provider and staff at the home had limited knowledge of the Mental Capacity Act 2005 and the deprivation of liberty safeguards.

This is a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people who used this service had not been properly supported to make decisions about their care and welfare. You can see what action we told the provider to take at the back of the full version of the report.

This is a breach of Regulation 13: Safeguarding service users from abuse and improper treatment because people who used this service were not protected against the risks of unlawful restrictive practices. You can see what action we told the provider to take at the back of the full version of the report.

We observed that people’s medicines had not been managed safely and had not been stored securely. We found that appropriate plans were not in place to help staff effectively manage “when required” medicines, such as pain killers.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were placed at risk of not receiving the right treatment when they needed it. You can see what action we told the provider to take at the back of the full version of the report.

The sample of care records we looked at during our visit did not reflect the current needs of people who used this service. There was insufficient information and guidance available to staff to help ensure they knew how to support and keep people safe.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were placed at risk of receiving unsafe care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

We looked at the way in which the provider protected people from the risk of abuse or improper treatment. We found that although there were protocols in place at the home and staff had been trained to recognise signs of abuse, the provider had not dealt with potential allegations appropriately. The provider was not fully aware of their duty to report concerns and incidents.

This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were placed at risk of harm because the provider did not have effective systems in place and lacked understanding of their responsibilities. You can see what action we told the provider to take at the back of the full version of the report.

We looked at the way in which the provider recruited new staff to the service. We found that the process was not as robust as it should have been. This meant that people who used the service were placed at risk of receiving their care and support from people who may not be suitable.

We have made a recommendation that the service reviews their staff recruitment practices in line with current legislative requirements and good practice guidelines.

On the day of our visit there was little evidence of social or leisure activities available. Individuals did have their own newspapers and magazines and were able to watch TV or listen to their radios. We were told by people that lived at the home that musical entertainers came into the home from time to time and that there was a regular church service at the home.

We have made a recommendation that the provider finds out more about supporting people with their social and leisure activities, based on current best practice guidance to help ensure people are not left unnecessarily isolated.

Although the provider has started to carry out audits of the service and makes attempts to seek the views of people who use the service, we found that there were some gaps in the process of quality monitoring and service improvement.

We have made a recommendation that the provider seeks further guidance and advice on these aspects of the service to help ensure the service is effectively monitored against current legislation.

During our visit to the home we looked around all areas of the home. The provider had carried out some refurbishment work to the gardens, bathroom, kitchen and laundry areas. This had created a more pleasant environment and improved facilities for people who used this service. We found the home to be clean, tidy and fresh smelling on the day of our visit.

We spoke to people who lived at Little Acre and to some of their friends and relatives. Everyone we spoke to was very complimentary about the home, the staff and the service they received. All of the people we spoke with told us that they “felt safe” and “comfortable” with the staff and managers at the home.

We saw staff supporting some of the people that lived at Little Acre. We noted that staff were very attentive and respectful towards people and provided clear explanations when needed. We saw that staff encouraged people to remain as independent as possible but were on hand if someone did need help or support.

Although care records and risk assessments were not always up to date, the staff we spoke to during our visit were very aware of people’s care and support needs. There was a warm and friendly atmosphere at the home. People living at the home and their visitors commented on this to us. People living at the home at the time of our visit appeared to be compatible. The provider told us that they had made changes to the way in which people were assessed prior to their admission to the home. This included taking into consideration the needs and characters of the people already living at Little Acre.

There are no formal methods of assessing people’s satisfaction with the service. However, when we spoke to people who used the service they told us that they were comfortable in approaching any of the staff or managers in order to discuss concerns, issues or ideas.

We have made a recommendation that the provider seeks guidance about supporting people to express their views on their experience of the service more formally.

SUMMARY:

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?

People told us that they were comfortable at the home. They told us that they had access to call bells so that they could summon help quickly when needed.

One person we spoke to told us, “Staff are respectful and if I had any problems or concerns would speak to the manager or owner.”

We observed staff helping people with their mobility. We noted that assistance was given appropriately and safely. Staff explained the use of equipment and the procedures. This helped to reduce any anxieties service users might have had.

The staff we spoke to confirmed that they had received training with regard to adult protection and abuse. They were able to tell us about the signs of abuse and the processes that were in place to report any suspicions or allegations of abuse. Staff told us that they would not be afraid to speak out if they had concerns about the treatment of people who used this service.

We saw that CCTV had been installed in the hallway and communal lounge at the home. We were told that the camera in the hallway was in use as part of the security systems in place at the home. The camera in the lounge was described by the manager as “a second pair of eyes.” We raised concerns with the manager and the owner about this camera and the implications it presented about people’s privacy.

We found that restrictions had been placed on people who used this service and that there were times when they had been kept under close confinement within the home. Records showed the use of alarms and pressure pads but the records did not include how or why these decisions had been made. It was impossible to tell whether these arrangements were the least restrictive and had been placed on people in their best interests.

We spoke to the owner and registered manager about their responsibilities under the Mental Capacity Act 2005 with regard to the Deprivation of Liberty Safeguards.

We noted that the home was generally clean, tidy and odour free on the day of our inspection visit. There were areas of the home that were not as clean as they might have been and posed a risk to the control and prevention of infections.

We found that the provider had not always recruited new staff safely. Records showed that some required recruitment checks had not been carried out. This put people at risk of being supported by unsuitable staff.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people's needs and involving people in the planning of their care.

Is the service effective?

We found that people who used this service had received an assessment of their care and support needs but this had not included a detailed assessment of their nutritional requirements. More work was needed with this aspect of people’s care needs to help ensure they received appropriate support and interventions when risks had been identified.

Care plan summaries provided useful information about care needs “at a glance” for care staff, but these documents had not always been updated as people needs changed. This was particularly evident in the care plans of two people who had been identified for “end of life" care.

The people we spoke to during our visit to the home told us that they were satisfied with the care and support they received and indicated that their needs were met. We observed that people who used this service all appeared well groomed and well cared for.

Risks and support needs had been identified but there were no clear and detailed strategies recorded to help ensure staff managed these safely and appropriately. We observed staff supporting people with their mobility. In the examples we saw we noted that support was given safely and appropriately.

Is the service caring?

The people we spoke to during our visit to the service told us that they were satisfied with the home and the service they received.

One person told us they were, “Highly delighted with my care and treatment. The carers come in and help me when I need them. The staff are always polite and helpful.”

We were told by someone else, “It’s lovely here. I have regular baths and the food is good. I have a call bell in my room and the staff come quickly if I need them.”

The staff we spoke with were very knowledgeable about the care and support needs of the people who used this service. Staff could tell us about the needs of service users and what was recorded in their care plans.

We observed that staff were caring, attentive and treated people with respect. People were addressed by their preferred name, staff explained procedures to people during moving and handling transfers and checked that people had everything they needed to hand.

We noted that people were able to make choices about their daily lives. For example, what they had to eat and drink, the clothes they would like to wear and where they would like to spend their time.

We noted that people appeared well groomed and adequately supported with their personal care needs.

Is the service responsive?

We found that people who used this service had not received an assessment of their nutritional needs and support. There was some evidence of people having their nutritional intake and body weight monitored. More work was needed with this aspect of people’s care needs to help ensure people received appropriate support with their nutritional requirements.

We spoke to the provider about the gaps in the care planning process. They told us that staff knew the needs of service user's. They told us that they, and the manager, “Speak to the residents every day” so they knew about any changes to needs.

No one raised any current concerns or complaints with us. People told us that if they had any problems or concerns they would speak to the provider or the home manager directly. One of the people we spoke to told us of about an unpleasant incident they had experienced in the past. They told us that the provider had dealt with the matter to their satisfaction and that “everything is alright now.”

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people's needs and involving people in the planning of their care.

Is the service well led?

We saw that there was an annual development plan for quality assurance and a business plan to help ensure any planned improvements for the home stayed on track.

No one raised any current concerns or complaints with us. Only one person told us that they had previously made a complaint about the service. They confirmed that the provider had listened to their concerns and that they had been dealt with appropriately.

There was information available to confirm that systems were in place to assess and monitor the quality of service provision. However, they needed to be developed further and implemented consistently across the service to help demonstrate they were effective.

The provider had procedures in place to help ensure a safe and good quality service was provided. However, we found that these were not always followed. For example, there were gaps in the staff recruitment processes. We found that restrictions had been placed on people with no recorded evidence of best interests assessments.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if they were asked.

People told us they were happy with the care and support they received and were pleased with their accommodation.

“I love my room as it is on the front of the house and I have a lovely view”.

“I like to spend time in my own room and the staff pop in to make sure I am alright”.

Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We did not observe any overtly negative or harmful interactions between staff and people in the home.

People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted.

On our walk around the building we saw that bedrooms were well maintained and people had been able to personalise their rooms with their own pictures and personal items.

People told us they were happy with their care. Visitors told us they really appreciated the care and support their relatives received. Comments included:

"I enjoy living here, the staff are lovely".

"I have a lovely room".

"I have lived here for over a year and I love it".

"My mother could not be better looked after anywhere else. They ring me if there is ever a problem".

"I am always consulted about my husband's care".