Mallands provides accommodation and personal care for a maximum of 38 older people. 31 people were living there at the time of the inspection. People who use the service include people with dementia and people with physical needs, as well as people staying for a short while for respite or convalescence. 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.

Mallands also provides personal care support to people in their own homes in the community. Five people were receiving this support at the time of our inspection.

There was 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.

People, relatives and staff expressed a very high level of confidence in the leadership and management of the service. Comments included, “I truly believe you have a fabulous leader as someone who understands how care homes should be run and how the patients need to be treated” and, “It’s the first home I’ve worked in and I think it’s amazing. The directors are really supportive, not just sitting in the office and telling us what to do.”

The providers and registered manager were passionate and committed to developing a service where people received genuinely person centred care. Their ethos was influenced by current evidence based approaches such as ‘Dementia Care Matters’ and the ‘Eden Alternative’, and shared across the staff team. This approach saw ageing as a continued stage of development and growth and supported people to play a full and active role in their community by challenging loneliness, helplessness and boredom.

The providers had considered the layout and décor of the building and taken advice from a leading academic in dementia care, to create a dementia friendly environment. This meant they were challenging helplessness by enabling people living with dementia to find their way around independently. They had also considered how technology could be used to promote people’s independence through the provision of a ‘smart device’ which people could ask to play music, tell them the time or the weather forecast. This would be particularly useful for people with a visual impairment, or who were cared for in their rooms.

Activities were developed according to people’s history and interests and often had a purpose, enabling people to contribute to the life of the home and community. For example, people supported the homes’ cooking club and sewing club by growing lavender in the herb garden for the sewing club to make scented pouches, and spices for use in the cooking club. This challenged loneliness and boredom, giving people opportunities to socialise and a sense of purpose and wellbeing. Community links were established, which meant people could access life outside of the home.

People received care from staff who had received comprehensive relevant training and induction. There were sufficient numbers of staff on duty to meet the needs of people using the service and spend quality time with them. This meant that ‘impromptu’ and unplanned activities could take place like a walk in the garden followed by a hot chocolate. The service supported people to develop close relationships with each other and with care staff and we saw lots of positive interactions during the inspection. Staff ran clubs including weaving, cooking and painting after people had said they would like to spend more time speaking with them.

People’s nutritional needs were met because staff followed people’s support plans to make sure people were eating and drinking enough and potent

We carried out this inspection as a part of our scheduled inspection programme and to follow up on some concerns we had received.

This inspection was carried out by an adult social care inspector and an expert by experience. During the inspection we looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Mallands is a care home without nursing providing care and support for up to 38 older people, most of whom have some degree of dementia. The home also provides a small domiciliary care service to local people. We spoke with eight people who lived at the home and two people receiving a domiciliary care service about their experiences. We also spoke with four relatives, five members of staff and two members of the management team. We reviewed records relating to the management of the home which included seven care plans and observed the care and support people received.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

During our inspection we saw staff supporting people well. No-one we spoke with had any complaints about the staff or the care they delivered. They told us the staff were caring and we observed staff being friendly warm and cheerful with people. We saw staff speaking in affectionate and appropriate tones with people. For example we saw staff asking people “Do you fancy any more to eat?” and “Would you like another cup of tea?”. We saw staff sat with individuals in the home’s sensory room and discussed the daily papers with people in the main lounge.

We saw that on the day of the inspection the home was celebrating one person’s birthday. We saw and heard staff celebrating with the person and involving others in the event. We saw that people had celebrated with sherry and cake. This helped the person retain a sense of their past history and individuality.

A relative we spoke with told us they visited all the time and said the home was “Brilliant – I wouldn’t hesitate to come in here myself”.

Is the service responsive?

Two relatives we spoke with told us they thought that the staff understood people with dementia and responded to people’s needs well. We saw evidence in some of the care plans of guidance concerning management strategies for supporting people who became distressed or agitated due to their memory problems. This was personal to the individual and gave staff clear guidance on an appropriate stepped approach to support the person. Two relatives we spoke with described the atmosphere as “calm” and “relaxed” and that this helped people with dementia.

However we did not always find that staff were able to respond to people in a person centred way, as they did not know much about people or their lives before they came into the home. This was despite this information being available in the person’s care plans.

We saw that the home responded to complaints or concerns raised with them. A relative we spoke with told us about a minor concern they had raised with the home’s management. They told us the issue had been addressed and had not re-occurred and they were satisfied with the response they had received. We saw that concerns had also been raised with the provider prior to our inspection about the home’s induction programme. When we arrived we saw that changes had already been made to make this more in depth. This told us the home had responded appropriately to the concerns.

Is the service safe?

We found that people’s needs had been assessed but care and treatment was not planned in sufficient detail or delivered consistently in line with their individual care plan. Where plans did indicate an appropriate level of detail we saw that care was not always delivered in accordance with the plans. This put people at risk of unsafe or inappropriate care.

We had concerns about the safety of the systems for managing medication. We had concerns about the safe ordering, storage, recording and staff understanding of the medications in use.

We also had concerns about the staffing arrangements. We found that there were not enough staff on duty at night to manage the care needs of the people accommodated. We also found that although staff had received training we found that this was not always implemented in practice. We found some staff lacked the skills and knowledge they needed to support people’s needs well.

We identified some risks in the environment, such as safety razors left out in bathrooms and fire doors being kept open. These put people at risk.

Is the service effective?

The effectiveness of the service was challenged by the wide variation of the needs of the people who lived there. For example some people were living with advanced dementia which had left them in need of total care. Other people were able to go out into the local community unsupported, and some were only at the home for a short respite or recuperation stay. However people we spoke with told us they felt safe and well cared for at the home.

People we spoke with told us they were satisfied with their care. People told us for example that they received their medication at the appropriate time if this was outside of the regular medication rounds. For example some medication was given out by the night staff as it needed to be given at a specific time before food. One other person told us they had medication at 4pm as a part of a specialist regime. This helped people maintain their healthcare needs.

The home also provided a small domiciliary service to the local community. One person who received care from the domiciliary service told us “I have improved so much with all the help I have been receiving. I never thought I would be able to get this much better. I am delighted. And all the girls are lovely – really caring towards me.”

Is the service well led?

Mallands is a family run business, with an employed manager working full time and in day to day control. We saw that the staffing structure below this level was depleted of senior staff for which recruitment was occurring.

The manager was experienced and had a clear idea of the ethos and philosophy of care she wished Mallands to provide. She had made significant inroads into this area with regard to dementia care. Staff had been trained in appropriate care delivery. However we did not see that all staff were always following through the same principles or practice.

We saw that there were clear systems for auditing the quality of the service and making improvements. However we also identified a number of concerns on the inspection that had not been identified or had not been actioned yet by the home’s management and quality assurance systems.

30 people were living at Mallands when we inspected. We spoke with eight of those people and to relatives of two other people. People and their relatives were positive about the care delivered. Comments included, "They are all sweet here. I generally get the help I need".

During a previous inspection on 23 and 29 April 2013 we found that improvements were needed in some aspects of care recording and delivery, staffing, quality monitoring and adherence to infection control policies.

During our inspection on 23 July we found that the provider had taken a range of effective actions and was now meeting required standards.

We found improvements in the recording and updating of care records and consistency of care delivery. People told us they received their planned care. We observed that staffing levels were more consistent, particularly in the lounge area. Relatives also told us, "Staff are much more available now. There seem to be more in the lounge and there is a call button in there too." Records showed, and staff confirmed, that there was a better skills mix on each shift and that additional senior carers had been recruited.

The provider had taken prompt action to ensure that infection control policies were understood and followed. We observed good infection control practice during our visit. Substantial improvements had been made to ensure that quality assurance systems were more robust and effective, such as increasing the range and frequency of audits.

We (the Care Quality Commission) inspected Mallands Residential Care Home on 17 September 2012. During this scheduled inspection we also reviewed some improvements that the home had said they would make following an inspection on 9 December 2011. The home submitted an action plan and said that improvements would be made by the end of July 2012. We also looked at other essential standards which had not been recently inspected.

We spent eight hours at the home. We spoke with people who lived there and their relatives. We also spoke with eight staff who worked there and a visiting health professional.

Thirty people were living at Mallands on the day of our inspection.

We spoke with six people who lived at the home. Some other people who lived at the home were not able to communicate with us and we used an observational tool (SOFI - short observational framework for inspection) to help us to understand their experience of living at Mallands. We observed care which was appropriate to people's needs and was delivered respectfully.

The people we spoke with who lived at Mallands told us that they felt safe. They also said that staff were kind and their care was good. One person said, “Yes, they are always very kind and I am very comfortable here. I'm not worried about anything". Another person told us, "The staff are sometimes very busy but they do a very good job, I'm well looked after." People who lived there praised the overall condition of the home. Comments included, "The rooms are nice. I think the place is superbly clean", and "I think it's well looked after"

We also spoke with five relatives of people who lived at the home. Relatives we spoke with were generally positive about the care provided. Two relatives told us that they thought the home had improved in recent months. One person told us," I have had such support from the home, right from the start. I've also noticed an improvement over the recent months”. One person told us that they felt staff were very busy in the early evenings, but that staff were dedicated and caring.

We spoke with staff on different shifts throughout the day and evening. Staff told us that they enjoyed working there and thought the job they did was worthwhile and rewarding. They told us that they usually felt that there were enough staff to meet people's needs but that it was a busy home.

People who live in the home told us that they felt well treated and were happy with the staff at the home. Comments included “It's lovely here, all the staff are so kind”, “We live in a very nice place” and “l am happy living here but I would rather be in my own home”. Laughter and appropriate use of affection was heard and seen throughout the visit.

We saw signs of well being and many examples where people were being treated with respect by staff. People sitting in the lounge area appeared in a positive mood and were engaged in activities such as watching television, doing puzzles, talking to staff and walking around the home. Conversations were genuine, warm and enabled people to feel included and valued.

All those we spoke with confirmed that they are more than satisfied with the quality of care and attention they receive at Mallands. However, none could recall being involved in planning how they wished their needs to be met or in any reviews of care.

We asked people about the ability of the staff to provide the care and support they needed.

Their responses included, “They all seem to know what they are doing”' and another “they are all very good and work very hard, sometimes there don’t seem to be enough of them”. Other comments included; staff are “Helpful and cheerful", "Good and seem to know what they are doing”.

We asked people whether there were enough staff to meet their needs. We were told that staff were usually available when they needed them. Comments included “They are always very busy and I often have to wait, but I know there are other people they look after as well as me”, “They are all good, some better than other but they can never spend time with me” and another “They rush me”.

We were given examples of choices that people are given, such as what time they get up, where they eat, and how they spend their time. Six people we spoke with told us they did not have anything to complain about and said that if they did the manager or their deputy were at the home each day to sort things out.

This inspection was unannounced and took place on 10 February 2015 and 20 February 2015. The home was closed to visitors due to an outbreak of influenza on our first visit, so we returned for a second day to speak with the people who lived at the service and any visitors.

Mallands Residential Care Home provides accommodation and personal care for a maximum of 38 older people. People who use the service include people with dementia and people with physical needs, as well as people staying for a short while for respite or convalescence. Mallands also provides personal care to people who wish to retain their independence and live in their own home through a small domiciliary care service operated out of the home. At the time of our inspection this was providing care to seven people in the locality.

At our last inspection of the home on 28 July 2014 we had identified concerns about the operation of the home. These were related to people’s care and welfare, management of medicines, staffing levels, and how the service assured the quality of the services provided. The provider sent us an action plan telling us what they were going to do to put this right. They told us they would have completed this by November 2014. On this inspection we saw the necessary improvements had been made and sustained across these areas.

The service had 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.

Risks to people’s health and welfare were assessed and management plans put in place to address concerns and reduce risks. People were protected from abuse, discrimination and their rights to make decisions were upheld by staff who understood their responsibilities. Staff asked people for their consent before delivering care, and where people lacked capacity appropriate steps were taken to protect people’s welfare in accordance with the Mental Capacity Act 2005.

Improvements had been made to ensure that sufficient staff were available to ensure people were cared for in a safe way, both at the home and in the domiciliary care service. This had included the recruitment of new senior staff, and a new deputy manager post, and ensuring that there was an additional person on night duty each night. This meant that there were enough staff available to respond to people’s needs.

There were robust recruitment arrangements in place so staff recruited were suitable to care for vulnerable people. This included the taking up of disclosure and barring checks and references. Improvements had been made to staff training and staffing structures to ensure that decisions about people’s care were being made by staff with the appropriate skills, knowledge and experience.

Staff received the training they needed to care for people effectively, including induction and ongoing support. Staff were regularly updated on care issues with a rolling programme of training, and were not allowed to deliver care unsupervised until they had been assessed as being competent.

Improvements had been made to the medication systems at Mallands since the last inspection, and medication was being managed well. People received the correct medication at the correct time, and storage was secure. Medications were reviewed regularly both by the home and the supplying pharmacist.

Staff had an understanding of the Deprivation of Liberty safeguards and their responsibilities under the Mental Capacity Act 2005 for obtaining consent for care. Appropriate applications had been submitted for authorisations to deprive people of their liberty to maintain their safety.

People living at the home received a balanced diet with choices at each meal. People at risk of poor nutrition or hydration were assessed and records kept of all of their intake. Where significant risks were identified action plans were put in place to support the person with enhanced meals and snacks. Snacks and drinks were offered regularly but were also available for people to select from at any time.

We saw that staff and management were positive about providing good quality care. People who used the service were supported by staff who had built caring relationships with them. They were treated with respect and their privacy and dignity were promoted. We saw staff engaging in affectionate and good humoured interactions, and ensuring people’s communication was understood even if this was not verbal. People were involved in decisions about their care. We saw good relationships in place and an understanding of people’s emotional needs and well-being.

People’s needs were assessed and care plans identified how to support them with their care needs. These plans were tailored to the individual and reviewed as people’s needs changed. We saw that people had access to community healthcare to meet their needs, including access to medical, nursing and physiotherapy services.

Mallands had moved towards making activities more ‘person centred’ for people who lived there, and work was being undertaken to further identify areas from people’s social and personal history to support them with interests and lifestyle choices.

We saw that there was an open culture at the home. Staff told us the management team were approachable. They had also developed a clear management structure, which had been significantly strengthened since the last inspection. This meant that decisions about people’s care could be made by staff with the correct skills, knowledge and experience in a timely way. Complaints or concerns were managed well and learning took place as a result. People who used the domiciliary care service told us they were satisfied with the care they received.

Quality assurance systems drove improvements and raised standards of care. The service learned from incidents and regular audits highlighted potential for improvement.