About the service: Mary Fisher House provides residential care for up to 24 older people and people living with dementia. At the time of the inspection 23 people lived at the service.

People’s experience of using this service: The service was under the management of a court appointed administrator. Since their appointment in November 2018 the administrator had acted to meet recommendations and breaches found at the last inspection. Planned improvements were at an early stage and therefore progress on work carried out thus far was inevitably limited.

The registered manager displayed a commitment to providing high quality person-centred care. However, owing to other work commitments they had not implemented effective management systems to achieve this.

We found continued breaches of regulations regarding risk management and governance. Risk assessments were not being used effectively to identify potential risk and measure progress. Effective management systems for the prevention and control of infection had not been established.

Audits undertaken had not always identified where improvements were needed so appropriate action could be taken. For example, in relation to medicines management, environmental and hygiene standards and staffing.

Although staff knew people well some records required updating to reflect people’s changing needs or care preferences. Best interest decisions made on people’s behalf were not always recorded. We could not be confident people were supported to have maximum choice and control of their lives and staff would support them in the least restrictive way possible; policies and systems did not clearly support this practice. This meant people were at potential risk of receiving inconsistent or unsafe care.

We have identified a further breach in relation to the environment. Areas of the service were being refurbished. However, not all work was completed to a satisfactory standard to meet the law and published best practice guidance. People living in the service had complex needs including dementia care needs. The service had not been suitably adapted to include suitable use of signage and decoration to assist people to orientate themselves.

People had limited access to washing and bathing facilities. Although the registered manager told us boilers were to be replaced at the time of our inspection there was only an intermittent supply of hot water.

We have made recommendations about medicines handling and care planning to incorporate best practice to achieve improved outcomes.

People spoke positively about the registered manager; they felt they received good care and support from staff. They told us they were treated with respect and dignity and enjoyed the opportunities available to participate in activities.

Rating at last inspection: Requires improvement (report published 1 August 2018). Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve to at least Good. At this inspection we found the provider had failed to demonstrate sufficient improvement in their systems and remains rated Requires Improvement for the second consecutive time.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will meet with the nominated individual and the service’s administrator following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

This inspection took place on 8 and 22 May 2018 and was unannounced. This was the first inspection of this service following a change in its registration in August 2017.

Mary Fisher House 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.

Mary Fisher House accommodates 24 older people and people living with dementia in one adapted building. When we visited 23 people were living there.

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.

This is the first time the service has been rated Requires Improvement.

Environmental risks were not being proactively assessed and managed. The provider had not maintained safe, clean and hygienic facilities for people living at the service. Staff were not following correct infection control procedures to maintain hygiene.

Following the inspection, the registered manager told us they had addressed some of the concerns we had raised and the provider wrote to tell us how they were going to address the concerns.

The registered manager followed robust staff recruitment procedures. Staff told us they were busy but felt there were enough staff to respond to people’s needs in a timely way. We spoke with the registered manager about using a staffing tool to determine people’s dependency needs and staffing levels, to ensure staff had sufficient time to provide flexible, person centred care.

People’s needs including their nutritional needs were assessed and personalised care plans had been developed. We have made recommendations regarding improving the environment and supporting the communication needs for people living with dementia.

People spoke positively about the registered manager and staff and they said staff were kind and caring. A range of activities took place and we saw staff spent time with people and encouraged them to join in with activities.

Staff told us they felt well supported by the registered manager and had received induction, training, supervision and yearly appraisal. Records did not support this assertion. The registered manager had recognised shortfalls in record keeping and was working through this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Although we identified best interests principles had not been applied for one person we were confident this was an isolated incident.

Quality monitoring systems were not sufficiently developed or robust. We found checks had not picked up on issues we identified at this inspection. Systems were not in place to ensure information from accidents, incidents and complaints was used to drive improvement. We concluded the registered manager and the provider did not have full oversight of the service because of this.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.