We carried out an unannounced comprehensive inspection on 13 and 14 December 2018.

Michaelstowe is a care home without nursing for up to 24 people. On the day of our inspection there were 24 people living at the service. It specialises in care for older people some who are living with dementia.

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.

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.

At the last inspection on 23 December 2016, the service was rated Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service remains Good:

We met and spoke with all the people living in Michaelstowe during our visit. However, not all people were able to fully verbalise their views. Due to people’s needs, we spent time observing people with the staff supporting them. Others could tell us about the care and support they received. Staff told us and we observed other methods of communication with people were used who could not verbally express their views, for example the use of visual objects.

People remained safe at Michaelstowe. People who were able to told us they felt safe living there. Comments received about the service included; “Look after you well here, well fed and no cause to complain. The staff are friendly and caring” also “People who look after us are brilliant, very good home and can’t find anything wrong with the place.” A relative said; “All staff very approachable, extremely caring, friendly. Mum’s happy – then I’m happy.”

People continued to receive their medicines safely by staff who had received regular training. People were protected by safe recruitment procedures. This helped to ensure staff employed were suitable to work with vulnerable people. People, relatives and the staff team confirmed there were sufficient numbers of staff to keep people safe. Staff confirmed they could meet people’s needs and support them when needed.

People’s risks were assessed, monitored and managed by staff to ensure they remained safe. Risk assessments were completed to enable people to retain as much independence as possible.

People continued to receive care from a staff team that had the skills and knowledge required to effectively support them. Staff had completed safeguarding training. Staff without formal care qualifications completed the Care Certificate (a nationally recognised training course for staff new to care). The Care Certificate training looked at and discussed the Equality and Diversity and Human Rights policy of the company.

People continued to receive a caring service. People were observed to be treated with kindness and compassion by the staff who valued them. The staff, many who had worked at the service for many years, had built strong relationships with people. All staff demonstrated kindness for people through their conversations and interactions. Staff respected people’s privacy. People or their representatives, were involved in decisions about the care and support people received.

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. People’s wish

The inspection took place on 16 and 18 November and was unannounced. Michaelstowe is a residential home based in Plymouth that offers accommodation for up to 24 older persons. On the day of the inspection 21 people lived in the home. Michaelstowe provides care for older people, some of whom are living with dementia.

A registered manager was employed to manage 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. The registered manager was not present during the inspection. A temporary manager, who was registered to manage another home owned by the same company, was managing the service in the absence of the registered manager.

We last inspected Michaelstowe on 29 and 30 September 2015 and breaches of legal requirements were found. We asked the provider to take action to ensure people’s needs were met in relation to the risk of malnutrition, to ensure the safe management of medicines and to ensure accurate record keeping. The provider sent us an action plan detailing the improvements they would make by the end January 2016. At this inspection we found improvements had been made.

People’s nutritional needs and risks were monitored and action was taken if concerns were identified. People’s medicines were managed safely. New systems had been introduced and regular audits were carried out. A new care planning system had been implemented which allowed staff to easily maintain and share accurate records regarding people’s needs. It also enabled the manager to have an overview of the records and care provided.

People told us they felt safe using the service. There were risk assessments in place to help reduce any risks related to people’s care and support needs. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected. The recruitment process of new staff was robust. The manager was recruiting new members of staff and had increased the staffing levels to better meet people’s needs.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 16 and 18 November 2016 and was unannounced. The inspection was carried out by one inspector.

Prior to the inspection we reviewed the records held on the service. This included the Provider Information Return (PIR) which is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed notifications. Notifications are specific events registered people have to tell us about by law.

During the inspection we spoke with four people. We reviewed three people’s records in detail. We also spoke with five members of staff and reviewed three personnel records and the training records for all staff. Other records we reviewed included the records held to show how the registered manager reviewed the quality of the service. This included a range of audits, questionnaires to people who live at the service, minutes of meetings and policies and procedures.

Following the inspection we sought the views of a social care professional, who knows the service well. This was a care home practitioner. We also spoke with a relative of someone who lives at Michaelstowe, following the inspection.

We met and spoke with 17 of the people who used services, spoke with two visiting relatives and one health care professional. We talked with the staff on duty and checked the provider's records.

We saw people’s privacy and dignity being respected at all times. We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people’s choices and preferences.

We looked at care records for six people. We spoke with staff about the care given to these people, looked at records relating to them, met with them and observed staff working with them.

We saw that people's care records described their needs and how those needs were met. We saw that people's mental capacity had been assessed to determine whether they were able to make particular decisions about their lives.

We saw that medication was administered by suitably trained staff. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to administer and record medication.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. However staff and people who used the service felt the home needed more staff to spend time sitting and talking with people. One staff said “We never have time to sit and talk to people” and one person living in the home said, “There never seems to be enough staff available”.

There were effective systems in place for safeguarding people from abuse and monitoring the quality of the service to ensure that people's views were listened to and action taken where required.

We (the Care Quality Commission) spoke with five people, three staff, two relatives and a district nurse. We also spent time observing care and we looked at three care plans. On the day of our inspection 22 people were living at the home and receiving care from the service.

People living at the home we spoke with told us they were looked after well. One said “I am very happy here indeed.”

Many people living at this home had dementia. People looked happy and well cared for.

We found that people's privacy and dignity was protected. People exercised choice in their daily lives.

Where people did not have the capacity to take decisions about their care their rights were protected.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care plans were reviewed regularly and as necessary. Records showed that prompt referrals were made to health professionals and their advice was followed. Procedures were in place to deal with emergencies.

We saw that people were relaxed in the company of staff. They were kept safe from abuse because staff knew about abuse and how to report this. Their were sufficient numbers of skilled staff on duty to meet people’s needs.

There was enough equipment to promote the independence and comfort of people who use the service.

All records were kept securely and were well maintained.

On the day of our visit the manager was on duty at the home and they showed us around the home and answered any questions we had.

We spoke individually with four people living at the home, three other people in a group, the manager, three staff and one representative of someone living in the home.

Because of the complexities of their illnesses, some people were unable to tell us about their experience of living at the home. Therefore both direct and indirect observation were used to assess the wellbeing and happiness of people in the home, as well as speaking with them.

During the morning of our visit we spent time in the large ground floor lounge, observing the way staff and people interacted. During this time we heard staff speaking to people in a manner that was disrespectful and did not uphold people's dignity. However, during the afternoon we heard staff speaking with people in a kindly, friendly way. Staff that we spoke with during the afternoon demonstrated a good awareness and understanding of people's needs. They were able to describe people's personal preferences in the way they received care as well as displaying a good knowledge of their individual needs. The people we spoke with who were able to give us an opinion told us that they thought staff had the skills they needed to look after them.

Staff that we spoke with told us that they had received training on safeguarding people and they were able to tell us about different types of abuse and what they would do if they suspected abuse was occurring. Staff were aware of the home's policies and procedures in relation to safeguarding people.

However, we saw some staff who did not interact in a positive manner with people living at the home and in some instances they were neglectful of people's needs. This could lead to abusive practice.

We looked at the care records for three of the people who lived in the home to find out how the home had assessed their health and personal care needs, and how they planned to meet those needs. Each person had a care file that contained a wide range of documents relating to their care and support needs. The files were well organised and contained some useful information for staff to enable them to meet people's needs. There was no evidence in people's care plans that they or their representatives had been involved in drawing up the plans. However, the representative that we spoke with told us that they were always kept informed about their relative's care.

There were detailed risk assessments completed including those for physical health, bathing and showering and making drinks as well as those for nutrition, pressure areas and moving and handling. Although the risks identified were not always managed appropriately.

People told us they were satisfied with the food provided. One person told us "There is always plenty and always a choice". Staff told us that they have pictures of food to show to people to help them choose what they would like to eat.

We were told by the manager that people who sit in the main lounge do not have access to a call bell system that would enable them to summon help from staff.

The manager told us there was a system in place to ensure that they undertook regular checks on the quality of the services being provided.

The inspection took place on the 29 and 30 September 2015 and was unannounced. We last inspected the service on the 18 October 2013 and found no concerns.

Michaelstowe provides residential care for up to 24 older people who may be living with dementia or have a physical disability. They do not provide nursing care. Nursing care is provided by the community nursing team.

A registered manager was employed to manage 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.

People’s medicines were not always administered safely. People were not always having their medicines at the specific time or for a specific reason they were prescribed for. The practice of some staff was placing people at risk.

There were gaps in the recordings of people’s food and fluid intake which meant it was not always possible to evidence people’s nutritional and hydration needs were being met. Records for two people we reviewed showed they were prescribed food supplements. However, records did not detail these were given as prescribed. Where it had been identified people needed extra monitoring due to concerns about their having lost weight, action was not always taken as expected within their risk assessments. There was no indication staff followed guidance or sought advice from the GP or other professionals such as a dietician. There was also no record of why the guidance was not followed. This placed some people at risk of malnutrition.

People felt in control of their care however, their care plans did not always reflect how they would like their care delivered to ensure consistent and appropriate care. People’s records were not always completed fully to ensure they were accurate and provided staff with information required to provide safe and appropriate care. Records in relation to how people’s needs were addressed were not always available to ensure people’s needs had been met.

Activities were provided however, people had significant periods of time in the morning and afternoon when they had nothing to do and there was no interaction with staff to ensure people received some form of stimulation. People’s faith needs were met.

There were risk assessments in place to mitigate the risk to people when moving around the service or using the garden and equipment. Some individual risk assessments were in the process of being updated to ensure they were linked with people’s care plans. There were clear infection control policies in place to support staff to keep people safe. The home had been decorated to support people’s memory about times past and there were clear signs for people living with dementia to find their way around.

People had their right to consent to their care respected by staff. People were assessed in line with the Mental Capacity Act 2005 (MCA) as required. Where people may need to be deprived of their liberty to keep them safe, a formal application was made to the necessary authority. Staff demonstrated they knew how to care for people who lacked the capacity to make decisions for themselves.

People had their health needs assessed by relevant professionals as required. People said they had all medical care from outside professionals that they needed. Health professionals were positive about the role staff played in meeting people’s health needs.

People spoke highly of the staff and felt they were well cared for. Staff treated people with kindness and respect. People’s right to be treated with dignity was maintained.

Staff were trained to meet people’s individual needs and were recruited safely. Staff understood how to identify abuse and keep people safe from harm. The number of staff required to deliver care safely had been reassessed by the registered manager. A resultant shift pattern and number of staff had been identified.

There were clear systems of governance and leadership in place. A lot of changes were in the process of being implemented while we were visiting the service. They were based on a nationally agreed model of good dementia care. People’s complaints and concerns were investigated and people received feedback to ensure they were happy before they were closed.

The registered manager and provider carried out audits of the service to ensure good care. Some of the issues raised during the inspection had already been identified. They reflected on the issues identified during the inspection. They expressed a commitment to wanting to improve the culture and dementia care within the service.

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