This inspection took place on 15, 16 and 18 October 2018 and was unannounced.

Old Raven House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Old Raven House accommodates up to 36 older people in one adapted building. There were 35 people at the service at the time of inspection, some of whom were living with dementia.

The service had a registered manager in place at the time of our 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.

This inspection was prompted by the notification of concerns raised by health and social care professionals, regarding the management of pressure ulcers. This meant that people’s care, treatment and support had not always been provided in a safe way. At our inspection we found the registered manager and staff had implemented training and guidance from professionals to make the required improvements. People were now receiving appropriate care to ensure pressure ulcers were prevented or managed safely. However, more time was required to demonstrate that these improvements had become embedded across the service and were sustainable.

Prior to our inspection healthcare professionals had also raised concerns regarding techniques used by staff to support one person to move safely. Since these concerns were raised, healthcare professionals had provided staff with relevant training and guidance, tailored to support this person's individual needs. Staff were now supporting the person to move safely in accordance with their care plan. However, the provider required more time to demonstrate improvements had become embedded and sustained.

At our last inspection we rated the service good, though found that that the provider was not always working within the principles of the Mental Capacity Act (2005). At this inspection we found that the required improvements had been made. The registered manager had established an effective process for making decisions in people’s best interests, when they did not have the capacity to do so for themselves. . Staff supported people to make as many decisions as possible and protected their human rights. The registered manager had a clear understanding of consent, mental capacity and Deprivation of Liberty Safeguards legislation and guidance, which they followed.

Previously, governance and oversight of processes for monitoring and improving the quality and safety of the service had not always been reliable and effective, for example, the provider had not identified the concerns raised by healthcare professionals regarding pressure ulcers. At this inspection professionals consistently made positive comments regarding the registered manager’s determination to put things right and improve this aspect of the service. Professionals praised the registered manager and the team leaders’ openness, for listening to and following their advice and guidance. However, the provider needed more time to demonstrate new governance processes had become embedded, were sustained and effective.

People were protected from avoidable harm, neglect, and discrimination by staff who understood their responsibilities to safeguard people from abuse. When required the registered manager completed thorough investigations in partnership with local safeguarding bodies.

Staff were aware of people who were at risk of choking or falling and how to support them safely to mitigate these risks. Staff underwent appropriate training to support people to manage their medicines safely and had the

This inspection was unannounced and took place on the 31 July and 2 August 2017.

Old Raven House (to be referred to as the home throughout this report) is a home which provides residential care for up to 36 people who have a range of needs, including diabetes, people living with sensory conditions such as hearing and slight loss as well as people living with dementia. At the time of the inspection 36 people were using the service.

The home comprises of a period property with a purpose built extension with front and rear gardens which offers seating areas for people, relatives, visitors and staff to enjoy. The garden also contains hutches for two rabbits and two guinea pigs which are used in animal therapy sessions.

On the ground floor the home has living accommodation with communal areas including lounges, dining rooms, a conservatory and a sun lounge which faces to the front of the house. On the ground floor there is a kitchenette area where people, relatives, staff and visitors can make hot and cold drinks. The ground floor also has a hairdressing business and salon which is also available for use by members of the public. The first floor is accessible by one main staircase which has an operational stair lift. The first floor comprises of living accommodation. Communal bathrooms and accessible toilets are available on both floors.

The home has a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, the policies and systems in place did not always support this practice. It had not always been clearly documented that where people lacked the capacity to make specific decisions for themselves that actions taken on their behalf were always in their best interests. Immediate action was taken following the inspection to ensure these decisions were documented fully. Staff sought people's consent before delivering their care and support.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. The registered manager showed an understanding of what constituted a deprivation of a person's liberty by the correct submission of relevant applications to ensure people were not deprived of their liberty without legal authority.

People using the service told us they felt safe. Staff understood and followed guidance to enable them to recognise and address any safeguarding concerns about people. People's safety was promoted because risks that may cause them harm had been identified and guidance provided to staff to help them manage these appropriately for people.

People were supported by sufficient numbers of staff to meet their needs. The provider was able to adapt their staffing levels appropriately when required in order to meet changes in people’s needs.

Recruitment procedures were fully completed to ensure people were protected from the employment of unsuitable staff.

People received their medicines safely; senior staff were responsible for managing medicines and had received the appropriate training to enable them to complete their role safely. Medicines were stored, administered, disposed of and documented appropriately.

Contingency plans were in place to ensure the safe delivery of people's care in the event of adverse situations such as a fire or flood which may result in the loss of their living accommodation. These were accessible to staff and emergency personnel such as the fire service, if required to ensure people received continuity of care in the event of an on-going adverse situation which mea

The inspection team consisted of one adult social care CQC inspector. On the day of our inspection 36 people used the service. We spoke with six people, two people’s relatives, three care workers, and the deputy manager. We reviewed records relating to the management of the home which included seven people’s care plans.

We considered all the evidence we had gathered under the outcomes we inspected, which related to people’s care and welfare, cleanliness and infection control, supporting staff, assessing and monitoring the quality of service provision and records. We used the information to answer five key questions; is the service safe, effective, caring, responsive and well-led.

This is a summary of what we found.

Is the service safe?

People and relatives of people who use the service were complimentary of how the provider maintained people’s safety. One person told us “I feel absolutely safe here.” A survey to gather feedback from people was conducted in May 2014 by the provider. This recorded up to 19 responses from 36 people. We saw respondents agreed that they felt safe.

Evacuation plans were in place to ensure people’s safety in the event of a fire at the service. A member of the management team was available on call in case of emergencies outside usual working hours.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to this type of service. The service was safe because requirements in relation to the DoLs had been met.

People were cared for in an environment that was safe, clean and hygienic. People were protected from the risk of infection because protocols based on current Department of Health guidelines were followed.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others in relation to incidents.

However, people were not protected from the risks of unsafe or inappropriate care because staff used unsafe moving and handling practices when providing care and support to people. We found people’s medication profile forms in their care plans were not always accurate. They had not been updated when the prescribed medicines had been changed. This meant that there was an increased risk that medicines would not be administered in accordance with the most current prescription. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring steps are taken to ensure people are protected from the risks of unsafe or inappropriate care.

The provider did not have appropriate arrangements in place to manage people's medicines safely. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring effective processes are in place for the safe management of medicines.

Is the service effective?

The service demonstrated effective practices because people's views and their relatives about the type of care they wanted had been sought and acted upon. On person confirmed their involvement and told us “Staff asked me what I would like.” We found staff had a good understanding of people’s care and specific support needs, for example, in relation to pressure sore prevention.

All six people and relatives we spoke with were complimentary about the care received. One person said “The staff look after us very well.”

Is the service caring?

People were supported by kind and supportive staff. One relative told us “Staff have been very supportive. The overall care and atmosphere here is excellent. It feels like a happy family environment.” All interactions we observed between the staff and people were respectful and courteous. We saw that care workers gave encouragement when supporting people. People were able to do things at their own pace and were not rushed.

The compliments folder we looked at recorded responses from people’s relatives. We saw feedback was positive. Relatives rated staff support and care highly.

Is the service responsive?

People’s needs were assessed before they were admitted to the service. Records confirmed people’s preferences and diverse needs had been recorded. Staff provided examples of care and support being provided in accordance with people’s wishes, for example, in relation to meal preferences and personal hygiene.

Overall, we found care was planned and delivered to meet the identified needs for people to ensure theirs and others’ safety and welfare.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring care is planned and delivered to meet the needs of all people who use the service.

We saw evidence that the provider responded to feedback from people , their relatives, staff and outcome of service audits in order to improve the service.

Is the service well-led?

We saw people’s and relative’s feedback was sought through meetings and surveys. The provider was responsive to comments from people, such as improvements to the supper menu and the implementation of a planned refurbishment of the service to meet people’s wishes and suggestions.

Audits and checks ensured people’s safety and wellbeing was promoted. Where issues were identified, an action plan was formulated. Progress and completion of this was monitored. We saw issues were identified and actions completed appropriately.

People who used the services told us they felt safe, cared for and that staff respected choices they had made. Comments included, “well there is nothing to find fault with here” and “they are very good, without exception”.

People told us they enjoyed the quality of the food and were provided with a choice of meals. Visitor’s said when they had visited the home, “meals always looked healthy and were nicely prepared”. They said in their observation “there was always enough staff available to help people with their meals”.

We found improvements were needed to ensure the nutritional assessment used by the home was used effectively by staff. This was to ensure records of people’s weight were accurate and to minimise individual risks of undernourishment. During our inspection the manager told us of the immediate steps they had taken to minimise risk and to improve accuracy of records that informed nutritional assessments.

There were procedures to protect people from abuse and to minimise the risk of unsuitable staff being employed. We found that staff were knowledgeable of people's specific health and personal care needs and had received training to update their skills and knowledge.

People and their relatives told us they were kept informed, were listened to and given opportunity to give their view of the services provided. Comments included, “I’m very happy” and “I’ve even had my nails done for nothing”.

At the last inspection on 16th January 2012 we found that the provider was non compliant with outcome 10, regulation 15 Safety and suitability of premises. During this inspection we found that the provider had put in place appropriate systems to address our concerns and ensure people living in the home were protected.

Observation of care practices during our inspection confirmed people living in the home were receiving effective, safe and appropriate care which was individualised and designed to meet their specific needs. The care provided was carried out with sensitivity and patience. Staff were able to demonstrate to us they knew the people who used the service well and were aware of their care needs.

We observed people being offered choices about their care and support. Staff discussed with them any options and supported them to make an informed decision

People we spoke with said they had not needed to make a complaint and that they were very happy with the service they had received from the home.

People told us that were treated with respect and had sufficient privacy. They said they enjoyed the activities on offer, and that staff looked after them well and were caring. Not everyone was able to talk to us about their care, and from our observations we found that staff were encouraging and supportive of residents and helped them to maintain their independence.

The inspection took place on 24 and 26 March 2015.

Old Raven House is a care home in Hook that provides accommodation, care and support for up to 36 older people. At the time of the inspection 36 people were using the service. Some of the people using the service are living with dementia.

Old Raven House has 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 and associated Regulations about how the service is run.

At the last inspection in July 2014 we asked the provider to take action to make improvements regarding the care and welfare of people who use the service. We also asked them to make improvements in respect of management of medicines, supporting workers and record keeping. The provider wrote to us and told us what they would do to improve the above areas and we found that improvements had been made.

People using the service told us that they felt safe. Safeguarding training was delivered annually and care staff were able to identify and recognise signs of abuse. Procedures were in place identifying how people could raise concerns and staff were aware of these.

Care staff were knowledgeable about the requirements of The Mental Capacity Act 2005 (MCA) and documentation showed people's decisions to receive care had been appropriately assessed, respected and documented. Care staff were able to demonstrate a working knowledge of the MCA and the Deprivation of Liberty Safeguards (DoLS). They were able to evidence that they could identify when someone was being deprived of their liberty.

When risks were identified people were supported to remain safe. Care staff were able to recognise risk and change their care accordingly to meet any additional needs.

Staff recruitment procedures were in place so that people were protected from the employment of unsuitable staff. Induction training was mandatory to assess care staff were suitable for their roles.

Care staff responsible for supporting people with their medicines had received additional training to ensure people’s medicines were being administered, stored and disposed of correctly. However we found that for one person their medicine had not been given as they had wanted.

People were supported to eat and drink enough to maintain a balanced diet. When identified, people at risk of malnutrition and dehydration were properly assessed to ensure their needs were met. People told us the food was of a good standard and in more than sufficient quantities.

When people’s additional health care needs were identified the registered manager engaged with other health and social care agencies and professionals to maintain people’s safety and welfare.

People told us that their care was provided to a good standard. Care staff were able to demonstrate they had taken time to know the people they supported. People were encouraged and supported by care staff to make choices about their care on a daily basis.

People told us and we could see that all staff treated people with respect and ensured their dignity was respected at all times.

Care plans were personalised to each individual and contained detailed information to assist care staff to provide care in a manner that respected that person’s individual needs and wishes. Relatives were involved at the care planning stage and during regular reviews.

People knew how to complain and were happy to provide feedback if this was required. Procedures were in place to manage and respond to complaints in an effective way.

Residents, relatives and care staff were actively encouraged to provide feedback on the quality of the service provided by the use of quality assurance questionnaires and regular meetings. Care staff felt supported by the registered manager as a result.