About the service: Puttenhoe consisted of three separate units within the same building which supported people requiring residential and respite care, people who lived with dementia and people receiving home from hospital care. Puttenhoe was providing personal care to 29 people at the time of this inspection.

People’s experience of using this service:

People told us they felt safe and staff were kind to them.

We found practices, systems and process in place which demonstrated the service met the characteristics of good in all key areas with some elements of outstanding in caring, responsive and well-led.

Puttenhoe gave high quality safe and person-centred care. Staff offered people choice in all things and were caring and kind.

People, their relatives and staff told us the management team offered a good level of support.

Staff recruitment procedures were thorough including checks on criminal records and 2 references.

Staff told us management gave suitable training and supervision to enable them to carry out their roles safely.

Independence was very important to many of the people we spoke to and we found the same passion for enabling independence when we spoke with staff.

We saw staff treating people with dignity and respect. Staff provided meals and drinks in a way that met people’s personal preferences and nutritional and hydration needs.

The service was responsive to people’s needs and utilised people’s talents and interests to improve their health and well-being. For example, one person has used their gardening skills and now maintained all garden and outdoor spaces.

The staff team said they loved their jobs, understood their roles and were very happy working at the service.

Rating at last inspection: At the last inspection the service was rated as requires improvement (29 December 2017), with breaches in safe and well-led due to concerns around medicine management and documentation.

During this inspection, we found the service had improved in these areas and was now meeting the regulations; more information is in the full report.

Why we inspected: This was a planned inspection based on the previous rating and was unannounced.

We carried out an unannounced inspection on 6 and 7 November 2017. During our last inspection in September 2015 we rated the service as good. During this inspection the rating changed to requires improvement. This was because people were not always administered medicines in a safe manner.

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.

Puttenhoe is registered with the Care Quality Commission as a care home with nursing. It has 3 living communities for residents, Daffodil which supports up to 11 individuals requiring residential and respite care. Carnation which supports 12 individuals with dementia. Apple Blossom which supports up to 6 individuals on a short term bases after a hospital discharge, to enable them to return to their home safely. The location is registered for up to 29 people.

The home had a registered manager. 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.

Staff did not always administer medication in a safe manner and follow best practice guidelines. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were supported to access health and social care services when required but this was not always recorded within people’s care documents.

The provider had effective recruitment processes in place and there was sufficient staff to support people safely. Staff understood their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

Staff would gain people’s consent before they provided any care or support to them.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised and how to safeguard people from the risk of possible harm.

Staff had supervision, support and effective training that enabled them to support people well.

People were supported by caring and respectful staff who knew them well. Relatives we spoke with had described the staff as kind and caring. People were supported to go into the community and pursue their interests.

People’s needs and the risks they faced had been identified, and care plans took account of their individual needs, preferences, and choices.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people and acted on the comments received to continually improve the quality of the service. Although the provider had quality monitoring processes in place to ensure that they were meeting the required standards of care but this was not always effective.

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

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

Puttenhoe provides care and support for up to 29 older people, who may also be living with dementia. It is situated in a residential suburb of Bedford. Six of the bedrooms in the service are for short re-enablement visits and two are for respite stays, the remaining 21 bedrooms are for full time residents. On the day of our inspection all 21 full time rooms were occupied, as well as three of the re-enablement rooms. The respite bedrooms were both vacant.

The inspection took place 09 September 2015.

The service had a registered manager. 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.

Care plans had been written for people in the service, however they were not all aware of the content of these plans. There was no evidence to suggest that people or their relatives had been involved in the production of their care plans.

People felt safe in the service. Staff had been trained in safeguarding and were knowledgeable about abuse, and the ways to recognise and report it.

Risk to people and the general service had been assessed, and control measures implemented to ensure people were safe, whilst retaining as much independence as possible.

Staffing levels were appropriate, meaning there were enough staff on shift to meet people’s needs and provide support. Staff had been recruited following safe and robust procedures.

Medicines were stored and administered by staff who had been trained and assessed to handle them safely.

Staff had the skills and knowledge they needed to support people appropriately. They had regular training to maintain these skills, as well as regular supervision and support to identify areas for development or concern.

Staff sought people’s consent before providing them with care. If people were unable to make decisions for themselves, they were supported to do so following the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People were positive about the food and drink they received in the service. They had a balanced, varied and nutritious diet.

People had regular access to healthcare professionals both within the service and local community. Where necessary, people were supported to attend appointments by staff from the service.

There were positive relationships between people using the service and members of staff. Staff treated people with kindness and compassion, and referred to people using their preferred names.

Staff treated people with dignity and respect. They also ensured people’s privacy was upheld, particularly when carrying out tasks such as personal care.

People received personalised care which had been developed to meet their own specific needs and wishes. Staff knew and understood people well and care plans reflected their strengths and areas for support.

There were activities available to people which had been planned to meet their needs and wishes. There were also plans in place to develop the range of activities and increase the service’s involvement with the local community.

People and their relatives were able to give the service regular feedback and people felt the service listened when they did. If complaints were made, the service took them seriously and responded accordingly. Compliments were shared to promote good practice.

The service had good and visible leadership in place. People, relatives and members of staff knew who the registered manager was and were able to approach them with issues or concerns.

Staff were empowered to perform their roles and felt confident that they could raise concerns if they were unhappy in any way.

There were systems in place to gather feedback and comments from people and their families. In addition, the service carried out a number of checks and audits to identify areas for improvement.