We carried out an unannounced comprehensive inspection of Restgarth on 2 and 3 January 2019. Restgarth is a ‘care home’ that provides care for a maximum of 30 adults. 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.

At the time of the inspection there were 27 people living at the service, some of whom were living with dementia. The accommodation is over three floors with spacious shared lounges and a dining room. The upper floors are accessed either by a passenger lift or two sets of stairs, one of which is fitted with a stair lift. There are also well-maintained gardens which are accessible to people.

At our last inspection we rated the service 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 on-going 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.

We spent time during the inspection in the shared lounges and dining room observing and talking with people. There was a calm and relaxed atmosphere at the service. People and staff welcomed us into the service and were happy talk to us about their views of living and working there.

People received care and support that met their needs because staff had the skills and knowledge to provide responsive and personalised care. People, and their relatives, told us they were happy with the care they received and believed it was a safe environment. Comments included, “Very happy indeed”, “Can’t fault the staff”, “No problems” and “There’s no barriers, it’s home.”

Care plans contained personalised information about people’s individual needs and wishes. People were involved in the planning and reviewing of their care. These care plans gave direction and guidance for staff to follow to help ensure people received their care and support in the way they wanted.

Incidents and accidents were logged, robustly investigated and action taken to keep people safe. Risks were clearly identified and included guidance for staff on the actions they should take to minimise any risk of harm. Risk assessments were kept under review and were relevant to the care provided.

Safe arrangements were in place for the storing and administration of medicines. People were supported to access to healthcare services such as occupational therapists, GPs, chiropodists, community nurses and dentists. Staff enabled people to eat a healthy and varied diet. People told us they enjoyed their meals and there were ample choices on offer.

People were able to take part in a range of group and individual activities. An activities co-ordinator was in post who arranged regular events and outings for people. These included; bingo, film afternoons, arts and crafts, quizzes and history talks. In addition, external entertainers regularly visited such as singers, musicians and church services. Staff supported people to keep in touch with family and friends and people told us their friends and family were able to visit at any time.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People were supported to have maximum choice and control of their lives and the policies and systems in the service supported this practice.

There were sufficient numbers of suitably qualified staff on duty to meet people’s needs in a timely manner. Staff knew how to recognise and report the signs of abuse. Staff were supported to develop the necessary skills to carry out their roles through a system of induction, training, supervision and staff meetings. New staff completed a thorough recruitment process to ensure they had the appropriat

.This inspection took place on the 28 and 29 June 2016 and was unannounced.

At the last inspection on 29 and 30 July 2015, we asked the provider to take action to make improvements in several areas. At the time of the inspection the service did not have a registered manager in place and had not notified us of significant events in line with their legal obligations. There were not enough staff to keep people safe at all times and not all staff were aware of how to identify abuse or how to report suspected abuse. We found that not all staff training had been updated or reviewed and not all staff had appropriate ongoing support such as supervision and appraisals. Due to insufficient numbers of staff people did not always have their nutritional needs met or were not provided with enough encouragement to eat. Although the service had a complaints policy, not all people’s concerns were acted on or investigated and there wasn’t sufficient evidence to suggest that complaints were used to make continuous improvements. We also found that people’s care plans were not personalised, written with their involvement or reflective of people’s needs. The provider sent us an action plan which explained how they would address these breaches of regulation. During this inspection we found these issues had been fully addressed.

Restgarth is a residential care home which provides care and support to older people who predominately have a form of dementia. Accommodation is over three floors, with spacious shared lounges and a dining room. There are also well maintained gardens which are accessible to people. The home can accommodate up to a maximum of 30 people. At the time of our visit there were 27 people living at the service.

Restgarth 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.

We observed positive, compassionate and caring interactions between people and staff. Staff took the time to stop and chat with people and to share appropriate humour. Staff knew the people they cared for well and spoke about them with fondness and affection. One staff member said; “I love it here. I love the people”.

People’s care plans were detailed documents which contained information about their background, history, likes and dislikes. Staff confirmed that the care plans contained the correct guidance and information in order to provide the right level of support for people.

People enjoyed the meals. They told us they were of sufficient quality and quantity and there were alternatives on offer for people to choose from. People were involved in planning the menus and their feedback on the food was sought.

People had their healthcare needs met. For example, people told us they had their medicines as prescribed and on time. People were supported to see a range of healthcare professionals including district nurses, chiropodists, doctors and social workers.

People were kept cognitively and socially engaged through a range of activities, both inside the service and in the local community. The service employed an activities coordinator and there was something on offer each day. People were involved in suggesting activities.

People were kept safe by suitable staffing levels. People told us there were enough staff on duty. This meant that people’s needs were met in a timely manner. Interactions between people and staff were unhurried. Staff recruitment practices were safe. Checks were carried out prior to staff commencing their employment to ensure they had the correct characteristics to work with vulnerable people.

Staff had sufficient training to carry out their roles effectively. Staff had received training relevant to their role and there

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

This is a summary of what we found-

Is the service safe?

At the time of the inspection the service was safe.

People who lived at Restgarth told us that they felt safe living there.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager was aware of the DoLS legislation and was in the process of submitting applications to the Local Authority following the new Supreme Court Judgement. We saw from training records that staff had undertaken training in the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). This demonstrated that the manager had knowledge about the legislation and of the responsibilities associated with it.

There was a safe and robust recruitment process in place which ensured people who lived at the care home were not at risk.

Is the service effective?

At the time of the inspection the service was effective.

From our observations and discussions with the manager and with people who lived at the home, we concluded the home had positive working relationships with other professionals such as local GPs, district nursing teams, chiropody and dental services which ensured people received timely and consistent care.

Is the service caring?

At the time of the inspection we found the service to be caring.

We observed people who lived at the care home were relaxed when engaging with staff. People told us, “staff are lovely they are as helpful as they can be, if they can do it, they will do it” and “very helpful”.

From our observation, it was apparent that staff were kind, caring and responsive to people.

Is the service responsive?

At the time of the inspection we found the service to be responsive.

One person told us, “They are very kind to me, it doesn’t matter what I say or do, they are very kind”, “if I need anything they will come and help me all the more so because I’m partially sighted”.

The manager spoke passionately about the importance of working with other professionals and was keen for external professionals to visit the home and provide their advice and opinions on the quality of care and service delivery.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately. There was clear audit trail of the response, the action and the resolution to the complaint. A clear audit trail is important to ensure complaints are managed effectively.

Is the service well-led?

At the time of the inspection we found the service to be well-led.

The service had a manager who was registered with the Care Quality Commission.

During our inspection the manager and the provider were both present; we observed that they were visible and, that they took time to speak with people.

The provider had a system in place to identify, assess and manage risks to health, safety and welfare of people using the service and others.

We spoke with staff who told us they felt comfortable in speaking with the manager at any time. Staff told us that they felt their opinions and views were listened to and respected.

People who lived at Restgarth told us staff were kind and helpful. One person said “I only have to ask and they are here to help”. We saw there were a range of activities available that included quizzes, movie afternoons and outside entertainers.

The care records were being updated to better reflect peoples care and support needs and associated risk assessments.

We were shown that there was a robust system in place to order, store and dispense people’s prescribed medicines.

We saw systems in place to support staff. Staff and residents/relatives meetings have been held or are planned for the near future.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

We inspected Restgarth Care Home, but we did not inspect the domiciliary care service.

People who lived at Restgarth told us, “they are wonderful, they are very kind”, “nothing seems too much trouble,” and “on the whole they are very nice people”. People who lived at Restgarth also told us “bossy and they don’t bother to listen; this is only a few of them”, and “she’s a real pain to me”. Other comments included, “there’s a shortage of staff”, and “I would like to go out more”.

Following our inspection the registered manager told us she had reported one of the concerns we were told about during the inspection to social services.

We looked at care documentation and spoke to people and found that people’s views and experiences were not taken into account in the way the service was provided and delivered in relation to their care.

We found information missing from care plans; information, essential to ensure peoples health and social care needs.

We established that people were protected from the risks of inadequate nutrition and dehydration.

We found that people were protected from the risk of infection.

We inspected one staffing outcome and found that the there were enough qualified, skilled and experience staff to meet people’s needs.

You can see our judgements on the front page of this report.

The people who were more able told us that they were generally happy with the standard of care at Restgarth; they thought that the food was good, staff were kind and there were no rules about times to go to bed or get up. However, we found from what we saw and what we were told by relatives, that people who needed help with eating and drinking were not receiving the support or the monitoring they needed. Visiting healthcare professionals told us that they had offered guidance, but this was not put into action. We were told about concerns, and in one case we found that this had not been properly dealt with at the time. People also told us that they were cold during the first visit, and the heating seemed to have been improved by the second visit.

The inspection took place on the 29 and 30 July 2015 and was unannounced. We last inspected the service on the 7 July 2014 and found no concerns.

Restgarth provides residential care without nursing to up to 30 older people. People living with dementia may be living at the service. On the days we inspected 26 people were living at the service but one person was in hospital. Nursing care is provided by the community nursing team.

A registered manager was not in post at the time of the inspection as required as part of the service’s registration with the Care Quality Commission (CQC). 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 service had been without a registered manager since May 2015. Staff were in charge to manage the service. There was one manager in charge with two staff supporting from the provider’s other service. All three staff supported the inspection. However, they lacked any historical information having been at the service for a short period of time.

We inspected Restgarth due to receiving information of concern that people’s needs were not being met. For example, people were not having their continence needs met, people were not having regular baths and shower, people living with dementia were not having adequate nutrition and medicines were not administered as prescribed. We reviewed these concerns throughout the inspection.

There was not sufficient staff to meet people’s needs safely on the first day of the inspection. We requested the staff in charge took immediate action in respect of this. They completed an assessment of how people were dependent on staff (called a ‘dependency assessment’) and identified more staff were required. A representative of the provider attended the home each week and checked the quality of the service took place. When concerns about the service were received in July 2015 the provider acted and systems were put in place to identify and address a number of concerns. Staff numbers were found to be an issue but immediate action was not taken to address this while new staff were recruited.

Staff were employed from an agency to meet people’s needs and the requirements of the dependency assessment on the first day. On the second day we observed increased numbers of staffing was maintained. The provider gave an assurance the number of staff in the future would be in line with people’s needs.

People were not protected by staff who could identify abuse or knew what action to taken. Staff had not known how to share their concerns with agencies outside the service. People were placed at risk of inappropriate care as a result.

Staff were recruited safely. However, people were not looked after by staff, who were suitably trained, supervised, appraised or were having their competency checked on a regular basis. Staff had not undertaken sufficient training to enable them to understand and support the range of people’s needs. This was noticeable in relation to looking after people living with dementia. People living with dementia were not having their nutritional or social needs met. Other people’s nutritional needs were met and people contributed ideas for the menu. People could choose alternative meals to those available at each meal.

During the first day of inspection it was very difficult to assess whether people were treated kindly by staff as they were rarely visible. When we saw staff and people together we were heard staff speaking both kindly with and impatiently to people. They greeted people warmly and respectfully. However, staff did not have time to spend with people as they were rushed in carrying out their tasks. On the second day with more staff, staff and people were observed to be comfortable in each other’s company. There was a greater presence of people moving around the service and laughter between people and staff. People said their dignity was always respected and with more staff felt staff were less rushed.

People had risk assessments in place and care plans. However, these were not personalised and did not identify all the risk or needs of people who were living at the service. There was no evidence they had been written with people or their representatives. This has been identified in a recent audit carried out by a representative of the provider and was being addressed.

We had some queries about fire safety which we passed to the fire service, who have visited and are satisfied with the fire safety arrangements.

People could see their GP or other health professionals as required. However, people were not having their continence needs met but this was addressed before the inspection was completed. That is, the district nurse service was supporting staff to complete new assessments and supporting staff to manage people’s continence needs. Staff told us more staff meant they could prioritise supporting people to go to the toilet. Staff were supporting people to ensure they did not develop skin ulcers. The district nurse service were now supporting staff in relation to continence care as well as maintaining people’s skin integrity. Plans were in place to support people’s end of life.

People had their complaints investigated however, there was not sufficient evidence that the learning from people’s or relatives concerns resulted in changes to the service to reduce the likelihood of it occurring again. The main issue was in relation to people’s laundry and items of clothing being lost or taking a long time to come back. The issue with the laundry was raised with the service from December 2014 to July 2015 with no evidence this was resolved to people’s satisfaction.

People were not supported to follow their interests or prevent them becoming socially isolated. People were largely living isolated lives in their rooms and rarely generating friendships or companionship with other people in the service. We were unable to judge how much this was about choice and how much had become part of the staffing issue at the service. Group activities were offered most weeks. People could attend a religious service each month. Staff told us they did not have time to offer that one-to-one care and time. They hoped this would be possibly with the increased staff numbers. We have recommended the provider review the latest guidance on providing activities for people living in care homes.

Staff were not following a kitchen cleaning schedule and the kitchen was observed to be dirty. This was referred to the local authority food hygiene service. The food hygiene inspector has visited and found the service’s food hygiene practice to be safe. In all other respects, staff were following safe infection control procedures.

Staff in charge understood their responsibilities in relation to assessing people’s mental capacity and not depriving people of their liberty illegally. Staff asked people’s consent before providing care and support. People had their medicines administered safely.

Staff in charge had identified that audits of aspects of running the service needed to be improved. For example, audits of medicines, care plans, infection control, and falls had been intermittent. Systems were being developed to ensure these were more frequent. People had not been asked about staffing and whether they were concerned about this. We requested therefore the staff in charge asked people about their view of the numbers of staff. People responded that their needs had been met better with more staff. There were systems in place to check the building and equipment were checked and action taken when required.

CQC records showed we had not received any serious injury notifications for 2014 and 2015 to the date of the inspection. However the provider has advised there were no notifiable injuries that took place during this time.

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