This inspection took place on 28 June 2018 and was unannounced. The service is registered to provide accommodation and personal care for up to 17 people (one shared room is however only ever used by one person, reducing occupancy to 16). The home is a converted house and facilities are over three floors. There is a stair lift in situ but this does not access the two bedrooms on the half-landing. Some of the bedrooms have en-suite facilities. At the time of our inspection there were 13 people living in the 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.

When we inspected the service in April 2017 we found there were two breaches of legal requirements and further improvements were required in Well Led. Following that inspection, we asked the provider to submit an action plan telling us what improvements they would make to rectify the breaches. We have assessed this as part of this inspection. The improvements had been made and we have added the detail in the main body of the report.

There was a registered manager in post who had worked at Rosewood House for many years. 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 were safe at Rosewood House. Staff received safeguarding vulnerable adult training and were knowledgeable about safeguarding issues. They knew what to do if there were concerns about a person’s welfare and who to report their concerns too. In the majority of cases the care staff would report to the registered manager or the ‘head office’. Safe recruitment procedures were in place to ensure only suitable staff were employed. The appropriate steps were in place to protect people from being harmed.

As part of the assessment and care planning processes any risks to people’s health and welfare were identified. Their care plans detailed how these risks were managed to reduce or eliminate the risk. Medicines were managed safely and this is an improvement from our last inspection. The premises were well maintained with regular maintenance checks being completed. Checks were also made of the fire safety systems, the hot and cold-water temperatures and any equipment to make sure it was safe for staff and people to use.

Staffing levels were adjusted as and when necessary. Whilst the number of care staff on duty was based on the number of people in residence, account was taken of the care and support needs of each person and any social activities that were taking place in, or outside of the home. People were safe because the staffing levels were sufficient.

People received an effective service. Care staff had mandatory training to complete and any new staff had an induction training programme which prepared them for their role. This ensured the staff team had the necessary skills and knowledge to care for people correctly. Care staff were encouraged to complete nationally recognised qualifications in health and social care.

People’s capacity to make decisions was part of the care planning process. People were always asked to consent before receiving care. They were encouraged to make their own choices about aspects of their daily life. We found the service to be meeting the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People were provided with sufficient food and drink. Consideration was given to their likes and dislikes and any specific dietary needs for catered for. Where people were at risk of losing weight, they were provided with supplement drinks or fortified foods

Rosewood House is a residential care home without nursing and provides care and support for up to 17 older people. On the day of our inspection there were 15 people resident in the home.

At the last inspection, the service was rated Good there was however one breach of regulations in relation to medicines. At this inspection we found although the service had improved in some areas of medicines they failed to meet the required standard and continued to be in breach of this and another regulatory standard.

A registered manager was in place for 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 and provider had quality monitoring systems in place. However these systems had not sufficiently addressed shortfalls in the service.

Not all staff had completed training to ensure they were suitably skilled to perform their role. Staff supervision was not undertaken regularly. The provider had failed to ensure they provided staff with opportunities to discuss their concerns, personal learning and development needs.

There was a robust staff recruitment process in operation designed to employ staff that would have or be able to develop the skills to keep people safe and support people to meet their needs.

People were involved in how the home was managed. Regular meetings took place to give people a chance to have their say; the feedback was used to improve the home and the people's experience of living there.

Staffing numbers were sufficient to meet people's needs and this ensured people were supported safely. Staff and people we spoke with felt the staffing level was appropriate. Staff demonstrated a detailed knowledge of people's needs. Staff understood their safeguarding responsibilities and the whistle-blowing policy and procedures.

There were positive and caring relationships between staff and people at the service. People praised the staff that provided their care. We received positive feedback from people's relatives and visitors. Staff respected people's privacy. We saw staff working with people in a kind and compassionate way when responding to their needs.

Care provided to people met their needs. Care records provided personalised information about how to support people. We saw that the service took time to work with and understand people's individual preferences in order that the staff could respond appropriately to the person. People were also supported to undertake person centred activities and be involved in the local community.

The staff had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely. Meetings had been arranged in order to enable people's best interests to be assessed when it had been identified that they lacked the capacity to consent to their care and treatment.

People had their physical and mental health needs monitored. The service maintained daily records of how people's needs were meet and this included information about medical appointments with GP's and dentists.

There was a complaints procedure for people, families and friends to use and compliments could also be recorded

We found two breaches of regulations at this inspection. We will be asking the provider to send us a report of the improvements they will make.

Further information is in the detailed findings below

We undertook an unannounced inspection of Rosewood House on Wednesday 30 March 2016. When the service was last inspected during June 2014 no breaches of the legal requirements were identified. Rosewood House provides accommodation for people who require personal care to a maximum of 17 people. At the time of our inspection 15 people were living at the service.

A registered manager was in post at the time of 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.

The current listed registered manager of Rosewood House was now employed at a different service run by the provider. There was an acting manager in post, who was previously the deputy manager at Rosewood House and was currently undertaking the process with the Commission to apply to become the registered manager.

The provider did not ensure that medicines were managed safely. The controlled drugs register was inaccurate and we found that records relating to people’s medicines were not always accurately maintained.

There was enough staff on duty to meet people’s needs and we found that recruitment of staff was safe. Assessment of the risks associated with different people’s needs had been completed and where required, risk management guidance had been produced. Where incidents or accidents had occurred, the manager reviewed these with a view to reducing the chance of them happening again. Staff we spoke with were confident they could identify actual or suspected abuse and understood the options available to them when reporting this.

The provider had ensured that staff received appropriate training to provide effective care. Staff felt supported through supervision and appraisal processes. Training to meet the needs of people was provided and staff had the opportunity to obtain nationally recognised qualifications. People had sufficient amounts of food and drink to keep them healthy and a choice of meals was available. The provider had a system to monitor people’s weights and a nationally recognised tool was used to identify malnutrition or obesity risks.

The Mental Capacity Act 2005 [MCA] provides the legal framework to assess people’s capacity to make certain decisions, at a certain time The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provides a process by which a person can be deprived of their liberty when they do not have the capacity to make certain decisions and there is no other way to look after the person safely. The service had complied with the requirements of the DoLS. Staff understood how the MCA impacted on their roles and explained how they empowered people through giving choices.

People told us the staff were caring and observations supported this. Staff understood the people they cared for and people’s visitors were welcomed at the service. The provider had received compliments from people’s relatives about the care provision given by staff. There were systems for staff to communicate about people to ensure they were responsive to people’s needs. People’s records contained unique information to aid staff in providing personalised care. There were a range of activities people could participate in and the provider had a complaints procedure in operation.

Staff told us they felt well supported by the manager and told us they were visible and actively involved with people. Staff commented positively about the staff team at the service and how they worked together to ensure people received a good standard of care. There were systems to capture the views of people and their relatives. There were audits and quality assurance systems in operation, however we highlighted

We set out to answer our five questions during our inspection; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

At the time of our inspection there were 15 people living in the home. We made observations of how staff interacted with people that used the service and examined the care documentation that was in place to support people. We spoke with six people that used the service and we spoke with four members of staff.

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records.

There is no registered manager in place in this service. Following our inspection the provider confirmed the manger's application to become the registered manager had been submitted.

If you wish to see the evidence supporting our summary please read the full report.

Is it safe?

People we spoke with told us they felt safe living in the home and told us if they had any concerns they would tell the manager or their key worker. One person told us “Oh yes I feel very safe and comfortable around the staff here. The girls know me very well”.

Safeguarding procedures were in place and staff understood their role in safeguarding the people they supported. Staff received safeguarding training and knew who they needed to contact should they have any concerns around people’s welfare. People who used the service were cared for by staff who knew how to protect them from the risk of abuse.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (Dols). The manager confirmed no one currently living in the home was subject to such an application. We discussed the processes that were in place to make referrals should the need arise. The manager demonstrated a good understanding of this process and who to contact. This meant that people will be safeguarded as required.

We saw that incidents and accidents were regularly audited by the manager and provider. This reduced the risks to people and helps the service to continually improve people’s safety.

Is it caring?

People were supported by sensitive and attentive staff and people told us they were treated with dignity and respect in relation to their care routines. One person told us “I am more than happy here. It couldn’t be better. They are lovely to me”.

We saw that care staff showed patience and gave encouragement when supporting people. We spent time in the communal area observing interactions between staff and people that used the service. The observations that we made demonstrated staff supported people in a calm unhurried manner, using communication methods conducive with their individual assessed needs.

Is it effective?

We found people’s health and care needs were assessed with them and reviewed regularly. Some people we spoke with confirmed their involvement. Care plans provided guidance for staff to follow that ensured people’s individual needs were met.

Care documentation that we viewed was reflective of people’s current level of need. Some documentation in relation to planning activities was pictorial. This ensured people could participate fully.

People’s health and care needs were assessed with them, and they were involved in writing their plans of care. People had signed their documentation and demonstrated their involvement. People told us their keyworker met with them on a monthly basis.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well.

Is it responsive?

People's needs had been assessed before they moved into the home. Documentation called ‘A prospective service user needs assessment’ was in people’s files and highlighted people’s current level of need. The manager told us people met with their key worker monthly to discuss their care plans and relatives were involved as people required and agreed by the person.

People received co-ordinated care. We saw evidence in people's care plans that demonstrated people had been visited by their GP and other health care professionals. For example people's files held information and advice sought from the community mental health team when a person’s cognitive decline was noted by staff.

Is it well-led?

People we spoke with were able to tell us their experience. They confirmed they felt listened to by staff and knew how to raise a complaint if they needed to. One person told us “Yes I do meet with staff often and they ask if I am happy with the care I have. If I wasn’t I would tell them. Most of us here have the savvy to do that”.

People that used the service, their relatives and external professionals completed a satisfaction survey once a year. The manager told us if any concerns were raised these would be addressed promptly.

At the time of our inspection 14 people were living in Rosewood House. During our inspection we spoke with people living in the home, staff, relatives and examined the care records.

Most people we spoke with were able to verbally tell us about the care they received and if they were happy. For those who were unable to verbally communicate we observed how staff interacted and supported these people in the communal areas. This enabled us to make a judgement on whether their needs were being met.

People appeared happy and relaxed in the company of the staff and were seen to be engaged in conversations during our inspection in a relaxed manner. Staff supported people in a sensitive manner.

We looked at people’s personal care files to see if their care assessment documentation met their needs. We spoke with five people who used the service, one relative and four staff during our inspection.

We received positive feedback from people living in the home. Comments included; “yes its ok here. I’m well looked after”. “I don’t know how anyone could complain they are lovely”. “It’s lovely and clean here”. “I know how to complain and would do it if I need to, but I don’t need to they are lovely girls”.

One relative told us “it is excellent here. The manager is excellent. I really can’t fault it. They try to meet X needs as an individual person”.

We used a number of different methods to help us understand the experiences of people using the service. Methods included talking with people who live there and their relatives, talking with staff and talking with the registered provider. We also looked at records, care files and made observations of practice throughout our visit.

We spoke with five people who lived in the home, five members of staff and one relative. People who use the service told us, “they are nice here”, “The staff are lovely and helpful”, “I get choices of things” and “its ok and staff work very hard”.

Staff comments included; “we get lots of support, we are a good team”, “we provide good care here”.

At the time of our visit thirteen people were living in the home.