We undertook an unannounced inspection of Seahorses on 19 October 2017.

Seahorses is registered to provide accommodation and personal care for up to 20 people. On the day of our inspection there were 15 people living at the home. People were living with various stages of dementia and associated conditions.

At our last inspection on 4 and 23 March 2016 we found breaches of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Records did not show the Mental Capacity Act (MCA) 2005 had been followed in relation to consent, the home was not always clean, risks were not always identified and appropriately managed, medicines were not always managed safely and audits were not always effective. In addition the environment and décor of the home did not always support people living with dementia.

At this inspection we found the home had made improvements to address the areas of concern and bring the service up to the required standards.

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.

Staff understood the Mental Capacity Act (MCA) and applied its principles in their work. The MCA protects the rights of people who may not be able to make particular decisions themselves. The registered manager was knowledgeable about the MCA and how to ensure the rights of people who lacked capacity were protected, this included people who were deprived of their liberty. Records relating to the MCA were accurate and up to date. People were offered choices and their decisions were respected.

The home was clean and free of malodours. Cleaning schedules were in place and staff followed schedules using personal protective equipment. New carpets and easy clean furniture had been installed and the bathrooms, toilets and laundry were clean and smelt fresh.

Where risks to people had been identified, risk assessments were in place and action had been taken to manage the risks. Staff were aware of people’s needs and followed guidance to keep them safe.

People received their medicines as prescribed and systems were in place to safely store and manage medicines. Medicine records were accurate and up to date.

Records in relation to people who used the service were complete and accurate. The registered manager conducted regular audits to monitor the quality of service. Learning from these audits was used to make improvements.

Whilst some improvements had been made the décor and environment did not always support people living with dementia. The registered manager was aware and understood the need to improve the environment. We have made a recommendation in relation to the dementia environment.

We were greeted warmly by staff at the service who seemed genuinely pleased to see us. The atmosphere was open and friendly.

People told us they were safe. Staff understood their responsibilities in relation to safeguarding. Staff had received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the appropriate authorities where concerns were identified.

People were supported by staff that were extremely knowledgeable about people’s needs and provided support with compassion and kindness. All staff had received dementia training. People received quality care that was personalised and met their needs.

There were sufficient staff to meet people’s needs. Staff responded promptly where people required assistance. The service had robust recruitment procedures and conducted background checks to ensure staff were suitable for their role.

The service responded to people’s changing needs. People and their fam

We carried out this inspection over two days on 4 and 23 March 2016. The first day of the inspection was unannounced. There was a delay until the inspection was completed due to the availability of the registered manager.

The last inspection to the service was on 15 May 2014. Shortfalls in the safety and suitability of the premises and assessing and monitoring the quality of the service were identified. In October 2014, a review was undertaken to assess whether improvements had been made to address the shortfalls. The provider and registered manager provided sufficient information to evidence improvements had been made.

Seahorses is registered to provide accommodation and personal care for up to 20 people. However, due to no longer using bedrooms allocated for double occupancy, 18 people were usually accommodated. During the inspection, there were 17 people living at the home. People were living with various stages of dementia and associated conditions.

A registered manager was employed by 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 available for the majority of the inspection.

Audits to monitor the quality of the service were not effective, as shortfalls were not being identified and addressed. Potential risk was being addressed on a generic basis with control measures impacting on people’s welfare or activity. This included locking all internal doors to prevent people entering unsupported and removing call bell chords, in response to minimising harm.

Not all areas of the home were clean. This included less visible areas, such as the underside of the bath hoist and along the beading of over-bed tables and in the groves of the dining room chairs. Infection control guidance was not consistently being followed as toiletries and unnamed topical creams were being stored in bathrooms.

Staff knew people well and were aware of their needs. However, care plans did not demonstrate this knowledge. Information did not state how staff should manage particular behaviours or resistance to care. Some care plans lacked clarity regarding the support people required.

Staff and the registered manager told us they received a range of training to complete their role effectively. However, records were disorganised and did not reflect the training staff had completed. Due to this, it was not clear if staff had received training in core subjects such as safeguarding people and dementia care.

Staffing levels were in the process of being increased as it had been identified, an additional member of staff during the day would be beneficial. During the inspection, the home was calm and people were not waiting for assistance. Staff had time to sit and talk with people.

People were given their medicines in a person centred manner. However, some shortfalls in the procedures increased the risk of error. People were fully supported to meet their health care needs by regular consultations and intervention from professionals such as GPs and district nurses.

The registered manager was committed to people’s wellbeing and ensured staff had the right qualities of care and compassion, to support people effectively. Staff had established a good rapport with individuals and treated people with kindness. Staff spoke to people in a friendly manner and promoted their privacy and dignity.

People were supported by staff who felt valued and were well supported by each other and management. Staff had day-to-day contact with the registered manager and regularly met more formally, to discuss their work.

People had enough to eat and drink. The menu did not offer a choice of main meal although staff and the registered manager confirmed

One inspector visited the care home and 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who use the service, the staff, speaking with relatives of people who use the service, talking with commissioners of the service and from looking at records. We also requested the provider to send more information to us after the inspection.

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

Is the service caring?

The care home had a person-centred approach in their delivery of care and this was evidenced at the inspection. Care workers who provided care to people ensured that people’s needs were taken care of, which included checking that their needs were addressed. Care was provided in privacy and in a dignified way. Care staff knew each person at the service as an individual and what their preferences were. People were given choice in the way their care was provided.

Is the service responsive?

We saw that people’s needs were met. The provider ensured that appropriate interventions were taken where people were at risk because of their health. Examples of good practice we saw included referral to and intervention by the GP, dietician and speech and language therapist when people were not taking enough food or fluids. There was also a community mental health nurse contracted by the provider to screen people for confusion, dementia progression or depression.

Is the service safe?

Day to day care provided by the staff to people was safe. There were enough staff to provide care in a prompt manner and ensure that people did not have to wait for their needs to be met. Basic health and safety requirements were handled satisfactorily. However, we found evidence that people were at risk from the safety of the premises and related maintenance requirements. The provider did not have some necessary checks in place to ensure that the premises did not pose a risk to people’s health and safety. We made referrals to other agencies regarding the premises.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People were complimentary about the care they received and had no complaints when we asked. Relatives and commissioners of services confirmed this when we asked. It was clear from our observations and from speaking with staff they had a good understanding of peoples care needs and that they knew them well.

Is the service well-led?

The care home had a registered manager in post who worked with the other staff to provide management oversight of care provided. The registered manager took responsibility for quality and safety of the care with their involvement in risk assessment, care planning and care delivery. Although people could have a say in the operation of the care home, this was not routine or recorded to monitor improvement. There were some basic audits in place, but an effective quality system was not in place to ensure risks to people and others were adequately addressed.

People who lived in the home had dementia and were unable to comment fully upon their care and support. People we spoke with told us they enjoyed living in the home and were well looked after.

People were offered a varied diet and the home ensured that nutritional needs were assessed and monitored on an ongoing basis.

We observed that the care staff were skilled at the meeting the needs of people with dementia and responded to people living in the home in a caring and professional manner.

The home had safe procedures in place for the administering and storing of medications.

We found there were shortfalls in the provision of staff which meant people did not all receive the support they required, particularly at mealtimes. The home did not employ a cook and the meals were prepared and served by the care staff.

All of the people living in the home had dementia needs and were unable to comment in detail about their care but people told us they enjoyed living in the home and were well treated by the staff and manager. We observed staff responding to confused behaviours with a calm and reassuring approach. Staff had a good understanding of peoples individual needs.

We found that the home was clean and hygienic and free from odours.

We found that medications were being safely stored and administered.

The home had an established staff team who understood the needs of the people living in the home but improvements were needed to the recruitment process and the documenting of staff records.

At our last review of this service we identified a number of shortfalls in relation to the meeting of some of the essential standards.

We found that improvements were needed in the recording of consent, cleanliness and infection control, the safety and suitability of the premises and the assessing and monitoring of the quality of service provision.

An action plan had subsequently been provided and we undertook this review to monitor the progress towards compliance.

During this visit we observed that improvements had been made and that the service was now compliant in relation to the areas were concerns had been identified.

The service had a consent policy in place and there was documentation in all the individual files relating to this.

Action had been taken to improve the cleaning and maintenance procedures and improved auditing and checking was being undertaken to ensure standards were being maintained.

The service has begun introducing a quality assurance system.

People told us they were happy living in the home and that the staff treated them well and with respect. People said they enjoyed the food and the activities that were provided.

We were told that the staff worked well as a team and were well supported by the manager and the provider. Staff said they worked to provide a homely and family type environment.

Care staff were satisfied with the training they have received in dementia awareness and believed they had a good understanding of peoples needs.