The inspection took place on 19 and 26 July 2016 and was unannounced.

Following an inspection in August 2015, we asked the provider to take action in response to breaches of regulation. The service was not safe in all areas. Risk assessments were in place but people may not have been protected from harm as their care records did not always contain the most up-to-date guidance on how to mitigate risks. Medicines were not always managed properly or safely and there was unclear guidance for staff on the use of barrier creams. There were not enough staff at all times of day to meet people’s needs in a timely way. The service was not consistently responsive. People could not be certain to receive personalised care that met their needs because records detailing their needs were inconsistent. The service was not well-led. The quality assurance system was not effective at monitoring and improving the quality of the services provided. As a result, the provider sent us an action plan that outlined the actions that had been taken in order to achieve compliance. At this visit, we found that action had been taken and these requirements had been met.

St Bridget's - Care Home Physical Disabilities is run by the provider Leonard Cheshire Disability. It is a care home for people needing personal care and accommodation that provides care for up to 38 people who have a range of physical disabilities, some of whom have an associated learning disability. At the time of our visit there were 30 people living at the home. The home’s brochure states that they [Leonard Cheshire Disability], ‘Have been providing support to people for over 60 years and we now work at over 200 sites in the UK.’ The website states that, ‘We support disabled people to have the freedom to live their lives the way they choose.’

In the Provider Information Return (PIR), the registered manager stated that, ‘In addition to their bedrooms people have access to communal areas including lounges, activities room, a small kitchen, and various outside spaces. All accommodation and facilities for people who live at St. Bridget's is on the ground floor and accessible for people who use a wheelchair. All bathrooms have been refurbished in the last year and have fully automatic baths and ceiling track hoists.’

The home had a registered manager in place. 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 protected from risks to their health and wellbeing. Up to date plans were in place to manage risks, without unduly restricting people’s independence. Risk assessments were reviewed regularly so information was updated for staff to follow.

People said they felt safe at the service and knew who they would speak to if they had concerns. The service followed the West Sussex safeguarding procedure, which was available to staff. Staff knew what their responsibilities were in reporting any suspicion of abuse.

People were treated with respect and their privacy was promoted. Staff were caring and responsive to the needs of the people they supported. Staff sought people's consent before working with them and encouraged and supported their involvement.

People's health and well-being was assessed and measures put in place to ensure people's needs were met in an individualised way. Medicines were administered safely.

People were supported to eat and drink enough to maintain their health. People at risk of choking had been assessed by a Speech and Language Therapist (SaLT). The assessments gave clear details of people’s eating, drinking and swallowing needs. This included the different textures of food and thicknesses of fluids that people needed to manage their individual risk of choking. Addition

During our visit we spoke with four people who live in the home and a visiting relative. We spoke with the manager and four members of staff. We also spoke with the local safeguarding team.

We used this inspection to answer our five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service and the staff told us.

Is the service safe?

We spoke with four people who live in the home. People told us they had no concerns about the support they received and they felt safe. A person told us, “I’ve never seen the staff being abusive to anyone.” We saw that care was planned and delivered in a way that ensured people's safety and welfare. All of the care plans we looked at had assessment tools in place to assist staff in establishing the level of risk for people.

The provider and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).

There were arrangements in place for the service to deal with foreseeable emergencies such as loss of electrical power or loss of gas supply. The home had a contingency plan should the home become uninhabitable and people could not return to the home after an evacuation.

Is the service effective?

Each person had a plan of care and support. These explained what the person could do for themselves and what support they needed from staff. Staff told us the care and support plans gave them the information they needed to provide the level of support people required.

We observed staff supporting people. The care staff we spoke with were aware of the needs and the preferences of people they cared for, and how people wanted their care to be delivered. A person told us, “Care is individualised. I like things a certain way.” We saw staff offering advice and support and enabling people to make their own choices and decisions.

Is the service caring?

We saw people being treated kindly and with dignity and respect by the care staff. Care staff spent time chatting with people and responded promptly to people’s request for assistance. People described their satisfaction with the home. One person told us, "If staff weren’t caring it would be identified.” Another person told us, “The staff are generally caring.”

We heard staff speaking to people appropriately and staff using people’s preferred form of address. People told us the staff’ were kind and patient in their approach. A person said, “Most of the staff are tolerant.”

Is the service responsive?

Staff responded promptly to peoples request for assistance. People had regular reviews of the care and support they received and care plans showed alterations that had been made to people’s plans of care, as people’s needs had changed. One person told us, “They are responsive to people.”

People who used the service and their relatives were asked for their views about how the home was meeting people’s needs, and any concerns or ways to improve the service were acted on.

Is the service well led?

A relative we spoke with told us they had regular contact with the home and said, “They are approachable.” The relative told us they were kept informed about any issues which affected their relative.

All of the staff we spoke with said they felt supported. A person told us, “The manager is very hands on.” We saw the provider had systems to monitor and assess the quality of the service provided by the home. These included senior staff at the home conducting a number of monthly audits including inspections of the property, people’s care records, and staff training. The provider also conducted a comprehensive annual audit of the home’s services.

Records we viewed confirmed the provider had effective recruitment procedures to ensure that staff were of good character and had the necessary skills for the job.

We spoke with two of the 34 people who lived at St Bridget's - Care Home Physical Disabilities. We asked them if they thought there were sufficient staff on duty. People told us they did not think so. They told us that, this was because people accommodated had become more dependent. One person told us, “The problems we have are to do with the changing patterns of people living in care homes. Their needs have become more complex and how they are met is more labour intensive.” Another person told us, “Everybody needs more help.”

We spoke with three members of staff, who were on duty. They told us they believed they had sufficient time during their shifts to do what was expected of them.

We also gathered evidence of people's experiences of the service by looking at staff rotas and records of assessments of people’s needs. This demonstrated that the manager had a means of working out how many staff needed to be on duty, according to peoples’ identified needs.

We spoke with two people who lived at the home and three family members. Overall the people who lived at the home were happy with the care provided. One person said, "The care is tailored to me and I can tell them what I want." Another said, "I'm happy living here." The family members we spoke to said that they had some concerns about the care provided but that it had improved recently.

We spoke with four members of staff. They said that overall they received sufficient training to undertake their roles. Not all of the staff felt that the arrangements in place for staff supervision were effective. They therefore did not always feel well supported.

We looked at the care records of three people. We saw evidence that people's needs had been assessed and that care plans were in place. The care plans were regularly reviewed and updated to reflect any changes that were required.

We looked at staffing levels in the home. The staff and the people we spoke with all said that they did not always feel there were enough care workers on duty, particularly at certain times of the day. This meant that they could not always meet people's needs.

We found that people who used the service had been asked for their views about their care and treatment. The provider had systems in place to monitor the quality of the service it provided.

We spoke with three people accommodated at the service. They told us about their experiences whilst living at St Bridget's - Care Home Physical Disabilities.

They told us they have been respected and involved in the delivery of their care. One person told us, " I have given my consent to the care provided. It has been in line with my expectations."

When we asked about staffing levels people gave us mixed views. People mostly told us staffing levels were sufficent. However, we were also told that recent changes to staffing rotas meant there were not as many staff on duty at certain times of the day.

They told us they were satisfied with the care and support they have received. One person told us, " My wishes and preferences have been taken into account."

They also told us they found staff were sufficiently skilled and competent when delivering care. One person told us, "I have found that staff know what they are doing when providing my care."

People we spoke with confirmed that, overall, they were satisfied with the care they have received.

People told us that they liked living at the home and that they were happy there and that staff were attentive, kind and caring.

People told us they were treated with respect and that staff asked them how they like to be supported. People said staff talked to them and explained what they were doing when providing support.

People said that their needs were met by staff at the home. People told us the staff always responded to calls for assistance; however people said that sometimes they had to wait a short time before staff came to help them.

Three of the people we spoke with said that they felt that some staff were not happy in their work. One person told us “You can feel an atmosphere”. Another person said “ The care provided is still good but you can tell that staff are not happy in their work”

People said that they knew how to make a complaint and said they would speak to staff if they had any complaints.

We spoke with two visiting relatives who told us that in their opinion the care provided was good. One person told us that he/she felt that staff at the home were not adequately supported by management. He/she said that staff remained professional but it was noticeable that some staff were not happy. They said that staff did not always seem to work as a team and that there was conflict between some staff members.

We spoke with nine members of staff who were on duty and six told us that they felt that they had not been supported by the management at the home. Three people said they had not received any supervision for over six months. Staff said that they were not having their voice heard.

Staff also told us that they felt the current staffing levels were at an absolute minimum. They said they were working to capacity. One staff member said “I used to have time to stop and chat with people, however as people’s needs increased the staffing levels have remained the same”.

The inspection took place on 11 and 13 August 2015 and was an unannounced inspection.

St Bridget's - Care Home Physical Disabilities provides accommodation and personal care for up to 38 people. The service consists of a main building split into three wings and separate bungalows. The bungalows are set up for people to live more independently and can be used for transition into or out of the service. At the time of our visit, there were 32 people in residence, including one person on respite care.

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.

We identified issues with how the quality and safety of the service was monitored. The registered manager did not have an effective governance system in place to ensure that all aspects of the service were assessed and to mitigate risks to people’s safety. People’s care records did not provide consistent information to staff on how to meet their needs and there was no record of some agreed support being delivered. We also observed that medicines were not always locked securely when unattended and that staff lacked guidance on the application of topical creams prescribed to people on an ‘as required’ basis.

People spoke positively about the staff who supported them but were unhappy about the recent use of agency staff. They had raised their concerns with the registered manager who had apologised and explained that agency staff had been used to maintain staffing numbers in a period of staff sickness and holiday. The registered manager had identified that additional staff were needed at particular points in the day and was completing their analysis. We have made a recommendation about staff deployment to ensure that people’s needs are met in a timely way.

Staff received regular training and were supported in their roles. They spoke of a strong staff team and valued the support of their colleagues. New staff were given an induction and the opportunity to shadow experienced staff until they were confident and assessed as competent in their role

Following an incident in May 2015, the service had worked closely with the safeguarding team and with external healthcare professionals. People who were at risk of choking had been referred to the Speech and Language Therapist (SALT). Staff had also attended training in food textures, providing support at mealtimes and emergency first aid. People were happy with the choice of food on offer at the service. They were also able to use a residents’ kitchen to prepare their own meals if they wished.

There was an open and positive atmosphere at the home. People and staff appeared relaxed and happy in each other’s company. People and staff felt able to raise concerns with the registered manager and were confident that action would be taken. Staff understood local safeguarding procedures. They were able to speak about the action they would take if they were concerned that someone was at risk of abuse.

Staff understood how people’s capacity should be considered and had taken steps to ensure that their rights were protected in line with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). People were supported to be as independent as they were able and to make decisions relating to their care and treatment.

People were supported to participate in activities that interested them. In addition to a varied activity programme, the service had a team of volunteers who assisted people individually or in groups.

People’s mobility needs had been considered in the design of the premises. The corridors were wide and bedrooms were equipped with tracking hoists. People were able to open key-coded doors as sensors had been fitted to their wheelchairs. A new button-operated system for opening and closing bedroom doors had recently been installed to promote people’s independence.

People were supported to access healthcare services. The service also provided in-house physiotherapy and occupational therapy services which were available to everyone who lived at the home at no extra cost.

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