St Francis Residential Care Home is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Francis Residential Care Home could accommodate up to 29 people who may have dementia in a two storey building. The ground floor had been reconfigured and extended and the provider had applied to increase the bed numbers to 39. At the time of this inspection, there were 27 people using the service.

This inspection took place on 22 and 29 October 2018 and was unannounced. At the last inspection in July 2016, the service was rated as Good. During this inspection, we found two breaches of the regulations and the service is now Requires Improvement. This was the first time the service has been rated Requires Improvement. We found there was not always enough staff to meet people’s needs and the provider’s quality assurance systems did not identify the issues we picked up on at inspection.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 were knowledgeable about reporting safeguarding concerns and whistleblowing. People had risk assessments carried out to mitigate the risks of harm they may face. However, the risk assessment for the building and renovations work lacked detail and we identified trip hazards in the newly created garden area. Building safety checks were carried out in line with building safety requirements. Recruitment checks were carried out before new staff began working at the service. There were systems in place to manage medicines safely. People were protected from the risks associated with the spread of infection. The provider used accidents and incidents to make improvements to the service.

People’s needs were assessed before they began to use the service to ensure the right care could be provided. Staff were supported with regular supervisions, annual appraisal and training opportunities to help them to carry out their role effectively. The provider had communication systems in place for staff to be updated on people’s well-being and changes in care needs. People were supported to eat a nutritionally balanced diet and to maintain their health. However, the dining experience for people was not always positive. The provider and staff understood the requirements of the Mental Capacity Act (2005).

People and their relatives were involved in decisions about the care and thought staff were caring. Staff knew people well and understood their care needs. People were supported to maintain their independence and their privacy and dignity was promoted. Staff were knowledgeable about equality and diversity.

Staff understood how to deliver personalised care. Care plans were detailed and contained people’s preferences. However, care plans were not always accurate. People were offered a variety of activities and their communication needs were met. Complaints and compliments were recorded and used to improve the service. The provider had a system to capture people’s end of life care wishes.

Not all people and relatives knew the new registered manager. The provider obtained feedback from people using the service, relatives and health professionals. People had regular meetings to be updated on service development and for improvement suggestions. The provider worked in partnership with other agencies to improve the service provided.

We found the registered provider was not meeting legal requirements and was in breach of two regulations. These were in relation to staffing and good governance.

We have made three

St Francis Residential Care Home provides accommodation and support with care for older people and people living with dementia. It is registered for 29 people and at the time of this inspection there were 27 people using the service. At the last inspection in June 2014 the service was found to be meeting the legal requirements.

There was a registered manager at this 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.

We found staff knew how to report concerns or abuse. There were enough staff on duty to meet people’s needs who were employed through safe recruitment processes. Risk assessments were carried out and management plans put in place to enable people to receive safe care. There were effective and up to date systems to check and maintain the safety of the premises. The provider had systems in place to ensure the safe management, storage and administration of medicines.

Staff received support through regular supervisions, appraisals and training opportunities. Appropriate applications for Deprivation of Liberty Safeguards had been applied for and authorised and staff knew when they needed to obtain people’s consent. People were offered a varied and nutritious food menu and had access to healthcare professionals as required to meet their day-to-day health needs.

People thought staff were caring and staff knew how to build up positive relationships with the people using the service. Staff ensured people were given choices, their privacy and dignity was respected and their levels of independence were maintained.

Staff knew the people they were supporting including their preferences to ensure a personalised service was provided. A variety of activities were offered which included trips outside the home. The service dealt with complaints in accordance with their policy and timescales.

People, visitors and staff thought the manager was approachable and supportive. The provider held regular meetings for staff and for people and their relatives. People and their representatives were given the opportunity to complete feedback surveys. The provider had quality assurance systems in place to identify areas for improvement.

We considered our inspection findings to answer 5 key questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Is the service caring?

The manager told us that family members are invited to attend the residents meetings and any events they hold. This was confirmed when we spoke with staff and family members. Staff were observed to speak to people in a kind and caring way. For example, a staff member was observed to ask one person if they were okay and if they needed help. One person told us “yes we have caring staff, they have a lot of patience.” A family member said “I have nothing but praise for them and I love the way they interact with people.”

Is the service responsive?

People's needs had been assessed before they started to use the service. We saw evidence that plans were put into place before people moved into the home. People's preferences, likes and dislikes had been recorded on support plans. We saw evidence that referrals to other services had been made when needed, for example, to a dietician when a person had diabetes or when a person’s weight had dramatically reduced or increased. Care plans were reviewed regularly and were up to date. Our observations showed that staff responded in a timely manner when people called for assistance.

Is the service effective?

We saw evidence from staff files that staff had received an appropriate induction and training was updated annually. Staff received regular supervision and annual appraisals. We saw evidence from records of 'knowledge checks' in staff supervision notes that staff increased their competency about working with people living with dementia. This showed that people could be confident that they received effective care from staff who have the knowledge and skills necessary to carry out their roles and responsibilities.

Is the service well-led?

Staff and family members told us that the manager had an open door policy and they felt able to approach the manager if they had any concerns or suggestions. There was evidence that the provider visited the home weekly to monitor the service provision. The manager and senior staff observed how the staff worked with people and records showed that issues were raised appropriately during supervision sessions.

Is the service safe?

The provider had systems in place to ensure the service was safe. We saw that the fire alarm system was serviced every three months with the last service taking place on 11 March 2014. We saw that the fire extinguishers and kitchen fire blanket were also checked at that time. Records showed that there was a fire drill every month and these were up-to-date. The manager explained that the four senior staff were fire marshalls and they had the responsibility of completing a report after the fire drill. Records showed that staff had recently completed refresher training in health and safety and safeguarding. There were systems in place to deal with emergencies and staff were able to tell us the actions they would take. For example, one staff member said that she would immediately alert the senior on duty or the manager in the event of an emergency.

We spoke with twelve people who used the service and observed interactions between staff and people who could not verbally communicate with us effectively. We spoke with relatives and nine staff including the manager. We found that care was not always planned or delivered with the individual person in mind. Culturally specific dietary needs were not always catered for and guidelines for dementia care were not always followed.

Staff told us and we saw evidence that people were visited by other professionals such as GP's district nurses and community psychiatric nurses when required.

Staff knew how to identify different types of abuse. However, we saw some instances such as wake up times and the activities arranged for people that were not always their choice.

There was enough equipment to move people. We saw a cupboard that contained extra manual handling equipment. However one hoist was due to be serviced in October and had not been serviced. Other furnishings in people's rooms needed some repairs.

We found that some of the night staff had very limited English and could not communicate with people properly and therefore could not effectively meet the needs of the people.

People told us that they were happy living at St Francis. One person said, "I am very pleased with care I receive." Another said, "I have no complaints at all. Staff are friendly and polite."

People were offered choice. People chose what activities they wanted to do, where they wanted to sit and what they wanted to eat. We found that people’s likes and dislikes were documented in care plans. Staff had knowledge of these and people we spoke to confirmed that they had been asked about their preferences.

We reviewed five care plans and found them to be individual and up to date. Staff had knowledge of the contents of these care plans and were aware of specific needs of the people they looked after.

We checked six staff files and found that appropriate recruitment checks had been taken before people started to work at St Francis.

We observed care during meal times and medication administration. We found that staff waited until people had finished taking their medication before moving onto the next person. Medication was administered by senior staff who had been trained on how to administer medication safely.

At our last visit we had concerns about the maintenance of equipment, the cleanliness of the bathrooms and the availability of hand wash. We found that bathrooms had been renovated, hand gels were available in bathrooms and that equipment had valid service reports.

People told us they were looked after by supportive staff. Most relatives were happy with the care at Francis residential care. One relative told us that they were “kept informed always of any change to her care needs.” People and their relatives were involved in planning care. One person said, “I enjoy setting the table.”

We found that staff supported people appropriately and were knowledgeable about the care required by the people who used the service. Although staff had attended safeguarding training recently they did not always remember where they would report any alleged abuse in the absence of the manger or in instances where the manager was implicated in alleged abuse.

People told us they chose what time they got up and what they wanted to wear. Most people said they did not want to go out so most activities were done at the home. People told us they enjoyed birthday celebrations and others had particular chairs and lounges they preferred to sit in.

People were given a varied menu choice and were supported to eat sufficient amounts. Relatives told us that, “there are no complaints about the food.” One person said, “I love porridge, but can request for a cooked breakfast when I fancy a change.”

We found that there was a lack of hand washing soap. We were concerned about the cleanliness of some of the toilets and bathrooms. We were also concerned about that one hoist was overdue for maintenance and there was a rusty bath lift chair and base.