This comprehensive inspection took place on 19 June 2018 and was unannounced. At our last inspection of the service in December 2016 we rated it as requiring improvement overall and made two recommendations to the registered provider.

At this inspection we found that the provider had acted on those recommendations and that the service was meeting the fundamental standards of quality and safety. Providers of health and social care services are required to inform us of significant events that happen such as serious injuries and allegations of abuse. Whilst the provider had dealt with such events appropriately they had not always notified CQC. The failure to notify us of matters of concern as outlined in the registration regulations is a breach of the provider's condition of registration and this matter is being dealt with outside of the inspection process.

St Gregory's House is a ‘care 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.

The home can accommodate up to 30 people who need nursing and personal care. There were 25 people residing there at the time of the inspection. St Gregory's House is a large detached three storey Victorian house and is situated in the hamlet of Preston Patrick, near the town of Milnthorpe. Extensions have been added to the main house to provide bedrooms on the ground floor and communal living spaces. There is lift access to the upper floor accommodation.

At the time of the inspection the provider was actively recruiting for 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. The previous registered manager left employment in May 2018 and since then the home had been overseen by the nominated individual and the deputy manager.

We found medicines were being administered, recorded and kept safely.

There were sufficient numbers of staff to meet people’s needs. Staff training was ongoing and staff had received sufficient training to safely support and care for people. Staff were supported through regular staff meetings, supervision and appraisals.

We saw that the service worked with a variety of external agencies and health professionals to provide appropriate care and support to meet people’s physical and emotional health needs.

Where safeguarding concerns or incidents had occurred, these had been reported to the local authority and commissioners and we saw records of the actions that had been taken by the home to protect people.

When employing fit and proper persons the recruitment process had included all of the required checks of suitability.

People’s rights were protected. The staff were knowledgeable about their responsibilities under the Mental Capacity Act 2005. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Hazards to people’s safety had been identified and managed. People were supported to access activities that were made available to them and pastimes of their choice.

People’s dignity and privacy were actively promoted by the staff supporting them.

People were treated with respect and their relatives made very positive comments about the staff team who supported them.

The provider had introduced a new electronic care records management system which meant information about people’s needs was current.

This comprehensive inspection took place on 20 December 2016 and was unannounced. We last inspected St Gregory’s House on 29 January 2015. At that inspection we found areas that required improvement but they did not breach any of the (Regulated Activities) Regulations 2014 of The Health and Social Care Act 2008.

St Gregory’s House provides accommodation for up to 31 people who need nursing or personal care and or treatment of disease, disorders or injuries. St Gregory's House is a large detached three storey Victorian house that was formerly the local vicarage. It is situated in open countryside on the edge of Preston Patrick, near Kendal. Extensions have been added to provide bedrooms and communal living spaces. Accommodation is over two floors with access to the upper floor by a lift.

There was a registered manager. A registered manager is a person who has registered with the (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.

Medicines were being administered and recorded appropriately and were being kept safely. However, we found that supporting information or ‘protocols’ were not always recorded to guide staff in the administration of medicines which were prescribed to be given “when required” or as a “variable dose”. A small number of people were prescribed thickening agents for fluids but we did not always see specific care plans in place for the management of this.

We have made a recommendation that written protocols for staff to follow would help ensure people are given these medicines safely and in the way they were prescribed.

There were sufficient numbers of suitable staff to meet people’s needs and to provide their care and treatment safely. Staff told us they had received regular supervision to support them in their roles.

Where safeguarding concerns or incidents had occurred these had been reported by the registered manager to the appropriate authorities and we could see records of the actions that had been taken by the home to protect people.

We observed staff displayed caring and meaningful interactions with people and they were treated with respect. We observed people’s dignity and privacy were actively promoted by the staff supporting them. People living in and visiting the home spoke highly of the staff and told us they were very happy with their care and support.

The recruitment procedures demonstrated that the provider operated a safe recruitment procedure to ensure that fit and proper persons had been employed.

The service followed the requirements of the Mental Capacity Act 2005 (MCA) Code of practice and Deprivation of Liberty Safeguarding (DoLS). This helped to protect the rights of people who were not able to make important decisions themselves. Where decisions had been made in people’s best interest we did not see that these had always been recorded.

We have made a recommendation that the provider review their best interest decision making process and how they obtain consent to ensure it follows guidance outlined in the Mental Capacity Act 2005.

A range of activities were made available to people living in the home.

Auditing and quality monitoring systems were in place that allowed the service to demonstrate effectively the safety and quality of the home.

This inspection took place on 29 January 2015 and was unannounced. St Gregory’s House provides accommodation for up to 31 people who need personal care. St Gregory's House is a large detached three storey Victorian house, that was formerly the local vicarage. It is situated in open countryside on the edge of Preston Patrick, near Kendal. Extensions have been added to provide bedrooms and communal living spaces.

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.

At our last inspection in March 2014 we found that the provider was compliant with four out of five of the Regulations of the Health and Social Care Act 2008 that we looked at. We found there was a breach of Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010 Consent to care treatment.

Following the previous inspection the provider sent us an action plan telling us about the improvements they intended to make. During this inspection we looked at whether or not those improvements had been made.

We found that improvements had been made in gaining consent to deliver care and treatment from the appropriate people on behalf of those who lacked the capacity to make important decisions about their care and welfare.

At this inspection we found that information in different records relating to people’s care had not always been included in the care plan. When changes had occurred in people’s needs we did not see that all of the information was included in their care plans. This meant care staff did not always have accurate information about how to support people and placed them at risk of receiving inappropriate care.

There were enough staff to provide the support that people needed not all people received the level of support required to minimise risk of behaviours that could challenge the service.

The registered manager had not reported two incidents that had resulted in injury to a person to the required authorities.

Some of the regular checks of medication records completed to monitor the quality and safety of the service did not always identify concerns.

People were provided with meals and drinks that they enjoyed. People who required support to eat or drink received this is a patient and kind way. People who could tell us said they were happy and well cared for at the home. People we spoke with knew how to make a complaint and we saw that procedures for managing complaints were in place.

Throughout our visit we observed caring and supportive relationships between people living at St Gregory’s House and the care staff. People were treated with kindness, respect and their dignity was maintained.

Care staff had received training that enabled them to appropriately support people. Staff told us they felt they were well supported by the management and the provider.

People were supported to maintain good health and appropriate referrals to other healthcare professionals were made. For example, to the Care Home Education Support Service (CHESS). People received support from the community nurses as required with regards to their health needs.

The inspection was carried out by a pharmacist inspector. We set out to answer three key questions; 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, discussions with staff and people who use the service, looking at supplies of medicines and looking at records.

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

Is the service safe?

We found that the service was safe because people were protected against the risks associated with use and management of medicines.

People received their medicines at the times they needed them and in a safe way. Medicines were administered and recorded appropriately, and were kept safely.

Is the service effective?

We found that care plans for managing medicines were much improved and staff had guidance available to them to make sure that people received appropriate care.

Is the service well led?

We saw that audits, or checks of medicines, were done to assess the way medicines were managed and the paperwork for this was being reviewed at the time of this visit.

Following our last inspection in October 2013 we set some compliance actions for the provider to protect the interests of the people using the service. Some of these matters we needed to check did not necessarily relate to people's views and experiences. Therefore at this visit we did not ask people to comment on all of the outcomes we looked at.

We saw in all the records we looked at that consent to the use of photography had been signed for by the person or the identified person responsible for making decisions on their behalf. Care plans had a section for people to sign to acknowledge their consent to care and treatment. We found that this had not been completed to indicate consent in all cases. This meant that we could not confirm whether people had any knowledge or understanding of their care plan.

We observed the interactions between people living at St Gregory’s House and the staff supporting and caring for them. We used the 'Short Observational Framework for Inspection' (SOFI) to help us do this. SOFI is a specific way of observing care to help us understand the experiences of people who could not easily talk with us. We observed the interactions between the staff and five people living there. We found that the interactions were very positive for all five people and that the main reason for the interactions was task orientated for example assisting with a drink. From the interactions observed we saw that people were treated with respect.

We saw the home’s processes of gathering information to monitor the service had been improved to enable the senior management to action changes to improve the quality of the service. This included gathering data about accidents or incidents and the monitoring of people’s behaviour being taken into account and used to inform risk assessments and care plans.

Since our last inspection in October 2013 we have received statutory notifications for incidents we are required to be notified of. We have been able to effectively monitor actions taken by the provider to ensure that people’s health and wellbeing have been protected as far as reasonably possible.

We carried out this visit to look at the arrangements for handling medicines following receipt of information regarding medication errors.

The people who we spoke with did not give an opinion of their experiences with regard to how their medicines are managed.

Overall, we found that medicines were not managed in a safe way.

We spoke with four people living at St.Gregory's House and one person told us that, ‘’Things are okay. I get plenty of visitors and the girls (staff) are lovely’’.

We did not see in the records that people were supported to give consent or make decisions about their care and treatment if their conditions changed or deteriorated. We did not see that people had been asked for their consent in order to take their photographs for records. Nor did we see that consent had been obtained for the use of any bedrails.

During an observation of 45 minutes that took place in the communal lounge we saw staff walk past the lounge to enter the dining area. No other staff came into the lounge to support people until the member of staff who had been there during all the time of the observation pressed the bell for assistance as a person who had been consistently shouting and disturbing other residents requested to go to bed.

We reviewed the recruitment records of the staff and found that they had been recruited using an effective procedure. This included all of the appropriate checks to ensure that the person being employed was of good character.

On our tour of the home we found that the flooring in the dining room was loose in parts and posed a safety hazard. Some of the dining room chairs were torn with wear and tear. We also noted that on two of the table legs there was what appeared to be spilt food that had dried. We did not see that there was any formal audit or checks completed on the environment that identified these safety hazards.

Six accidents and incidents that had been recorded were important events that affected the health, welfare and safety of people using the service and had not been notified to us, two of these accidents included people who had sustained fractured bones.

We found that people's personal records including medical records were accurate and fit for purpose. Staff records and other records relevant to the management of the services were properly maintained. Records were kept securely and could be located promptly when needed

Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We observed lively and positive interactions between staff and people in the home which made for a relaxed and friendly atmosphere. We also observed staff responding sensitively to people and picking up cues from body language when they needed assistance or reassurance.

We spent time observing daily life in the home and at the lunch time meal and saw that there were staff available to help people with their meals and prompt them to eat and drink. We did not receive any negative comments about the individual attention people received from staff, the food on offer to them, the cleanliness of the home or the staff approaches and support.

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if something bothered them. People told us they liked the staff who worked there.

Residents at St Gregory's House told us they were happy with the care they received, and found the staff patient, helpful and cheerful. Most relatives who answered the last satisfaction survey conducted by the home reported positively on their experiences.