The inspection was unannounced and took place on 17 & 18 November 2016. St Valery is a family run residential service for up to 16 older people living with dementia; the service was full at the time of inspection. Some bedrooms are located on the first floor and can be reached using a stair lift. The majority of bedrooms are for single occupancy, some shared rooms are also mostly used in this capacity. St Valery is a large detached and extended former family home with ample parking.

This service was last inspected in September 2015 when we found the provider was not meeting all the regulations inspected at that time in regard to staff recruitment and training, staffs understanding of safeguarding people from abuse, medicines management needed improvement and the quality monitoring and assessment of service quality was not effective. We asked the provider to send us an action plan of what they intended to do to address these shortfalls which they did. This inspection found that the provider had implemented all the improvements they had told us about.

There was a registered manager in post but for personal reasons they had delegated day to day operational management of the service to an interim manager who had worked at the service for 25 years, and had the appropriate knowledge and qualifications to take on this role. An application to register the interim manager was currently being processed by the Care Quality Commission. A registered manager is a person who is 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 provided with a safe, clean environment that was maintained to a high standard, with all safety checks and tests routinely completed. There were enough skilled staff to support people and provide continuity. Recruitment processes ensured only suitable staff were employed. New staff were inducted appropriately into their role, they received training to give them the knowledge and skills they needed to meet people’s needs. Staff felt listened to and supported and were given opportunities to meet regularly with senior staff on an individual basis or within staff meetings.

Staff understood how to keep people safe and protect them from harm, they understood how to respond to emergencies that required them to evacuate the building quickly and safely. It was recognised that for people with behaviour that could be challenging some restrictive practices were necessary to maintain people’s safety for example, the use of bed rails; although there was a clear culture of least restrictive practice embedded in the service. Risks were appropriately assessed to ensure measures implemented kept people safe. Medicines were managed appropriately.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been authorised for some people and others were waiting to be processed by the local authority to ensure the people concerned were not deprived of their liberty unnecessarily. People were encouraged by staff to make everyday decisions for themselves, but staff understood and were working to the principles of the Mental Capacity Act 2005 (MCA) where people could not do so. The MCA provides a framework for acting and making decisions on behalf of people who lack mental capacity to make particular decisions for themselves.

People’s privacy and dignity was respected. Staff spoke to people in a dignified way and we observed them discreetly intervening if they thought people needed help or support without drawing undue attention to them, this approach ensured the person's dignity w

Our inspection of 15 May 2013 found that people had not always consented before restrictions were put into place in the service or before sharing a bedroom. People had not always consented to a ‘do not resuscitate’ order being put into place. It was not clear how people’s capacity to consent to such decisions had been assessed, or if the appropriate process had been followed for someone else to make the decision on their behalf if required. We found that appropriate action had not always been taken to respond to changes in people’s health needs or to ensure people were protected against the risk of fire in the premises. The provider wrote to us on 1 July 2013 and told us they had taken action to address the shortfalls.

At this inspection we found that people’s capacity to make their own decisions about sharing a bedroom and about having a ‘do not resuscitate’ order in place had been assessed. Where people could consent to this they had done so. Where they were unable to consent a decision had been made on their behalf by the appropriate person. The policy of locking the lounge doors had been reviewed. One door had been opened and risk assessments carried out for locking the other door to keep people safe. Records showed that staff had responded appropriately to changes in people’s health needs. We found that action had been taken to ensure the premises complied with fire safety regulations and that staff understood what they needed to do to keep people safe in the event of a fire.

The service employed a registered manager, but they were not currently in day to day charge of the service. An acting manager had been appointed who managed the day to day running of the service. We were not able to speak directly to people using the service about their experience of using the service because of communication difficulties created by their dementia. We gathered evidence of people’s experiences of the service by observing care.

We found that people had not been asked for their consent before they shared a bedroom with another person. Where people were not able to make their own decisions about this the provider had not followed the law to ensure decisions were made in the person’s best interests. Two bedrooms were regularly being used for hairdressing purposes without the consent of the occupants. Some people had written orders in place for them not to be resuscitated in the event of a health emergency. The records stated that they had not been able to consent to the decision. It was not clear how the assessment of their capacity to make their own decision around this matter had been carried out or that the proper process had been followed.

People were restricted in their movement around the service as the lounge doors were kept locked during the day. This meant that people could not freely access their bedrooms when they wanted to without asking staff first. People had not been asked to give their consent to this restriction.

People generally had their health and care needs met, but there was a lack of guidance for staff to be able to respond to sudden changes in health.

The provider had not ensured that an appropriate and up to date fire risk assessment had been completed and we found that some outstanding work to comply with fire regulations had not been completed. Staff were not clear about the procedures for evacuating the building in the event of a fire.

There were sufficient numbers of staff employed to meet the needs of people that used the service. The staff were appropriately qualified, but lacked some understanding around issues relating to consent.

The inspection was unannounced and took place on 15 & 16 September 2015. St Valery is a residential service for up to 16 people living with dementia, but shared rooms are often used for single occupancy. At the time of inspection there were 15 people living in the service.

The service has a registered manager who is a director of this family run company. They had taken a leave of absence for some time and in the interim the service had been managed by another director and family member. These arrangements had worked successfully and changes to the manager registration were in the process of being formalised. A registered manager is a person who is 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 last inspected this service on 9 July 2013 when we found the provider was meeting all the regulations.

Some improvements were needed however, to ensure the service continued to offer a safe and responsive environment for people living with dementia. Staff showed sensitivity warmth and understanding for the people they supported, they were provided with a wide range of training but were not accessing this fully with 75% or less having completed the essential training they needed to support people safely. Staff understood how to protect people from abuse but two out of three were unable to say how they would report concerns to the local authority.

The premises were well maintained and equipment used to support people was serviced regularly, checks and tests of the fire alarm, and extinguishers were conducted on weekly and monthly intervals respectively to ensure these remained in working order. Emergency lighting tests were not happening monthly and we have asked that required frequencies be checked with the local fire service. Each person had a personal evacuation plan in the event of fire; we have asked that those for people on the first floor be reviewed with the local fire service to ensure they meet the legal requirements.

Medicines ordering, receipt, administration and disposal were well managed by trained staff, but storage temperatures were not recorded and monitored; staff might not therefore, be aware when temperatures exceeded the recommended level and that this could impact on the effectiveness of the medicines. Sticky labels were used on Medicine Administration Records: this is not seen as good practice because these can so easily be removed or tampered with.

The interim manager undertook regular spot checks and audits at the service. For the most part these were effective in ensuring good standards were maintained throughout, but, had not been sufficiently comprehensive to pick up some of the shortfalls we have identified from this inspection for example, shortfalls in recording, and improvements needed to medicines.

We spoke with relatives that visited regularly. They told us they felt their relatives were safe and received a good standard of care. They thought that staff had the right attitudes and showed they cared and understood the needs of people living with dementia commenting how kind and lovely the care staff were.

We saw many very positive interactions and people were seen to enjoy the talks they had with staff. We observed people were sitting companionably with others or engaging in an activity on their own or with staff. Staff were attentive and vigilant in their observations and attention to people’s need for support. Visitors were made welcome and there were no restrictions.

Appropriate checks were made of new staff to ensure they were suitable. Staff were provided with induction in line with the new care certificate to give them a basic awareness of how to work with people correctly. Staff also had access to specialist intensive courses overseen by a college that gave them an advanced understanding of for example medicines, and dementia. Thirteen out of 22 staff had achieved nationally recognised qualifications at level 2 or 3 in health and social care.

Systems were in place to ensure people ate and drank enough and their specific dietary needs were catered for. Their health was monitored, staff referred them for health treatment, and they were supported by staff to access healthcare appointments.

People were treated with kindness, compassion and respect and staff took time to speak with them. They and their representatives were involved in discussions about care needs. Staff support assumed people had capacity to make their own everyday decisions; however they understood more difficult decisions needed to be more widely discussed. The interim manager ensured the service provided was compliant with the Mental Capacity Act principles and there was evidence of best interest discussions and Deprivation of Liberty Safeguarding authorisations.

There were enough staff with the right skills and attitudes to support people with their care and support. Staff were respectful of people’s privacy, dignity and rights, they encouraged people’s independence. The interim manager and staff were innovative in trying to find the most suitable and effective ways of working with people. Health and social care professionals spoke highly of the service and had no concerns about the quality of the support and care people received.

Staff said they felt well supported and motivated by the interim manager and found her approachable, they said the other directors of the company were a visible presence in the service and they found them easy to talk to. Staff had opportunities to express their views and felt able to share ideas, they received supervision and observations of their competency which gave them confidence that they were supporting people correctly. People and relatives told us they were asked to comment about the service people received. They felt able to raise concerns if they needed to and the majority were confident these would be dealt with to their satisfaction.

We have made two recommendations:

The provider should consult the Fire Service regarding the frequency of emergency lighting checks and whether evacuation plans for people on the first floor meet current fire legislation

Regulatory Reform (Fire Safety) Order 2005.

We have recommended that the provider review the use of sticky labels on Medicine Administration records and considers their use in line with NICE guidance in regard to Managing medicines in care homes (published March 2014).

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