Symonds House is registered to provide accommodation and nursing and personal care for up to 58 people. The service is provided for older people, some of whom may live with dementia. The home is a converted Victorian building and is located on the outskirts of the rural Cambridgeshire village of Linton.

At the last inspection, which took place October 2015, the service was rated Good. At this inspection we found the service remained Good. There were 43 people living at the home at the time of our visit.

There was a registered manager in post at the time of our visit. 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 knew how to respond to possible abuse and how to reduce risks to people. There were enough staff who had been recruited properly to make sure they were suitable to work with people. Medicines were stored and administered safely.

People were cared for by staff who had received the appropriate training and had the skills and support to carry out their roles. Staff members understood and complied with the principles of the Mental Capacity Act 2005 (MCA). People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received a choice of meals, which they liked, and staff supported them to eat and drink. They were referred to health care professionals as needed and staff followed the advice professionals gave them.

Staff were caring, kind and treated people with respect. People were listened to and were involved in their care and what they did on a day to day basis. People’s right to privacy was maintained by the actions and care given by staff members.

People’s personal and health care needs were met and care records guided staff in how to do this. There was a variety of activities for people to do and take part in during the day, and people had enough social stimulation. Complaints were investigated and responded to and people knew who to speak with if they had concerns.

Staff worked well together and felt supported by the management team. The provider’s monitoring process looked at systems throughout the home, identified issues and staff took the appropriate action to resolve these.

Further information is in the detailed findings below.

Symonds House is registered to provide accommodation, care and nursing for up to 58 people. The home is a converted Victorian property and accommodation is offered on two floors. The service is provided in four units, each of which has lounge, dining, kitchen and bathroom facilities as well as single and double bedrooms.

This comprehensive inspection took place on 22 October 2015 and was unannounced. There were 38 people in residence. Our last inspection of this home was carried out on 03 March 2015. At that time we found that there were a number of breaches of the regulations. These were in respect of staffing levels; medicine management; consent to care and treatment; staff support; dignity and privacy; quality assurance; records; and notifications. The provider wrote and told us that they would be compliant with all the regulations by 31 August 2015. At the comprehensive inspection on 22 October 2015 we found that improvements had been made and the provider was no longer in breach of any of the regulations.

At the time of this inspection on 22 October 2015 there was no registered manager in place. 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. The manager at the time of this inspection had taken up their post the week after our last inspection. They had undergone all the required checks to register with CQC, including an interview, and were awaiting the results of their application.

People said that they were happy at Symonds House and told us they felt safe. They were complimentary about the staff and the management of the home. We saw that people who lived there and the staff got on well together and were comfortable with each other.

Staff had undergone training and were competent to recognise and report any incidents of harm. Potential risks to people were managed in a way that ensured people were kept as safe as possible.

There were enough staff on duty to meet people’s assessed needs. Pre-employment checks had been carried out to ensure that only staff suitable to work in a care home had been employed. Medicines were managed safely.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS), which apply to care services. People’s capacity to make decisions for themselves had been assessed. Appropriate applications had been made to the relevant authority to ensure that people’s rights were protected if they lacked mental capacity to make decisions for themselves.

People were given sufficient, nutritious food and drink and the nutritional needs of people who required special diets were met. People’s health was monitored by the involvement of a range of healthcare professionals.

Staff showed they cared about the people they were looking after. Relationships between people and the staff were good and staff treated people with kindness and respect. Staff ensured that people’s privacy, dignity and independence were upheld. People’s personal information was kept securely to maintain their confidentiality.

People and their relatives were involved in the planning of their care. Care plans contained sufficient, up to date guidance for staff to ensure that the care delivered by the staff was consistent and personalised. There were some activities and outings offered to keep people occupied although some improvement was needed in this area. Complaints were responded to appropriately.

There was an open culture in the home and people, relatives, visitors and staff were offered a number of ways to make their views about the service known. Audits carried out were effective in identifying shortfalls and in driving improvements in the quality of the service provided. Records were maintained as required.

Symonds House is registered to provide accommodation and care with nursing to up to 58 older people. The home is a converted Victorian property and accommodation is offered on two floors. The service is provided in four units, each of which has lounge, dining, kitchen and bathroom facilities as well as single and double bedrooms.

This inspection took place on 03 March 2015 and was unannounced. There were 41 people in residence.

The last inspection of this service was on 07 August 2014. During this inspection we found that the provider was failing to ensure that people’s privacy, dignity and independence were respected and upheld and that staff were failing to put their training into practice in a number of areas. We also found that the provider still did not have an effective system in place to assess and monitor the quality of the service that people received. The provider sent us an action plan and told us that they would be compliant with all the regulations by 30 September 2014.

This service requires 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. At the time of the inspection on 03 March 2015 there was no registered manager in place. The previous registered manager had left in October 2014.

Staff were properly recruited and were knowledgeable about their responsibilities to safeguard people from harm. Potential risks to people were identified and managed so that the risks were minimised. People were supported to maintain their health. Medicines were not managed in a way that ensured that people received their medicines safely and as prescribed.

There were not enough staff to make sure that people’s needs were met safely and in the way they preferred. Staff had undertaken a range of training relevant to their work, but they did not always put their training into practice. People were not always supported to make informed choices.

Some staff showed that they genuinely cared about the people they were looking after, whilst others showed no compassion and did not always treat people with the kindness and warmth they deserved. Some staff did not have a good enough grasp of the English language to be able to communicate effectively with people.

People’s needs relating to food and drink were supported but people’s experiences of mealtimes varied depending on which area of the home they lived in. People were not always supported to maintain their independence with eating and drinking. Most staff knew about mental capacity. However, the rights of people who could not make decisions for themselves were not always upheld lawfully as their capacity to make certain decisions had not been assessed.

Care plans showed that people’s relatives had been involved in planning the person’s care and support. Care plans gave staff detailed guidance on the care each person needed and the ways they preferred their care to be delivered by the staff. People and their relatives said they would raise any concerns with the staff, although the advertised complaints procedure gave people incorrect information.

People, relatives and staff were concerned about the number of managers who had been employed at the home. Staff did not receive regular supervision or appraisals and said they felt unsupported. The provider’s system to audit and monitor the service provided was not effective and the provider had failed to notify the Commission of significant events, which they are required to do.

We found a number of breaches of the Health and Social Care Act (Regulated Activities) Regulations 2010, which correspond to the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

An adult social care inspector carried out this this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we observed activities taking place, looked around the premises, spoke with eight people who used the service, spoke with a visiting health care professional, the registered manager and ten members of care staff. We also reviewed records relating to the management of the service which included ten care plans, daily records, staff records and quality assurance monitoring records.

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

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

Is the service safe?

People who used the service indicated that their social and health care needs were met in a safe and appropriate way. People said, or indicated, that they felt safe because they liked members of staff.

Health and safety risk assessments had been carried out and measures were in place to minimise these, to keep people safe.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. Applications have needed to be submitted and proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Improvements had been made in the way people’s choices and decisions about their support and care were respected and valued. This included offering people choices on what they would like to eat and drink.

Improvements have been made regarding how information about people’s individual needs was shared with other health and social care agencies.

Staff were supervised and supported to provide people they looked after with safe and appropriate care. People who used the service and a visiting health care professional told us that they had confidence in some of the members of staff’s abilities. One of the people told us, “Some staff look after me well, but some I have to ask.” However, they indicated that once asked, their care needs were met and to their satisfaction.

People’s health needs were effectively met. This included the prevention and healing of pressure ulcers and the management of people’s individual continence needs.

Members of staff were trained in dementia care and infection control. However, some staff members were unable to demonstrate that their training was put into practice. This meant there had been a breach of the relevant regulation and the action we have asked the provider to take can be found at the back of the full inspection report.

There had been improvements in relation to how people were supported to engage in social and recreational activities. However, due to recent staffing issues, this improvement had not been sustained. Action was being taken to address this issue.

Is the service caring?

Improvements have been made in how people were treated in a respectful and dignified way. However, improvements were still needed in relation to this. This meant there had been a breach of the relevant regulation and the action we have asked the provider to take can be found at the back of the full inspection report.

There was some evidence to indicate that people, or their legally appointed representative and family members, were actively involved in developing their care plans. However, this was not consistently carried out. Work was in progress to improve this area of care.

People who used the service, told us that they liked members of staff because they were kind and showed an interest in the individual person. Our observations noted that members of staff interacted with people who used the service in an attentive, respectful and caring way. One person said that members of staff were, “Helpful.”

A visiting health care professional told us that they believed people living at Symonds House were safe from abuse. They said that they had seen members of staff were kind and caring.

A number of thank you cards were seen. One of these read, “Thank you for all your kindness and help to (my relative).” Another of these thank you cards read, “Thank you to you and all your staff for giving (my relative) a lovely birthday.”

Is the service responsive?

Improvements have been made regarding the obtaining of information about people’s individual life histories. There was work in progress to use this information to provide people with individual support and care.

People’s individual social and health care needs were responded to. People were supported to maintain contact with their family members. They were also supported to access a range of health care services.

Is the service well-led?

Improvements have been made regarding obtaining people’s views about Symonds House. People who used the service, their relatives and members of staff were given opportunities to make suggestions and comments. We found evidence that these were considered and acted on, where this was possible.

Improvements have not been made regarding the analysing of information in relation to falls and incidents. There was a system in place to analyse this information but this was not used. This meant there had still been a breach of the relevant regulation and the action we have asked the provider to take can be found at the back of the full inspection report.

There have been improvements made regarding the quality assurance system. This was because audits were in place and the majority of remedial actions had been completed, so that people were safer. The audits included those of people’s care records and audits of people’s medicines.

Symonds House provided care to people across four separate units. One of the units had seven beds for people living with dementia who also had nursing care needs. Other units also supported people who were living with a form of dementia although staff were unable to tell us how many people living there were affected by the illness. We spoke with five people who were living with dementia and pathway tracked the care and support provided to two people.

Care records that we checked showed that people's needs were assessed and reviewed but care plans and the care people received did not always meet their needs. Care plans did not take into account people's life story or include activities that they enjoyed. One relative told us they had shared information about their relative's life story with the staff. However, they did not see staff interacting with the person as if they knew much about them. One person who was living with dementia told us,“There’s nothing to do all day."

Staff told us they offered choices to people they cared for but this was not always evidenced during our observations. We found that most staff had not received training in caring for people with dementia and did not always know how to care for them effectively. The language used by staff and displayed on information boards was not respectful. For example, people were referred to as being ‘quite hard to look after’ and as having ‘nice dementia’.

Relatives said, “(The) care is delivered with kindness, patience and always attentive.” And, “I have seen mistakes (by individual staff) but generally the care is very good, staff are respectful mostly and generally very kind.”

On the day of our visit we found that staff struggled to support people during the mealtime and people who needed help with toileting or repositioning did not always receive this.

Records that we checked and information that staff shared with us showed that the service did not always co-operate with others to ensure that people received appropriate care.

The provider did not have an effective system in place to assess and monitor the quality of the service or to ensure that learning from incidents and complaints took place.

As the purpose of this inspection was to assess improvements made in relation to shortfalls identified during our previous inspection visit of 2 September 2013, we did not request information directly from people using the service on this occasion.

Overall, we found that the provider had taken sufficient action to improve the home’s safeguarding procedures so that people were protected from harm.

People living in the home told us they they felt well cared for and supported. They also told us that they felt that the staff treated them with dignity and respect and that they were encouraged to be independent where possible but were offered help when they needed it.

We observed staff working with people and saw that they encouraged people to be independent but were responsive to their needs and offered help in a gentle and kind manner.

The records showed that the correct procedure for dealing with an allegation of abuse had not been followed and the local safeguarding team had not been notified of an allegation.

People we spoke with during our inspection told us they were content to be at Symonds House. One person said, “It’s alright, they’re very nice to you here and look after you well.” Another told us, “It’s alright, no-one treats me badly.” A relative said that their family member had been happier in recent weeks as the care they were now getting had improved.

Staff treated people with respect and mostly supported them to remain independent. People were involved in decisions about their care. Care plans were personalised and gave staff good guidance on how each person wanted their care to be delivered by staff.

Medicines were generally handled well. There was a sufficient number of suitably trained and supported staff on duty to meet people’s needs. The provider had a complaints procedure in place so that people knew how to complain if they needed to.

During our visit on 27 June 2012 we spoke with seven people who lived in the home. They all told us that the staff were kind and that they were respectful. All said that staff treated them with dignity. One person told us that occasionally she felt that staff were, "A bit rough as I have sensitive skin but I tell them and then they are fine."

One person told us about the care that they received and said that the staff had explained the alternatives to them with regard to specific care they received.

We spoke with relatives who told us that they felt that staff treated people living in the home with dignity and respect. They said that they had been involved in planning the care that their relatives received.

During our visit we observed staff speaking with people who lived in the home in a respectful and kind manner. Staff assisted people in a sensitive way, particularly when assisting them with personal care. We also observed one person being encouraged to be involved in household tasks which clearly gave the person pleasure.

One person said,"There are lots of activities which I enjoy, its a nice place to live." Another person told us, "Its a good place to live, I have no complaints." One person told us that, due to ill health, they had spent a lot of time in their bedroom and that they had been bored as staff did not have time to spend with them

During our visit on 27 July 2011 people told us they were satisfied with their care and told us that staff were responsive and attentive and provided the care that people had expected. Relatives told us that they had observed that when care was being provided that it had been focussed on the individual’s needs and that staff were always considerate.

We observed care being offered to people in a person centred manner and attention given to people's preferences.

People said they are able to make choices about when they want to do things, such as go to bed. They advised that they only have to ask and staff will help them. One person said that staff members are polite and don’t hurry people.