About the service: The Firs Care Home is a residential care home that was providing personal care to 21 people aged 65 and over at the time of the inspection; some of whom were living with dementia. Five people were on short stays. The home is registered for 28 people.

People’s experience of using this service:

There had been three managers in less than a year. However, staff and people living and visiting the home were positive about the new manager, who was already known to them. The new manager was praised by people, their relatives and staff, for their positive and supportive approach. They have not yet registered with the Care Quality Commission but have started the process.

Systems were in place to monitor the quality of care provided. Improvements had been put in place but needed time to be imbedded and sustained.

Communication within the staff group was improving, new systems had been introduced but needed to be embedded and sustained.

Work had started to improve meeting people’s individual interests and hobbies but this also needed to be embedded and sustained.

Improvements had been made to assessing the care needs and health risks for people who came to the home for a respite or short stay.

The manager worked closely with staff, spending time on the floor and ensuring the whole staff team was updated with people’s changing health and emotional needs. Staff commented on the improvements at the home in staffing levels and support to carry out their role. This included improved systems to update staff when people’s care needs changed.

People were cared for by staff who were kind and attentive. Staff were friendly and welcoming.

People's privacy was respected and their dignity maintained. Staff were responsive to people's individual needs and wishes and had an in-depth knowledge about each person.

People and their relatives were positive about their experiences and the care provided.

People were cared for by staff who knew how to keep them safe and protect them from avoidable harm.

Sufficient staff were available to meet people's needs and people told us they were generally available when they needed assistance, staff responded promptly. Care was delivered by staff who were trained and knowledgeable about people's care and support needs.

People received their medicines regularly. Systems were in place for the safe management and supply of medicines, although work was being instigated to address some areas of practice. For example, the time taken to administer medicines in the morning.

Incidents and accidents were investigated and actions were taken to prevent recurrence.

The premises were clean and staff followed infection control and prevention procedures. Work was planned to improve the layout of the laundry room and the downstairs toilet and shower room.

People's needs were assessed, including people receiving respite care. Care was planned and contained personalised information.

People were provided with a nutritious and varied diet. They were complimentary about the quality and choice of food offered.

Staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice. When people were unable to make decisions about their care and support, the principles of the Mental Capacity Act (2005) were followed.

Rating at last inspection: Requires Improvement (report published in September 2018).

In July 2018, a comprehensive inspection took place following the service becoming part of a whole service safeguarding and an individual safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the registered manager had been part of these discussions. Both of these alerts were closed based on the improvements and actions taken to address concerns id

We carried out an unannounced inspection of The Firs on 6, 16 and 17 July 2018. The Firs is a ‘care home’ without nursing. Nursing care, if needed, is provided by the community healthcare team. The Firs also offers temporary respite stays but no-one was staying as respite during this inspection. People in care homes receive accommodation and personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The Firs accommodates up to 27 people in one adapted building. At the time of our inspection there were 16 people living at The Firs.

There was a registered manager at the service. 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. They were currently not working at the home which was being managed by the deputy operations manager and the operations manager on site. Both had worked for the provider for some time.

The last comprehensive inspection was in September 2016; at that inspection the overall rating for the service was good and we found that people were safe. A recommendation was made that the service sought advice and guidance on developing activities for people living with dementia. At this inspection in July 2018, we found that staff spent time with people and there was a low risk of social isolation. However, people were not always enabled to take part in meaningful activities on a regular basis. There were no audits about how people were spending their day. Activities offered by staff and external entertainers, did not ensure each person had their social and leisure needs met.

A focussed inspection was completed in February 2017 to look at safety issues at the service following some concerns about how risk was managed; at that inspection we found the service was safe. In November 2017 we found during a focussed inspection that the service had not submitted statutory notifications to the Care Quality Commission when particular events had occurred. Checks and audits were carried out routinely but these had not always identified issues that were found during the inspection. Care plans did not always fully reflect people's risks and needs when changes occurred. When incidents had happened, plans did not always take into full consideration how to reduce the risks of reoccurrence. During this inspection in July 2018 we found people’s care plans were detailed and identified risks, safeguarding issues were identified and shared with the local authority, we received notifications as legally required and audits, other than for activities were good.

This inspection was brought forward because of safeguarding concerns. Prior to our inspection, the service became part of a whole service safeguarding. An individual safeguarding process remains ongoing. This meant the local authority safeguarding team, commissioners, CQC inspectors , police and other professionals had met to discuss the safety and well-being of the people living at the service.

The provider, their operations team and the registered manager had been part of these discussions. Actions from this process included reviewing and monitoring people’s care as part of a whole home safeguarding process. The service has recently completed a number of improvements in response to the concerns raised as part of the safeguarding process. For example, in relation to health concern and documentation. We did not look at the specific concerns relating to the individual’s care but inspected to check if other people were at risk. The whole home safeguarding process has now closed with the service making good progress in embedding improvement. We found during this inspection that th

The Firs 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 Firs accommodates people across two separate units, both having separate adapted facilities.

The service provides care and support for up to 27 people; some of who may be living with dementia. There were 24 people living at the service at the time of the inspection.

This unannounced focussed inspection took place on 10 and 15 November 2017. The inspection was prompted in part by concerns received about the care provided to people at The Firs. The information shared with the Care Quality Commission (CQC) indicated potential concerns about the management of risk of someone leaving the home who may not have been safe to do so on their own; the management of some behaviours that were challenging to others; staffing levels, staff training with respect to management of risks as well as the management of people’s safety. Concerns had also been raised about the cleanliness of the home.

Some of these concerns were not substantiated as we found the home clean. Staff had supported with relevant training. At the time of inspection we found staffing levels were meeting the needs of the people living at the Firs. However there had been occurrences in the previous two months when staffing levels were below the provider’s preferred establishment as the number of people living at the Firs had increased.

We had been made aware of an incident where one person, who lacked capacity to go out alone, had left the home without staff being aware. We had not received information about this incident from the provider or registered manager. We found that this incident had occurred and not been reported to the Care Quality Commission or to the local authority safeguarding team.

We found, at the time of inspection, there were sufficient staff to keep people safe. However, there had been a number of days during the preceding months where staffing levels had fallen below the number identified as needed by the provider. Staff understood people’s risks and needs and were confident when dealing with the management of specific incidents. We found no evidence to support the concern regarding the cleanliness of the home. However, incidents where a person had shown aggression to another person had not been reported to the local authority safeguarding team or to the CQC as they should have been. Risk assessments had not been reviewed or updated following an incident or accident to reduce the risks of a recurrence.

New staff had been recruited using safe recruitment practices. Checks were made before staff were allowed to work with people.

The team inspected the service against two of the five questions we ask about services: Is the service well led? and Is the service safe?

A focussed inspection was previously completed in February 2017 to look at safety issues at the service; at that inspection we found the service was safe. The last comprehensive inspection was in September 2016; at that inspection the overall rating for the service was good; however we found that the service required improvement in relation to the question: Is the service responsive? This was because people were not always supported to undertake activities of their choice.

Through our on-going monitoring, and during this inspection, no risks, concerns or significant improvement were identified in the remaining Key Questions, so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The service had a registered manager, who was present during the inspection. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered

We carried out an unannounced focused inspection of this service because of an incident at the service which was being investigated by the police. We wanted to ensure people at the service were safe so looked at the actions taken by the provider following the incident and at how risks were managed at the service. Following the inspection we were made aware that the police were taking no action regarding the incident.

The Firs is registered to provide accommodation for people who require personal care. The service provides care and support for 27 people; some people are living with dementia. There were 19 people living at the home at the time of the inspection.

We carried out an unannounced comprehensive inspection of this service on 2 and 6 September 2016. At that inspection we judged the service rating to be overall good, but required improvement in the responsive domain. All other domains were rated as good. We had made a recommendation that the service sought advice and guidance on developing activities for people living with dementia.

There was a manager at the service who had started the application process of registering with the Care Quality Commission (CQC) to become the registered manager at the service. 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.

The provider had considered on-going possible risks to people. At the inspection we were made aware by the director and through a statutory notification submitted to CQC, about the actions they had taken. These actions did not relate directly to the incident but had been identified as sensible safety enhancements.

Following the inspection the director confirmed that the actions had been carried out. They also confirmed alarm checks had been added to the weekly maintenance checks. The manager and deputy operations manager had been working on updating the service’s environmental risk assessment.

Accidents and incidents were safely managed. Staff had recorded incidents and accidents on the provider’s computerised system and the actions they had taken. The manager was well informed about incidents and accidents at the home and looked for trends and patterns.

People’s risk assessments and care plans were detailed and gave staff instructions about how to manage and reduce risks.

The director and the deputy operations manager had been at the service since the incident to liaise with all involved. They were also supporting the manager and staff to continue with their roles to provide a service to the other people at the home.

This report only covers our findings in relation to these topics. You can read the report from the last comprehensive inspection by selecting the 'all reports' link for The Firs on our website at www.cqc.org.uk

The Firs is registered to provide accommodation for people who require personal care. The service provides care and support for 27 people; some people are living with dementia. The inspection took place on 2 and 6 September 2016 and was unannounced. There were 21 people living at the home at the time of the inspection; this included one person on a respite stay, one person on a short stay and a person who was in hospital.

We last inspected The Firs on 20 and 24 February 2015; the overall rating for the service was ‘requires improvement’. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to medicines administration. In our inspection in September 2016, we judged this breach had been addressed; we found improvements had been made throughout the service.

The manager at the service was new in post. They showed us they were in the process of applying to be registered with CQC. 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 manager, the provider and operations team worked closely together. The manager had begun to make improvements within the home and staff were complimentary about their approach and the changes they were making.

People living at the home told us staff were kind and caring. However, several people mentioned there was not enough to do; there was not an established range of activities to meet the social needs of all the people living at the home. Improvements were being made to the garden and some areas of the home had been refurbished and updated. There was a commitment to making areas of home a more stimulating environment to create topics of conversation between people and staff. There were positive relationships between staff and people living at the home, and their visitors. There were systems in place to protect people from harm and abuse.

Improvements in communication ensured people were kept informed about changes within the home and plans to improve the service. People living at the home knew who the new manager was and spoke positively about his practice. People were confident their concerns or complaints would be listened to and acted upon. Since our inspection, a visitor has made a complaint about some aspects of their relative’s care. The provider has investigated and sent their response to the complainant. We have asked the provider to review their response to ensure all the concerns are answered.

Recruitment practices were well managed. There were sufficient numbers of suitable staff available to meet people's individual care needs. However, staff time to support people with individual and group activities to meet their social needs was not routinely available.

The manager was aware of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They demonstrated through their practice an understanding of how this impacted in the way they worked. People were offered a choice of meals. They were supported with their health and had access to health and social care professionals, when necessary.

The manager provided an approachable style of leadership . There were systems to monitor the quality of the service, including responding to suggestions for improvements. Work took place during our inspection to address areas of potential risk in the home’s environment. The manager took these concerns seriously and these were addressed immediately.

At the time of this inspection 23 people lived in the home and it’s Annexe. The people who lived at the home appeared comfortable in each others company as well as with the staff who supported them.

We looked at the care records of three people who lived at the home, and the recruitment records of two members of staff. We spoke with seven people who lived at the home, six staff who worked at the home the Manager and the home owner. We spoke with three health professionals who visit the home and two relatives of people who lived at the home. People were treated with dignity and respect and were involved in making decisions about their care. The care and welfare of people who lived there was well supported by staff.

Some aspects of the safety and suitability of the premises required some improvements on the day.

People expressed their views and were involved in making decisions about their care and treatment.

People who lived at the home were offered choices.

One member of staff told us they felt the most important thing in the home was respecting people’s “dignity and respect”.

We saw that proof of identity and necessary pre employment background checks had been completed prior to the staff working at the home. This helped to ensure the safety of people who lived at the home.

All of the people who lived at the home confirmed they knew how to complain if they had a problem and would feel comfortable in doing so.

We carried out an unannounced visit to the care home on 20 June 2012. We spent one day at the service. 22 older people were living at the home. Most of the people had dementia or mental health needs. Where we were unable to have in depth conversations with people to ask them about their experiences living at the home we spent time in communal areas of the home in the morning and afternoon observing care and talking with people in groups. We also spoke with care workers on duty and two health and social care professionals who were visiting the service to assess people’s needs.

People said or their behaviour indicated that they were content living at the home. People were enjoying friendly relationships with the staff who worked there. Social interaction between people was encouraged and fostered, for example, through the use of reminiscence sessions with specially trained staff.

Since our last published inspection report, January 2011, we found there have been a number of improvements made at the service in staff training, care practices and consent to care and treatment. The manager had also recently appointed a ‘dignity and care champion’ at the home. This was a care worker who was undergoing training to monitor and promote best practice when treating people with respect and also to understand the views and experiences of people using the service.

For this review we used results from a survey of people who live at the home that the provider completed in November 2010. In addition we visited the service and spent time talking with people individually or in communal lounges. We found, like the home’s survey results, that people living at The Firs were happy with the care they receive and that they find the staff and manager easy to converse with. Nobody we spoke with living at the home told us that they had concerns about living there.

This inspection was undertaken on 20 and 24 February 2015 and was unannounced.

At the last inspection on 17 and 24 September 2014 we found that the service was not meeting all the legal requirements and regulations associated with the Health and Social Care Act 2008. This was in relation to the care and welfare of people who use services and assessing and monitoring the quality of service provision.

Following the inspection the provider sent us an action plan telling us about the improvements they were going to make, including the timescales for being compliant with the regulations. During this inspection we found improvements had been made and were on-going in relation to care planning, the provision of social stimulation and activity and the monitoring of the quality of the service.

The Firs can accommodate up to 27 people. The home provides accommodation and personal care for older people, who may have a diagnosis of, or conditions relating to, dementia. The home does not provide nursing care. This is provided by the local community nurse team. This service offers short term respite care for people. At the time of our inspection there were 23 people living at The Firs.

The service has not had a registered manager since April 2014. A new manager had been appointed in December 2014. An application to register with the Care Quality Commission (CQC) had been submitted by them in February 2015 but was rejected due to incorrect information. A subsequent application had been submitted in March 2015 but had also been rejected. A valid application had been accepted in April 2015 and was pending an assessment by CQC. 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.

Prior to the inspection, we were aware of a safeguarding concern raised with Devon County Council safeguarding team about the care of one person. This was investigated under the safeguarding process by a Community Nurse, who found the care and support delivered at the service to be safe and appropriate. We followed up some of the issues raised during this inspection, for example the standards of personal care delivered, monitoring of diet and fluids and the management of catheter care.

Medicines were not always safely managed. The support and supervision some people required with their medicines was not recorded within care records or the medicine records to ensure safe practices were maintained. The administration of some topical medicines was not always accurately documented. The system for ‘checking medicines’ into the service was not robust. Systems were in place to ensure medicines, including controlled drugs, were stored safely and appropriately and staff responsible for the management of medicines had received training.

There were limited bathing and showering facilities available for people to use at the service. These improvements had been identified by the provider and plans were in place to address the shortfalls.

Staffing levels were generally maintained at the level the provider had assessed to meet peoples’ needs. However due to staff sickness on the second day of the inspection, communal areas were not always adequately supervised and people experienced delays in getting up.

The social activities offered at the service had improved since the last inspection, however, people with a diagnosis of dementia would benefit from activities based on current good practice guidance for dementia care.

A formal system to report on the views of people using the service and their relatives had been implemented since the last inspection. Further work was needed to ensure staff and external professionals were given opportunities to provide feedback about the quality of the service.

People said they felt safe at The Firs. Staff had a good understanding of how to identify and report risks to people’s safety. Risk assessments were in place for each person which detailed how to protect people from harm.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns.

People and their relatives told us staff were kind and caring and treated them well. We observed care and support and saw staff knew people well, spoke politely to them and showed a high level of respect. When we observed people becoming agitated or and distressed, staff were able to reassure them. People were supported to maintain their health and wellbeing. Nutritious meals and snacks were provided and people had access to a variety of health and social care professionals to address their health care needs.