About the service: The Manor Exminster is a residential care home that was providing personal care for up to 25 people aged 65 and over. 25 people lived there at the time of the inspection.

People’s experience of using this service:

People were supported by caring and compassionate staff who treated them with dignity and respect. They received person centred care based on their individual needs and preferences. Staff were aware of people's life history, and their communication needs. They used this information to develop positive, meaningful relationships with people.

People and relatives said the service was safe. Staff demonstrated an awareness of each person's safety and how to minimise risks for them. There were enough staff who worked flexibly to ensure people received care and support in a timely way.

People were supported by staff who received regular training and supervision to provide them with the skills and knowledge to meet people’s needs. Staff worked in partnership with local professionals to provide effective care, support and treatment.

People were asked for their consent before they received any care and treatment. People were supported in the least restrictive way possible; the policies, systems and culture in the service supported this practice.

People were encouraged to socialise and pursue their interests and hobbies in a variety of creative ways. Where people chose to remain in their room, isolation was prevented by regular visits from staff and volunteers. Care plans were up to date about people’s individual needs and preferences.

People’s concerns were listened and responded to. Accidents, incidents and complaints were used as opportunities to improve the service.

The service was well led. People, relatives and professionals told us about improvements under the leadership of the new registered manager. The provider’s quality monitoring systems which included audits, observation of staff practice and regular checks of the environment, with continuous improvements made in response to findings.

Rating at last inspection: Good. (14 November 2016)

Why we inspected: Why we inspected: This was a planned inspection based on the rating at the last comprehensive inspection. At this inspection, the service remained Good.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see full report which is on the CQC website at www.org.uk

The inspection took place on 21 and 22 September 2016 and was unannounced. The Manor Exminster provides accommodation with personal care for up to 25 older people, it does not provide nursing care. 24 people were living at the home when we visited.

When we previously we inspected the service on 13 and 19 August 2015 we identified four breaches of regulations in relation to staffing, consent, personalised care and quality monitoring. Following that inspection we served a warning notice in relation to quality monitoring and gave the provider four weeks to make urgent improvements. When we visited the service on 17 February 2016 the required improvements had been made and the warning notice had been met. We received an action plan from the provider outlining the remaining improvements underway and have met with them on 7 December 2015 to discuss progress. This inspection was to follow up the remaining improvements had been made and to check existing improvements were being sustained.

People's health and wellbeing had benefitted because significant improvements in the quality and standards of care had been made. There were no breaches in regulations and the remaining requirements had been met.

The home had a new manager, who started in November 2015 and registered with the care Quality Commission in August 2016. 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.

A substantial number of new staff had been recruited who shared the vison and values of the service to provide a homely, person centred service focused on the needs and wishes of people who lived at The Manor. People were supported by enough skilled staff so their care and support could be provided at a time and pace convenient for them. Staffing levels and daily routines had been reviewed and changed so that staff spent more time with people and worked flexibly to support them. The existing staff team had been increased to incude dedicated catering, housekeeping and maintenance staff. Daily cleaning schedules had been introduced and improvements made in cleanliness and infection control. Repairs and maintenance of the home had also improved, and there was further work ongoing to improve the environment of the home to make it more suitable to meet the needs of people living with dementia. For example, by helping people identify bathroom/toilet areas independently through use of themed colurs and by displaying clear word/symbol signange.

People were supported to express their views and were involved in decision making about their care and offered day to day choices. Staff had undertaken training in safeguarding, the Mental Capacity Act and Deprivation of Liberty Safeguards and sought people’s consent for care and treatment. Where people lacked capacity, staff demonstrated a good understanding of how to support people to make as many choices and decisions as possible. Staff consulted and involved relatives and professionals appropriately in making decisions in people’s best interest.

People and relatives were happy with the service provided at the Manor. Staff knew people well and treated them with dignity and respect. Care was holistic and person centred, staff knew about each person, their lives before they came to live at the home. They understood people’s needs well and cared for them as individuals. The ethos of the home had changed from a focus on tasks to a focus on people and supporting them to remain independent. Communal areas had been reorganised to encourage people and staff to spend time together. Commenting on this, an online survey feedback said, ‘I like the new arrangement.’ A varied programme of activities had been introduced that people participated i

The Manor, Exminster provides is a care home which provides accommodation with personal care for up to 25 older people, it does not provide nursing care.

This inspection took place on 17 February 2016 and was unannounced. 24 people lived at the home when we visited. We last inspected the service on 13 and 19 August 2015 and identified four breaches of regulations, which were affecting the care provided for people living at the service. These related to quality monitoring, staffing levels, personalised care and meeting the requirements of the Mental Capacity Act (MCA) 2005. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider and registered manager. This was because the provider had identified most of the concerns we found, but had not taken effective action to address. The warning notice required the provider to address this by 16 January 2016. We issued requirements for the other three breaches of regulations.

In November 2015, we received an action plan outlining the improvements being made, and have met with the provider to discuss progress. The provider has also been working with the local authority quality monitoring team to improve their systems and processes. This inspection was to follow up the warning notice had been met.

The home does not currently have a registered manager. The previous registered manager no longer works at the home and has applied to cancel their registration. A new manager was appointed in November 2015, and is planning to apply to become the registered manager in the near future. 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.

People were much more alert and active; they enjoyed a range of activities such as quizzes, games, a movie club, outside entertainment and a weekly exercise class. Care was person- centred, provided at each person’s convenience and was focused on their individual needs. Regular residents meetings were being held and people were contributing to decisions being made about their home. Staff were much more visible around the service, they had time to chat with people and attend to their needs at a time and pace a convenient for them. People received their medicines on time and call bells were responded to quickly.

In relation to staffing levels, the manager had reviewed the care and dependency needs of each person living at the home and had appointed two additional care staff, and filled the cleaner and chef vacancies. This meant care staff spent less time on cleaning and cooking duties and had more time to spend with people. A staff member said having more staff in the home had made a big difference. They commented, “The home is much cleaner, we are able to spend more time with people and chat to them. There is a programme of activities every day.” The improved staffing levels also had a positive impact on people’s wellbeing. For example, one person, speaking about the positive changes the manager had introduced said, “What a difference”. They said they were pleased with the increased activities at the home, and the ‘Film club’ that afternoon. They enjoyed the residents meetings and were looking forward to trips out to Powderham castle and Dartmoor when the weather got warmer.

The culture of the home was open, friendly and welcoming. The manager set high standards, was very visible around the home and acted as a ‘role model’ for staff. Staff described the impact of the new manager on the home, and said they were “dynamic, enthusiastic, open to ideas and positive” in their approach. One staff member said, “She has good ideas and she listens to us.” The manager worked closely with the local health professional

We found there were 19 people living at the home on the day of the inspection. We found that the manager and three other staff members had left their employment over the Christmas period. The provider had made temporary management arrangements to ensure cover over the interim period until a new manager was recruited.

We spoke with ten people who lived at the home. The majority of people said they were happy and comfortable and told us staff were 'very kind'.

We spoke with six relatives who said they were always welcomed by staff when they visited the home. Some of the relatives we spoke with expressed concern about recent staff changes and were unclear about ‘who was doing what’. We also spoke with six members of staff and with the provider.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

The home provided care, treatment and support to people with a range of dependency needs and several suffered from varying degrees of memory loss. We were told that the majority of people did not have capacity to make their own decisions. There were systems to assess people's capacity but we did not see any evidence to show how people were involved.

We saw that appetising home cooked foods were prepared daily which people said was 'always very good'.

At the time of our inspection 19 people were living at The Manor. People told us that their care was good. Comments included, “I have been very happy with the care here. When I was poorly they monitored me very well.” A relative of a person who lived at the home told us, “I am more relaxed knowing that X is looked after here”. We observed that people's needs were attended to promptly.

People told us that they were treated with respect by care workers and we observed this to be the case. People were involved in decisions about their care, as much as they wanted to be. The rights of people who did not have the capacity to make decisions were protected.

People's needs were assessed and care was planned and delivered in line with those assessments. Care plans were reviewed regularly and changes were made when necessary. Health professionals told us that the home responded to advice.

People told us they felt safe at the home. The provider had taken reasonable steps to protect people from the risks of abuse, such as training staff to identify abuse.

Equipment was provided which supported people's independence, such as a stair lift. Equipment was serviced and checked and staff were trained in the proper use of the equipment.

People had opportunities to provide feedback about the quality of the service. The provider responded to people's suggestions. The provider had effective systems to monitor and improve the quality of the service.

People appeared to be well care for at The Manor, and supported in their individuality. One person told us: “The staff are all excellent. They’re fantastic with elderly people”. Another said they could rise and retire when they want. One person added: “I have a shower whenever I ask for one. It’s very nice here”. Another said: “They’re not too rigid here. People are the priority”.

Community nurses speak highly of the home. They feel that people’s well-being is promoted and care workers are very good at prioritising, at reviewing people’s needs and ‘open’ in deciding if they can meet those needs. They say that the acting manager seems very focused and aware of people’s needs and the deputy manager is: “very good, personalised and thorough”.

Three people told us they were satisfied with the food provided and we saw that people’s dietary intake is monitored to ensure it is adequate for their health needs.

The atmosphere in the home is relaxed and we saw a good rapport between people using the service and care workers. Three people said that they felt safe in the home. We saw that care workers had time to work at people’s own pace and not be rushed.

The home is kept clean and was mostly fresh throughout. Care workers have protecting clothing available for their use, such as gloves and aprons, and there were hand washing facilities in all areas, which promotes hygiene and reduces the possibility of cross infection.

Two people told us that they have what they need and are very happy with the accommodation, which is comfortable, varied, homely in nature and in a state of good repair.

People told us that they would take any complaint to the manager, but they did not have any complaints.

The inspection took place on 13 and 19 August 2015 and was unannounced. 22 people were living at the home when we visited. We last inspected the service in May 2014 and did not identify any breaches of regulations in the standards inspected.

The Manor Exminster provides accommodation with personal care for up to 25 older people, it does not provide nursing care. The home has 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 service lacked consistent leadership. Relatives and professionals feedback showed the home was more organised and well run some days than others, depending on who was in charge and staffing levels. Since the departure of the previous registered manager at the end of 2013, there have been several changes of leadership. In March 2015, a director in the company became the registered manager. This is an interim arrangement, whilst a new manager is being  recruited.

The provider had a range of quality monitoring systems , these included audits of medicines and care records, regular meetings with people, and staff and two monthly provider visits. However, some systems were not effective and others had lapsed. The provider monitoring visits highlighted several areas for improvement, which included three of the four breaches of regulations identified at this inspection. However, no actions were taken in response, which meant the system of quality assurance was not robust.

Staffing levels at the home were not sufficient to meet people’s needs at all times. Rotas and staff feedback showed staff shortages occurred regularly and staff were working excessive hours. The service had a long term vacancy for cleaning staff, and a more recent vacancy for a chef. These vacancies meant care staff were stretched as they had to work extra hours to do cooking, cleaning and laundry in addition to providing people’s care. This meant staff were rushed and were not always able to provide care in response to people’s needs or interact with at a time convenient for them. Health professionals thought the service was short staffed, but said people’s needs were safely met.

Staff offered people choices and supported them with their preferences. However, where people appeared to lack capacity, mental capacity assessments were contradictory and were not completed in accordance with the Mental Capacity Act (MCA) 2005. This meant there was confusion about whether or not people had the ability to give consent about day to day decisions.

People and relatives were happy with the service provided at the Manor. Staff knew people well and were caring towards them. People said staff treated them with dignity and respect although we witnessed one episode of poor practice. However, the care provided were very task oriented, in that it was organised around routines of the home, rather than in response to people’s individual needs and wishes.

People, relatives and visiting professionals  commented on the lack of meaningful activities for people. Some people said they were bored and many people spent most of their time sitting around without much to occupy them.

People were supported to maintain their health and to access ongoing support from health care services. People received their prescribed medicines in a safe way.

People ‘s feedback about the food was mixed, some people were satisfied and others said the quality of food was variable. Although there was a choice of main meal each day, not everyone was aware of this.

Staff were aware of signs of abuse and knew how to report concerns and most were confident these would be appropriately investigated. A robust recruitment process was in place to ensure people were cared for by suitable staff. Staff were knowledgeable about people’s care needs, had qualifications in care and received regular training and updating.

We identified four breaches of regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.