We undertook the inspection of The Russets on the 15 and 16 October 2018. This inspection was unannounced, which meant that the provider did not know we would be visiting.

The Russets is registered to provide accommodation for people who require nursing or personal care for up to 105 people. Up to 73 people are accommodated in a specialist dementia unit called The Russets, whilst separate accommodation for up to 32 people with general nursing care needs is provided in the unit called Sherwood. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 102 people were accommodated at the service.

At the last inspection the service was rated as Requires Improvement. At this inspection we found the service Requires Improvement in safe, responsive and well-led.

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.

The provider’s quality assurance system had not identified all shortfalls found during the inspection. We found improvements were required to ensure adequate stock of medicines, check that bed rails in use were within guidelines, the accuracy of records relating to fluid intake and care plans relating to people’s health needs.

Two people were at risk from dirty and contaminated equipment as we found one person’s bed sides and another person’s cushion was dirty and had internal staining.

People were supported by staff who received supervision an annual appraisal and training. Checks had been completed prior to staff starting work at the service. Staff enjoyed working at the service and could approach the manager if needed.

People and relatives said staff were kind and caring. All people felt happy with the care they received.

People’s care plans were person centred and contained important information relating to their likes, dislikes and individual routines.

People were able to raise any complaints and numerous compliments had been received.

People felt safe, and staff were able to demonstrate different types of abuse and who to report it to.

People’s choices were respected. Staff were able to demonstrate how they supported people to make their own choices. People could choose how they spent their day and where they ate their meals.

People were supported with their medical appointments and these were arranged as and when required.

People could access a variety of activities throughout the month and people, relatives and staff had their views sought so that improvements could be made.

We found three breaches of the Health and Social Care Act 2008 (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.

We undertook an unannounced inspection of The Russets on 29 and 31 August 2017. At the last comprehensive inspection of the service in July 2015 no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. The service was rated Good.

The Russets provides accommodation for people who require nursing or personal care. They are registered to provide this regulated activity for up to a maximum of 105 people. Within the service up to 73 people are accommodated in The Russets which provides care and treatment for people living with dementia, this is separated into five houses. Separate accommodation for up to 32 people with general nursing care needs is provided in an area called Sherwood. At the time of our inspection the service was providing nursing and personal care to 102 people over both areas.

A registered manager was in post at the time of our inspection. 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.

Feedback we received across the service around staffing provision varied. This meant peoples experiences of the service were not consistently positive. Medicines records had not always been completed. Systems in place to take necessary actions when medicines records had not been completed were not always used. Systems to monitor and review the quality of the service were conducted and associated action plans produced. However, these were not consistently completed in all areas. People’s records in relation to medicines, position changes and daily care were not consistently completed.

Safe recruitment processes were in place. Staff were supported through a comprehensive induction and supervision. A training programme enabled staff to be knowledgeable within their role and to encourage continued development of their skills.

People received care and support from staff that were kind and caring. People’s privacy and dignity was respected. People’s family and friends were involved in their care and received effective communication from the service. Events the service organised supported families and encouraged engagement with the local community.

Care plans were person centred and described people’s preferences. People, relatives and staff spoke highly of the activities programme available. People benefited from the design and layout of the service. This promoted people’s independence and supported people’s needs. Regular checks of the equipment and environment were conducted to ensure people’s safety.

People’s views were sought through different methods, such as meetings and questionnaires. Actions were taken as a result. The service reflected in strategies used with people and promoted new ideas that may have a positive benefit to people. A volunteer scheme was in place which supported people with activities and social engagement.

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

We undertook an unannounced inspection of The Russets on 7 July 2015. When the service was last inspected in July 2013, we had identified concerns that care and treatment was not always planned in a way that ensured people’s safety and welfare. We found there were no appropriate systems to identify and manage risks relating to wound care and records completed in relation to wound care were not always accurate. During this inspection we found the provider had made the appropriate improvements.

The Russets provides accommodation for people who require nursing or personal care. They are registered to provide this regulated activity for up to a maximum of 105 people. Within the service up to 73 people are accommodated in The Russets which provide care and treatment for people living with dementia, whilst separate accommodation for up to 32 people with general nursing care needs is provided in the area called Sherwood. At the time of our inspection the service was providing nursing and personal care to 100 people over both areas.

A registered manager was in post at the time of inspection. 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 felt safe and staff demonstrated awareness of how to respond to actual or suspected abuse. The provider had appropriate safeguarding adults and whistleblowing policies for staff that gave guidance on the identification and reporting of suspected abuse.

People’s risks were assessed and risk management guidance was produced whilst promoting people’s independence. People and staff told us that staffing levels were sufficient and we made observations to support this. Safe recruitment procedures were completed.

The service had systems that monitored the safety of the environment and the equipment used within it. People received their medicines on time and the service had arrangements in place for the ordering and administration of medicines. Medicines records had been completed appropriately and the provider had an auditing system to monitor people’s medicines.

People praised the effective care they received from the staff and told us they received a high standard of care. Staff received regular training and regular updates on essential training subjects. An appraisal and supervision processes meant staff felt supported by the provider.

People were asked for their consent before any care was provided and staff acted in accordance with their wishes. The registered manager understood the Deprivation of Liberty Safeguard (DoLS) framework and appropriate applications had been made. Staff understood their obligations under the Mental Capacity Act 2005 and how people should be supported to make informed decisions.

People’s risk of malnutrition was monitored and people received the support they needed during meal periods. People were supported to see healthcare professionals when required and records showed that staff responded promptly to people’s changing needs. The service had appropriate systems that ensured referrals to healthcare professionals were made.

There were caring relationships between staff and people. People spoke very highly of the staff that provided their care and we also received very positive feedback from people’s relatives. People and their relatives were involved in decisions about the care package they received. We made continual observations during the inspection of people being making encouraged by staff to make independent decisions.

People told us the service was responsive and they received the care they needed and when they needed it. All said their agreed care package met their needs. There were a wide range of activities for people to partake in and we observed people engaged in activities during the inspection. The provider had a complaints procedure and people had been given appropriate information about how to raise a complaint if required.

The registered manager was highly spoken of by the staff. Staff felt supported in their roles and the management had sufficient systems to communicate with the staff. There were good links with members of the local community and local school.

People and their relatives knew the management structure within the service. Staff told us they worked in a positive environment and that they could raise suggestions. The registered manager had systems to monitor the quality of care provided and auditing systems to monitor records and documentation used by staff.

In August 2011 we carried out a review of The Russets and we identified some areas where the service needed to make improvements. Following the review The Council of St Monica Trust told us about the changes they intended to make. This a planned review of compliance of the service but we were also checking that the improvements made had been sustained.

Those people that live in The Russets have dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they had positive experiences.

We received positive comments from people living in both The Russets and Sherwood about the way they are looked after. “Everything is OK” and “I am safe and they are all very nice to me in here”. People living in Sherwood told us that they were happy with the care they were provided with. “I am very well looked after”, “they always help me” and “I like things done a certain way and the staff know this”. One person said “I am very privileged to live here”.

Visitors told us “I know my relative is safe, and I know the staff will make sure she is not harmed” and “my relative is very well looked after, they need a lot of care but the staff are very skilled in providing this”.

People who use the service have access to a range of activities either as a group or individually. We asked some people what they like to do and they told us "I love to sing and dance", others said they "liked the garden and doing lots of things" and to join in with and be together with others. Some people who use the service are at high risk of falling. We saw that people had regular monthly falls assessments and for those at high risk of falling there were additional risk assessments and evidence of input from the physiotherapist. Where people have nutritional assessments the documentation required was not always complete.

The inspection was carried out by one adult social care inspector over two days, who answered the five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

We found some aspects of the service not to be safe because accident and incident report forms were not used effectively in relation to body maps and wound management plans. This increased the risk of harm to people. However, we noted the registered manager took immediate action when advised of our concerns during the first day of our inspection. All registered nurses were written to regarding requirements of documentation and compliance review dates were set.

People were treated with respect and dignity by the staff. Staff knew what to do when safeguarding concerns were raised and they followed effective policies and procedures. Staff told us, “I’d keep pushing till something was done” and “If something’s wrong it’s got to be dealt with."

There were systems in place to make sure that managers and staff learnt from events such as complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The manager was in the process of re-assessing the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) for people who use the service and was having discussions with local authorities about this. This meant that people were protected from discrimination and their human rights were protected.

The service followed safe recruitment practices. People were safe because the service considered skill mix and experience when arranging staffing.

Is the service effective?

We found the service to be effective because there was an advocacy service available. This meant people could access additional support to express their views and concerns.

Care plans reflected people’s current individual needs, choices and preferences. People’s health was regularly monitored to identify any changes that required additional support or intervention.

The environment enabled staff to meet people’s diverse care, cultural and support needs.

Staff had effective support and induction.

Is the service caring?

We found the service to be caring because people were supported by kind and attentive staff. We saw support workers showed patience and gave encouragement when supporting people. Staff responded in a caring way to people’s needs when they needed it. People we spoke with said, “I’m very pleased with it” and “They’re brilliant.” Staff told us, “We’re like a big family” and “We’re close knit.”

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. Appropriate healthcare professionals were involved in planning, management and decision making.

Staff knew the people they were caring for and supporting. People were as independent as they wanted to be.

Is the service responsive?

We found the service not always responsive because although the service had a quality assurance system, this system had not identified shortfalls in the support plan documentation. People were involved in quality reviews.

A person’s capacity was considered under the Mental Capacity Act 2005. When a person did not have capacity, decisions were always made in their best interests. Advocacy support was provided when needed.

Is the service well-led?

We found some aspects of the service were not well-led because the leadership and management did not assure the delivery of high quality care.

There was a registered manager in post and all other conditions of registration were met.

The registered manager understood their responsibilities and was supported by senior management to deliver what was required.

Concerns and complaints were used as an opportunity for learning or improvement.