We carried out an unannounced comprehensive inspection on 26 June 2017.

Underhill House Residential Home provides care without nursing for up to 28 older people who may be living with dementia. At the time of our inspection there were 27 people living at the service.

The provider was the 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.

At our last inspection on 15 and16 March 2016 we asked the provider to make improvements to ensure people were protected from risks associated with their care and the environment, that people’s medicine were managed safely and to ensure people’s human rights were protected by the Mental Capacity Act 2005 (MCA). We also asked then to make improvements to how people's complaints were managed, and to how they assessed, monitored and improved the ongoing quality of the service. Following our inspection, the provider sent us an action plan telling us how they intended to meet the associated regulations. During this inspection we looked to see if improvements had been made and we found action had been taken.

People told us they felt safe living at the service. People were protected from abuse because staff understood what action to take if they suspected someone was being abused, mistreated or neglected. People were cared for by staff who, had been recruited safely to ensure they were suitable to work with vulnerable people. People were supported by suitable numbers of staff. People were supported by staff who had received training to be able to meet their needs.

People who had risks associated with their care had these managed appropriately to help ensure their ongoing safety. Accidents and incidents were recorded and assessed for themes and trends to help protect people and reduce the likelihood of re-occurrence.

People lived in an environment which had been assessed for risks. Fire tests were carried out and equipment was serviced in line with manufactures requirements. In some bathrooms, there was an unpleasant odour, this was because clinical waste bags had not been emptied. The provider told us they would take action and review how often bins were emptied.

People’s medicines were managed safely, and the provider’s processes followed best practice guidelines as set out by the National Institute for Clinical Excellence (NICE). However, people’s topical medicines (creams or gels) were not always dated upon opening, which meant there was a risk that they may be used past their expiry date. The provider explained they had spoken with staff about this, but told us they would re-look at their auditing processes to ensure medicines were dated appropriately. Staff at lunch time, were observed to not always be vigilant in ensuring when people had been given their medicines in their medicine pot that they had taken them. The provider told us she would speak with staff about the importance of observing medicines had been taken before medicine administration records (MARs) had been signed. Staff responsible for medicine administration, including night staff had received training and action was being taken to ensure staffs ongoing competence was assessed.

People's consent to care was sought and their human rights were protected. People had access to external health and social care professionals which helped to promote their ongoing health and wellbeing.

People told us they liked the meals and that there was always enough to eat. People were supported to eat and drink when necessary.

The provider had taken some action to ensure people living with dementia were supported and empowered by their environment, for example there was pictorial signage in place for the dining room, howeve

The inspection took place on the 15 and 16 March 2016 and was unannounced. We last inspected the service on the 7 August 2014 and found the service was meeting the requirements of the regulations.

Underhill House provides residential care without nursing for up to 28 older people who may be living with dementia. Twenty eight people were living at the service when we visited.

A registered manager was employed at the service. 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 registered manager, who is also one of the providers, was on holiday when the inspection took place. The deputy manager was the person in charge in the absence of the registered manager and they were present during the inspection.

Prior to the inspection we received information of concern about people’s care at Underhill House from different sources. This included concerns about care not being personalised, people receiving medicines which then made them sleepy, personal care not always completed to a high standard, food portions were described as “small” and staff were not following choking risk assessments. We were also told people’s care at their end of life was not well planned and medicines to alleviate pain at this time were not readily available. We were also told the service had strict routines in place and people who could not consent to care due to their level of dementia were having routines decided for them. We were also told the water people had access to was “scalding”. We checked these concerns as part of the inspection. We found concerns during the inspection which are summarised below but can be reviewed in the full report.

People’s medicines were not always managed safely. For example, staff trained in the safe administration of medicines were not on duty overnight. This meant people had to wait to be administered pain relief from an on call member of staff. Gaps between the administration of some medicines were not sufficiently spaced. For example, antibiotics were given over a shorter timescale than recommended. Storage of some medicines was not in line with current guidance and temperatures of medicines were not being recorded. Staff who were administering medicines were suitably trained but were not having their competency checked.

People’s medicine administration records were completed. People were happy with how their medicines were administered. There were clear systems of ordering and returning unused medicines. A medicines audit was in place to check systems were being followed.

People were not having their ability to consent to their own care and treatment assessed, as required by the Mental Capacity Act 2005 (MCA). When people could not make decisions about their care and treatment due to their living with a condition which may have affected their ability to consent this had not been assessed. Best interest decisions had not been recorded. People who were having their medicines given without their consent had not been assessed in line with the MCA. However, staff were observed asking for consent when offering care and applications had been made to seek an assessment of people who may be deprived of their liberty to keep them safe.

Staff demonstrated they knew people well and how to meet people’s needs. However, people’s care was not recorded in a personalised way which reflected their needs and how they wanted their care to be given. For example, care plans showed no evidence of having been planned with people or their family or representative as required. People’s preferences were not recorded. For example, what time people wanted to get up or go to bed. Staff recordings in daily records were inconsistent and often made it difficult

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

As part of the inspection we spoke with five people who lived at the home, four relatives, three care staff, the deputy manager and the registered manager, who was also the provider. We reviewed policies and records relating to the management of the home which included, six care plans, daily care records and six staff files. There were 27 people living at the home when we visited. Everyone who lived at the home had some degree of memory loss or dementia.

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

Is the service safe?

We found that people were cared for in a fresh and clean environment and that the home was well maintained.

People told us they felt safe at the home. One person said, “I’m unsteady on my feet and when I was at home I kept thinking I might fall over. Here I know there is always someone around who can help”.

One of the relatives we spoke with said, “It’s such a relief to me to know that (my relative) is secure here”. Another person told us that a “safe and sound environment” was one of the essential requirements for them in making the decision for their relative to move in. Another commented, “Safety was a real issue before my relative came here”.

We spoke with four relatives who all commented that one of the greatest considerations had been their relative’s safety prior to their arrival at the home. One relative said, “I now have peace of mind that my relative is safe".

There were systems, policies and procedures in place which ensured risks to people were reduced and that the service was safe. Risk assessments had been undertaken and helped ensure people received care safely. People were given choice and remained in control of decisions about their care and daily lives.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We were told there was one application to the DoLS which was in process. We noted that the home followed procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and took advice and guidance from medical professionals.

Is the service effective?

We spoke with five people who lived at the home who told us they were happy with the care they received. They felt their individual needs were understood by staff and were met. One person said, “The girls are very good and kind. They are always around”.

One of the relatives we spoke with said “Communication here is very good, especially with the manager”. Another said, “We can talk to any of the staff, everyone seems to be in touch with what’s going on”.

We met a person, who had arrived at the home a week earlier and their relatives. One of the relatives said, “I can’t believe what a difference there is (in my relative). In one week they have become more relaxed, they have put on weight and have had their toe nails cut by the visiting chiropodist”.

People’s health and care needs were assessed and care plans developed which ensured appropriate care and support was provided.

Is the service caring?

The home is run as a family home. The registered manager was fully involved in all aspects of the home and the care provided.

Relatives told us, “Staff are brilliant, it feels like home and we couldn’t wish for anything better”. We were told the service was “consistently compassionate” and run as a “family home”.

People were supported by kind and caring staff. People commented, “The staff are always around”, “the girls are very kind”. We observed that staff knew people they cared for well and were gentle and reassuring in their communication with them.

Is the service responsive?

We spoke with four relatives who all commented on the responsiveness of the home to people’s needs. One person told us about their relatives’ recent hospital admission where staff had been proactive in ensuring immediate action had been taken. Another relative told us how quickly the home had responded to a request for an emergency admission to the home. They said, “We don’t know how we would have managed without the immediate response from the home”.

We noticed staff promptly and appropriately responded to a person who had fallen on the day of the inspection and how staff gave caring support and reassurance throughout the incident.

We saw that call bells were installed in people’s rooms and people told us these were always responded to promptly.

Is the service well led?

The registered manager was also the provider of the home. The ownership and management of the home had been under the same provider and registered manager for 25 years. The registered manager was actively involved in all aspects of the day to day operation of the home and knew everyone who lived and worked at the home well.

The registered manager was supported by a deputy manager who had recently been appointed. We were told that an administrator was in the process of being appointed to assist with the organisation and maintenance of records and documentation required at the home.

We found that there were formal and informal systems and mechanisms in place to monitor the service provided and to provide training and support for staff. However some of the systems for receiving feedback, involving people in decisions about the home and for supporting and training staff were not in operation at the time of our inspection. We found there were shortfalls in staff training and support systems which could mean that staff were not always up to date with working practice or changes in legislation which could affect their ability to appropriately perform their duty of care to people at the home.

We were told that the appointment of new staff would help to ensure that all formal systems could be re-introduced and records kept up to date.

We carried out the inspection due to concerns raised about certain aspects of the home. We spoke to staff about the care given, looked at records relating to people living in the home , met with them and observed how staff worked with them.

We found that those people who were able to communicate with us felt their care was delivered with respect and dignity.

For those person’s less able to communicate their needs due to a diagnosis of dementia, we found that assessments around their capacity to make decisions had not been completed.

We found that the care plans ensured that people’s needs were understood and was delivered in line with need as the care plan was clearly written. However not all care plans were able to show that the care was being delivered with the person’s consent. People or their representative’s views had not been documented.

We found the cleanliness and hygiene of the home was generally very good with strong policies and training in place to support its delivery. However we found that the way the commodes were cleaned did not ensure cross contamination was managed. We also found other communal used items such as bath hoists were not routinely cleaned.

Staff received a good level of training that was regularly updated and they felt supported in their role.

We found that the home had a good system of quality assurance in place and utilised the services of an external auditor to ensure that there was independent oversight.

We (The Care Quality Commission) conducted an unannounced visit to Underhill House Residential Home on 23 September 2012 as part of a programme of scheduled inspections.

We met 14 people who use services, a relative; talked with the seven staff and checked the provider's records.

We looked at the care records of four people who use services. We met them, looked at records and asked staff about their care. The provider and deputy manager also provided information.

One person told us, "My second home". We talked with most of the people who lived in the home.

We saw people's privacy and dignity being respected and staff were being helpful. Comments from people who lived in the care home included, "Staff are very good to us" and, 'the food is lovely". "Very clean, they can’t do enough for you".

One person told us, "We go out a lot". People told us that if they had any concerns that they would speak to staff or the management and felt confident that appropriate action would be taken.

We saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people's choices and preferences. We looked in detail at the care four people received. We spoke to staff about the care given, looked at records related to them, met with them and observed staff working with them.

We saw that the staff had a good understanding of people's individual needs and that they were kind and respectful. They took time to work at people's own pace.

We observed people being supported to make decisions about their lives and be as independent as possible. We saw that people's care records described their needs and how those needs were to be met. One staff told us how any information about new admissions to the home would be communicated to them.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. We spoke with seven staff members working during our visit. Most staff had worked at the home for a number of years with one saying, "We are like a family here".