This unannounced comprehensive inspection took place on 3 and 10 May 2018.

Venn House is a care home registered to provide accommodation with personal care for a maximum of 25 people. It comprises of two buildings, the main house, and the Coach House, which is primarily for people living with dementia. 14 people lived at the service when we visited.

When we completed our previous inspection on 29 November 2017 we found concerns relating to staffing levels; risk management; medicine management; safeguarding; management of odours; adherence with the Mental Capacity Act; personalisation of care; complaints management; inadequate governance arrangements; inaccurate statement of purpose and a lack of incident reporting. At this time these topic areas were included under the key questions of safe, effective, caring, responsive and well-led. The service was rated as inadequate overall. Safe and well-led were rated as inadequate and effective, caring and responsive were rated as requires improvement. In light of our concerns, we also raised a safeguarding alert with the local authority. As a result, the service was placed in a whole home safeguarding process. A number of health and social care professionals became actively involved in the service. This included reviews of people’s care and support from the local authority Quality Assurance Improvement Team (QAIT). The provider was engaged in the process and as a result, the whole home safeguarding process was closed in April 2018. We also met with the provider to discuss the concerns and what action they were going to take. This inspection found improvements had been made.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service did not have a registered manager. The previous registered manager left in January 2018. 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. However, a new manager had been appointed and was in the process of registering with the Care Quality Commission.

Staffing levels were under regular review. A dependency tool had been introduced which assessed people’s specific needs in detail, such as mobility. The tool provides practice and management guidance for people delivering and planning care and support services. It is used to provide a summary of a person’s functional needs and/or the degree of dependence/independence. As a result, it calculated the staffing levels required to meet people’s needs safely and in a timely manner. The service continued to actively recruit new members of competent staff.

Risk management was much more robust to ensure people’s safety. Risk assessments and care plans had been updated and contained more detail for staff to follow to mitigate risks.

We also had serious concerns about environmental risks relating to the security of the Coach House. As a result the patio had been made safer, including the heightening of the fence and doors leading to this area had been fitted with a better locking system. In addition, an environmental audit had been conducted in March 2018. This identified areas for improvement, such as a redecoration programme being implemented.

Medicines management had improved. Incidents and accidents were much more scrutinised and appropriate referrals made to other agencies. People felt safe and staff knew their safeguarding

This unannounced comprehensive inspection took place on 22, 23, 28 and 29 November 2017. The inspection was to follow up to see whether improvements had been made from the previous inspection in May 2017. It was brought forward because we received a number of concerns about the level of care provided by the service.

Venn House is a care home registered to provide accommodation with personal care for a maximum of 25 people. It comprises of two buildings, the main house, and the Coach House, which is primarily for people living with dementia. 17 people lived at the service when we visited.

The service had 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.

At the last inspection in May 2017 the service was rated as requires improvement overall. Safe and Well led were rated requires improvement and Effective, Caring and Responsive were rated as good. Two breaches of regulations were found in Staffing and Good governance.

Following the inspection in May 2017 the Care Quality Commission (CQC) took enforcement action in relation to staffing, which required the provider to ensure sufficient numbers of staff were deployed to meet people's care needs by 14 Aug 2017. We also made a requirement that the provider must improve their system to assess, monitor and improve the quality and safety of the service. The provider sent us an action plan outlining improvements being made.

At a previous inspection in January 2016, the service was also rated as requires improvement, we found four breaches of regulations in relation to Safe care and treatment, Safeguarding, Staffing and Good governance. At an inspection in October 2013, we found two breaches of regulations in relation to the safety and suitability of premises and recruitment.

At this inspection, people remained at risk because there were insufficient numbers of staff with the right skills to safely meet people’s care and supervision needs at all times. The service had admitted five people with complex care needs since we last visited, whilst the needs of others already living at the home had also increased. Eight staff had left the home since we last visited, and were replaced with newly recruited and agency staff. This, combined with staff sickness meant a number of staff working at the service did not know people’s needs well or how to safely care for them. Contingency arrangements for obtaining assistance in an emergency were inadequate.

On 22 and 23 November 2017 we witnessed a number of incidents and near misses in the Coach House. For example, on several occasions a person at high risk of leaving the home unaccompanied was able to unlock a door unobserved and get out on a patio area when it was unsafe for them to go out alone. The previous week the person had climbed over the fence from this patio area and got outside, which put them at high risk. The actions taken to improve security in response to that incident were not sufficient to make this area safe and secure.

Another person was verbally and physically aggressive towards staff and other people living at the home which staff did not have the skills to manage. Staff had not been trained to manage challenging behaviours. People's care records lacked guidance for staff about how to manage these behaviours, which meant people and staff continued to be at risk.

On 23 November 2017, we advised the provider people were at risk because the service did not have enough staff to safely care for people and meet their needs. We identified six people at increased risk and made a safeguarding alert to the local authority safeguarding team about those people. We requested the provider take further urgent action to ensure t

This inspection took place on the 9 and 23 May, 2017. The first day of inspection was unannounced.

Venn House is registered to provide accommodation and personal care to a maximum of 25 people. It is not a nursing home. The accommodation consists of two buildings: the main house, which is an old building and a new purpose-built Coach House. This had been designed for people living with dementia and incorporated several aspects which research has shown created a dementia friendly environment, such as large and tactile signage. When the inspection began there were nine people living in the main house and six people in the Coach House.

The service was last inspected on 5, 8, and 20 January 2016 when it was rated as Requires Improvement overall. At that inspection, we found four breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to monitoring the quality and safety of the service, staffing arrangements and the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. The provider had developed an action plan to ensure improvements were made and sustained. We found that improvements had been made at this inspection to most of those areas, but some concerns remained about risk assessment of staffing levels and of the premises.

A registered manager was in place. 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.

Previously, we identified concerns about levels of staffing at night. Although staffing levels had been improved for the night shift by increasing the numbers of staff on duty from two to three, levels on the day shift were a source of concern. This applied particularly to the afternoons and early evenings when there was just one person on duty in The Coach House with no other support in the building.

Risk assessments and audits of premises and equipment were in place, but those relating to premises were not always fully implemented or reviewed in a timely way. A full premises and equipment review took place after the inspection.

People living at the service and people visiting, including healthcare professionals, all made positive comments about the staff and the buildings. For example, one said, “I like it. It’s cosy, homely and clean. The atmosphere is very nice, it feels very relaxed. Staff are always very helpful and friendly.” People said they felt safe living at the home.

Staff were able to describe signs of potential abuse and knew how to report concerns. A robust recruitment process ensured that only appropriate staff were employed. Medicines were administered safely.

People were cared for by experienced, trained staff who treated them with kindness, compassion and care. Regular training and supervision was provided to ensure staff remained competent. People their relatives and health care professionals spoke highly about the care provided by staff. One person said, “I have experienced the highest quality care here… I couldn’t speak too highly of their thoughtfulness and care”. Healthcare professionals confirmed that referrals were made to them in a timely and effective manner.

People’s legal rights were being upheld. Decision-making was in line with the principles of the Mental Capacity Act and the least restrictive option was used when someone was being deprived of their liberty.

The standard of food at the service was high with a wide variety of healthy choices. There was a brand-new purpose built kitchen within the new dementia wing, which provided food to both sites. People confirmed that they enjoyed the food.

Assessment and care planning was person centred. People confirmed that they were always offered choices regarding t

The inspection took place on 5, 8 and 20 January 2016. The second day included an evening visit. The first two visits were unannounced but we gave short notice of the third visit because we needed to be sure that the provider would be available. Our previous inspection, April 2014, found the standards we looked at were being met. We brought this inspection forward because we had received concerns about staffing at the home.

Venn House is registered to provide accommodation and personal care to a maximum of 25 people. It is not a nursing home. The accommodation is over two buildings, the Coach House and the main house, on the one site. There were 12 people in the main house and six people in the Coach House when the inspection began.

The service is required to have 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. Venn House has a registered manager but they have not been in day to day control of the service since August 2015. They have not yet removed their name from the register.

People were not benefitting from a stable management of the home because it had been managed by three consecutive managers in the last five months. The last ended their employment during the inspection. People said they were not sure who was running the home. However, a new manager was due to start on 22 January 2016.

There were no embedded systems to monitor the quality and safety of the service. This meant risk was not always identified and managed so people were protected.

Staffing arrangements did not always ensure people were safe and there had been an increasing number of falls at the home. Although steps had been taken to mitigate risks to individuals, and staffing numbers had increased, this had not fully protected people. Risk assessments were not always reviewed. New risks had not been assessed taking into account the vulnerability of individual people, such as moving to the new Coach House. Prior to moving to the new Coach House people were living in premises not safe for their use, including damp. The new Coach House provided a home for people with dementia based on research into suitable dementia friendly environments.

People's legal rights were not always upheld because they were not free to leave the home and were under constant supervision. Some applications to deprive people of their liberty had been requested for their safety and welfare, in line with the Mental Capacity Act and deprivation of liberty safeguards. Decision making arrangements were in place where needed, in line with the principles of the Mental Capacity Act.

Staff did not receive regular supervision or appraisal of their work and so training needs and support might not be identified. Staff training had lapsed but was being reorganised and updated.

People received their medicines as prescribed and when needed but records were not always completed and audit of medicine use not always available. We have made a recommendation about the management of some medicines.

People's needs were assessed and their care planned with them or a family member. Staff knew people's needs well and provided person centred care when they were able. People had interests which they followed, such as reading and quizzes an some activities were provided, but with people's increased frailty some had only limited company, when staff had time. We have made a recommendation about activities to prevent isolation.

Staff were kind, friendly and treated people with respect and dignity. They showed great concerned for people's welfare. People said of the staff, “Wonderful”; “The carers are very nice” and “They’ve made me feel very welcome.” Community health care professionals said th

There were 18 people living at the home on the day of our visit - this included 17 people who lived there permanently and one person who was staying there for a limited time only (respite care).

We saw, met or spoke with most of the people living at the home. We had meaningful conversations with eight of the people. We spoke with one relative and one visiting GP. We spoke with seven members of staff and the registered manager.

The home had a welcoming, friendly and open atmosphere. People told us they liked the home very much and felt safe. Comments included “you haven’t got anything to worry about here”, “I feel safe” and “we are extremely fortunate where we live”.

Each person had a plan of care to meet their individual needs. Care staff knew each person need's well and how to meet them. People were treated in a kind, respectful and friendly way.

People we spoke with were very complimentary about the staff and the home. Comments included “it’s an awfully good place”, “it couldn’t be better” and “wouldn’t swap this place for anything”. We observed that staff provided care and support in a kind, respectful and friendly manner. Staff we spoke with understood the needs and wishes of the people they cared for. People told us that staff always asked for their consent before carrying out any care or treatment. Comments included “it’s fantastic here”, “the staff are lovely”, “the girls have good manners” and “if I ring my bell someone comes!". Not all of the staff employed at the home had undergone the necessary recruitment checks before starting work.

People were consulted and chose the activities they wanted in the home.

People were very complimentary of the food and comments included “they always give me good meals”, “food is very good” and “we have very good cooks”. They told us that they could have an alternative if they did not like their main meal. People were asked for their choices of food when they first came to live at the home.

The home was a listed building and retained many of its original features. People were very complimentary of their rooms and comments included “I like my room”, “it’s always clean and there is no smell” and “it’s (the room) wonderful”. Rooms were individual and varied in layout. Due to the type of building, people were not always safe due to environmental risks not being assessed and managed in the home.

The manager had an open door policy. People living at the home, relatives and care staff told us that they would have no hesitation in discussing any issues or concerns with the manager and felt the home had an open and inclusive atmosphere.

We asked three people their experience of living at Venn House and met several others. We spoke to one person’s family and a district nurse.

People told us. “They know me and I know them”; “Staff are very, very good. All of them” and “The level of care that Xxx receives is exemplary”.

We found that people were offered choice and consulted about their care. No care was delivered that people had not agreed or consented to. People’s rights and dignity were upheld.

A district nurse described the care as “very good”. We saw that detailed records were available to inform care workers about people’s needs and how they were to be met. We saw from people’s records and talking to them that their needs were met.

Staff were aware of how to safeguard people from abuse and there was good information for them to refer to. Medicines were handled in people’s best interest and safety. Individual risk to people was well managed. However, general risks within the home, such as stairwells and equipment use, had not been assessed to ensure that any risk was understood and managed.

The arrangements for listening to people's views and managing the home effectively ensured people’s welfare was fully promoted.

We conducted an unannounced visit to Venn House on 10 February 2012 as part of our programme of planned inspections. We visited both the main house and the annexe known as the Coach House. We spoke with seven people who used the service, five staff, the manager and a visiting district nurse. We also looked at some records.

All comments about the service were positive. They included:

"The staff are kind and caring"

"They couldn't be nicer. The girls are very well mannered and the food is excellent"

"The staff are absolutely wonderful"

There was repeated praise for the kindness of the staff and the standard of food provided.

People told us that they had control over their day to day lives at Venn House and their health care needs were fully met. They said that they felt safe at the home and they knew who to talk to if they had any concerns. They said that they were happy with the daily living arrangements and activities at the home.

We saw that the standard of personal care delivered was high and a visiting district nurse said "They are incredibly caring of their clients, genuinely concerned about their health and very enthusiastic about training sessions. Their care of the dying is brilliant."

We saw that people who used the service lived in a warm, clean, well maintained and cared for environment but we found that there may be unmanaged risks, as not all hazards had been assessed.

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 19 people living at Venn House. The summary is based on conversations with 10 people using the service, the registered manager, four staff supporting them, observation and records.

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

Is the service safe?

People had confidence in staff's ability and felt safe receiving care from them, one person saying "They're very skilled". Risks to people's health and welfare were managed through detailed care planning, supervised and competent staff. Recruitment arrangements protected people. Environmental risks had been assessed and minimised. Events at the home, such as falls, were monitored and acted upon.

Is the service caring?

People were treated with dignity and respect; their care was unhurried. People's opinion was sought and taken into account. There was a relaxed, homely atmosphere with smiles and humour between staff and people using the service.

Is the service effective?

People spoke highly of the care they received with comments including "You ring your bell and somebody comes" and "Very, very good". People were involved in planning their care and their needs were monitored and reviewed when required. People received care based on their individual needs and wishes and risks were managed without undue effect on their day to day life.

Is the service responsive?

People’s opinion was sought in several ways. Where a person wanted changes in their room those changes were made. When a person had a fall new equipment was provided for their benefit. Where external health care advice was needed for an individual this was promptly arranged. The service responded to finding by CQC at the previous inspection and made immediate changes.

Is the service well led?

The provider and registered manager worked together to ensure the standards they expected were maintained. Staff were very positive about the home’s management one saying "(The registered manager) is always available and listens”. The registered manager was seen to lead by example. They ensured staff received the support they required to provide a good service.