This inspection took place on 4 April 2018 and was unannounced. At the last inspection on 25 February 2016, the service was rated Good. At this inspection we found the service remained Good.

Waterfall House is a residential care home for up to 18 people with mental health needs. At the time of this inspection there were 11 people living at the service. 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.

At our last inspection we rated the service ‘Good’. At this inspection we found the evidence continued to support the rating of ‘Good’ and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People told us and we observed that they were happy and settled living at Waterfall House. Some people had been living at the home in excess of 25 years.

Risks associated with people’s health, medical and social care needs had been identified and assessed to ensure people were supported to reduce or mitigate the risk in order to keep them safe and free from harm.

People and relatives confirmed that they and their relatives were safe living at Waterfall House. Care staff demonstrated a good understanding on how to recognise and report suspected abuse.

The service followed robust processes to ensure the safe management and administration of medicines.

We observed sufficient staffing levels in place which met the needs of the people living at the home.

The service followed their recruitment policy in order to ensure that only staff assessed as safe to work with vulnerable adults were employed.

Care staff told us and records confirmed that they were appropriately supported through training, supervision and annual appraisals.

Pre-admission assessments were comprehensively completed to ensure that people’s needs, choices and preferences were discussed so that the service could determine whether they were able to meet people’s identified needs.

Care plans in place where person centred and clearly reflected people’s needs, choices and preferences. These were reviewed regularly.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s nutrition and hydration needs were appropriately met and took into account their choices, preferences and any specialist dietary requirements. People were supported with their nutrition and hydration needs where required.

People and relatives knew who to speak with if they had a complaint and were confident that the issues that they raised would be appropriately addressed.

At the last inspection the service did not keep records of the checks that they completed to monitor the quality of care people received. At this inspection the service had addressed this issue. The provider had a number of processes in place to monitor the quality of care in order to learn and improve.

Further information is in the detailed findings below.

This inspection took place on 25 February 2016. The inspection was unannounced. At our last inspection on the 25 June 2014 the service met the regulations that were inspected.

Waterfall House provides residential accommodation for up to 18 adults with continuing mental health problems. On the day of the inspection there were 12 people using the service. The home had two floors with communal living areas situated on the ground floor and bedrooms situated on the ground and first floor. A stair lift was available for those people unable to climb the stairs due to physical or cognitive disability.

The service had 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.

People that we spoke with were positive about the service they received and about the staff that supported them. People told us they felt safe within the home. We saw positive and friendly interactions between staff and people. People were treated with dignity and respect.

Procedures relating to safeguarding people from harm were in place. Staff received regular training in this area. The registered manager and staff understood how to protect people from abuse and knew and understood what to do and who to report to if people were at risk of harm.

The manager and staff had sound knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, one newer member of staff did show lack of understanding in these areas but was due to attend training. One DoLS application had been submitted to the local authority and the service was awaiting a response from the DoLS team. Mostly all people living at the service had capacity and were supported to maintain an independent life where possible. People had been given a set of keys to the home and were able to leave the home as and when they wished.

Care plans were detailed and contained relevant information about the person, their needs and preferences. However, care plans lacked a person centred approach and provided little information on people’s background and history. Consent to care was sought from the person using the service and care plans recorded people’s involvement when reviewing and updating the care plans. Risk assessments within the care plan identified the risks to people and how these could be prevented and although staff and the registered manager knew people very well and were aware of all potential risks some of these had not been recorded as part of the care planning process.

The registered manager ensured safe and robust recruitment processes were in place to protect people from the risk of harm. Staff received appropriate induction and mandatory training and demonstrated the knowledge and skills to carry out their role effectively, however some gaps had been identified within the training schedule especially in the subject areas of MCA and DoLS and equality and diversity. Staff received regular supervisions and support and were given the opportunity to discuss their strengths, performance and training needs. Annual appraisals had also been completed for all staff files that we looked at.

Staffing levels were determined based on level of need assessments which had been completed for each person living at the service. The registered manager also formed part of the staff team during the day and was observed to be ‘hands on’ and involved in the provision of care and support.

People were supported to have their medicines safely and on time. The registered manager and senior care staff completed regular weekly audits to ensure safe management of medicines, however, these were not recorded. We spoke to the registered manager about this who assured us that they wi

A single inspector carried out this inspection. The focus of the inspection was to gather evidence to answer five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

During this inspection we spoke with four people who used the service and two relatives of people who used the service. We also spoke with the registered manager and care staff.

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

Is the service safe?

People who used the service told us that they felt safe in the home. People said that they felt comfortable in the home and that members of staff treated them with respect and dignity.

Safeguarding procedures were in place. When we discussed safeguarding with staff, they were aware of the signs of abuse and the action to take when responding to allegations or incidents of abuse.

We looked at the safeguarding training records for staff and found that six out of nine members of staff had received safeguarding training. The training certificates we looked at said that the training was valid for one year and therefore staff required a safeguarding refresher training session.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have been submitted, appropriate policies and procedures were in place.

The service had systems in place to identify assess and manage risks related to health, welfare and safety of people who used the service.

Is the service effective?

People told us that they were satisfied with the care they received at the home and felt that their needs had been met. One person who used the service told us, “I am quite happy here” and one relative said, "My relative is in good hands at the home”.

We looked at four care files and saw that people's care needs had been assessed and care was planned and delivered in line with their individual care plan. Risk assessments had been carried out where necessary. Care plans included information about people's preferred routines and healthcare needs.

Relatives we spoke with told us that they were involved with their relative’s care and that the home kept them informed of developments.

Staff told us that they were well supported by the registered manager and that there was good communication amongst staff. This enabled them to carry out their roles effectively, which in turn had an impact on the quality of care people received.

One member of staff said, “Staff work as a team. The manager is supportive”.

Is the service caring?

People who used the service and relatives were positive about the staff at the home. They told us that they had been treated with respect and dignity in the home. One relative told us, “I am very happy with the care. Staff are respectful and helpful”.

During our inspection, we saw that there was good interaction between staff and people who used the service. People looked well cared for and we saw that the atmosphere was relaxed in the home.

Staff we spoke with said that they were aware that all people should be treated with respect and dignity and were able to give us examples to demonstrate how they ensured this.

Is the service responsive?

People who used the service and relatives we spoke with told us that if they had any concerns or complaints, they would feel comfortable raising them with staff or the registered manager.

We saw that the home had a complaints policy and procedure. Complaints were documented and we saw evidence that the home had dealt with these accordingly.

We saw evidence that the service had carried out a survey in March 2014 asking people for their views about the home.

People's care and health progress was monitored closely. Written notes about people's health and care were completed by staff. People's care plans and their health needs were reviewed with people who used the service.

Is the service well-led?

The home had quality assurance processes in place to help ensure that people received a good quality service. People who used the service told us that they felt listened to by members of staff and the registered manager.

Resident meetings were held every two months which enabled people to discuss issues regarding the running of the home. This encouraged people to raise queries and concerns with management and members of staff.

Staff told us that staff meetings took place monthly which aimed to enable staff to raise queries and concerns with their team and share information. All staff we spoke with told us that they felt able to consult the registered manager if they had concerns or queries and said that they felt supported.

Management in the home completed regular audits which included medication and fire safety.

During this inspection we met and spoke with most of the people using the service.

People we spoke with confirmed that staff communicated well with them and asked for their permission before any care or treatment took place. They told us that staff would always respect their wishes and preferences. One person commented “the staff ask me if it’s alright to help.”

People who use the service were positive about the care and treatment they received at the home. They confirmed that staff assisted them when they needed support with their care and that staff were very helpful. One person commented “all the staff are so nice.” Another person told us “it’s good. It’s well run.” People told us they had no complaints about the service but knew how to make a complaint if they needed to.

Effective recruitment and selection processes where in place and appropriate checks were undertaken before staff began work.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an Expert by Experience people who have experience of using services and who can provide that perspective.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

People who use the service told us that staff were kind and respected their privacy.

People using the service confirmed that they were offered a choice in relation to activities, care preferences and food and drink.

One person we spoke with told us, “My requests are treated with care and respect. I am allowed to maintain my privacy. I am quite happy about the way I am treated”.

People using the service told us that they were satisfied with the food provided by the home.

People described the food as, “Excellent”, “Lovely”, “Nice” and “Alright”.

They confirmed they had a choice of menu and that their religious and cultural menu requirements were being met.

People who use the service told us that they felt safe at the home.

They told us they had no concerns or complaints about their care but would speak with the manager or the staff if they needed to.

People told us that the manager was approachable and listened to their problems.

People who use the service were positive about the staff who supported them. They told us there were enough staff on duty to meet their needs.

People told us the staff were, “polite” and “Not too rushed” when they needed support.

The service was ensuring that records in relation to nutrition and health care needs were up to date, reviewed with the person concerned and were kept securely.

This meant that any changes in a person’s nutritional requirements or possible associated health care problems were identified promptly so the manager could take the appropriate action.