Archived: The Peele

The Peele is a care home providing personal and nursing care to 62 older and younger people and people living with dementia, at the time of the inspection. The service can support up to 108 people.

The Peele is a large adapted building consisting of nine separate households. At the time of the inspection, three households were closed. Two of the households supported people with nursing needs.

People’s experience of using this service and what we found

People felt safe while living at The Peele. Medicines were safely managed, and people received their medicines as prescribed. Risks were assessed, monitored and reviewed. Staff were recruited safety and oversight of the recruitment processes had been greatly improved. People felt there was enough staff on duty and people were supported by a consistent staff team. The health and safety of the premises was continually reviewed. The home was clean and housekeeping staff worked hard to prevent the spread of infection.

Staff received appropriate induction, training and supervision to enable them to carry out their job role. Staff told us the training was good and they had received robust training to enable them to effectively complete care plans. Assessments of needs were completed to ensure the service could meet people’s needs. People were supported to eat and drink with dignity. Choices around food and drink were captured in care plans. People were complimentary of the food. People’s personal health was regularly monitored and referrals for health interventions were requested promptly.

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

Staff were caring and kind. People’s and relatives’ comments echoed this. Staff were aware of people’s needs and preferences and had been involved in developing people’s care plans which enabled staff to get to know people better. We saw kind and dignified interactions throughout our inspection.

Care plans captured people’s needs, choices and preferences. Care plans were regularly reviewed. Life histories had been formulated in conjunction with families and staff which had promoted conversations between the staff team and the people they support. Activities had improved and activities were based on people’s preferences and needs. The home had built links with local schools to enable people to interact with the young. Complaints were listened and responded to. People were supported effectively at the end of their life.

The registered manager had been supported by the wider management team to improve the home since the last inspection. Improvements in care planning, medicines and oversight meant the home was now meeting the regulations of the Health and Social Care Act 2008. The staff team were complimentary about the work that had been undertaken to improve the home and consistently told us the registered manager had been at the helm of the improvements and they were well supported. Quality monitoring audits had improved and were regularly completed which gave a greater oversight of the service.

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

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 5 October 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 5 October 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

The Peele is a nursing and residential care home. The Peele provided personal and nursing care to 86 people aged 65 and over at the time of the inspection. The service can support up to 108 people across nine separate households. At the time of our inspection one household was not being used and another household was at 50% capacity.

There is one intermediate care household, for people who need short term rehabilitation support after discharge from hospital before returning home. On this household, CIC provide the nursing and care staff and the NHS provide the physiotherapists and occupational therapists.

People’s experience of using this service and what we found

Care plans were not always person-centred and varied in the level of detail and guidance they contained about people’s care and support needs. People’s advanced wishes for the end of their life had not been discussed. There was a lack of information about people’s life history, likes, dislikes and communication needs.

Most people and relatives said they had not been involved in reviewing their care plans. The registered manager acknowledged this and said that the new monthly reviews prompted staff to discuss the care plans with people and their relatives and record their views.

People and relatives said there was a lack of activities for people. Three activity co-ordinators were employed across the home, but we did not see any plan of the activities available. Care staff did not have the time to engage in activities with people.

The provider had not had sufficient oversight of the home. A succession of registered managers had managed The Peele. The provider had not had robust quality assurance, recruitment or training systems in place during this time.

Information the inspectors requested was not always available for us to view or was not readily available.

The new registered manager had recruited more staff, reducing the reliance on agency staff and ensured staff completed their training and induction. New audits had been introduced, including for the intermediate care household, although these did not always identify the issues we found at this inspection, or actions identified were still to be completed.

A range of information, for example falls, pressure sores and people’s weights were not currently analysed by the registered manager. They told us they had prioritised other issues, such as recruitment and training and now planned to start analysing the available information for trends and patterns to improve the service.

Medicines on the intermediate household were not always safely managed. Medicines were well managed on the other households.

Not all pre-employment checks had been completed, with gaps in staff employment history not being explained and references not always being from the staff members previous employer.

There were now fewer agency staff used at the service, although agency staff were still used at night. Agency staff inductions had not been completed. Profiles for the agency staff to ensure they had the training and experience to meet the needs of people living at The Peele had not been obtained from the agency.

People and relatives were complimentary about the staff supporting them, saying they treated them with dignity and respect. Staff said they enjoyed working at the service and felt well supported by the residential and registered managers. They said the availability of training had improved and there were more permanent staff employed.

People were supported to maintain their health and nutrition. Referrals were made appropriately to GPs, district nurses and other health professionals.

The Peele was visibly clean and the layout, decoration and signage supported people to orientate themselves within the households.

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

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

Rating at last inspection (and update)

The last rating for this service was requires improvement overall, with one domain being rated as inadequate (published 19 February 2019) and there were two breaches of regulation. After the last inspection we issued two Warning Notices.

At this inspection not enough improvement had not been made and the provider was still in breach of regulations. The service is now rated inadequate. This service had been rated requires improvement for the last five consecutive inspections.

This service has been in Special Measures since November 2017.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to four regulations at this inspection.

Care plans were not person-centred and did not contain sufficient information about people’s support needs, life history or communication needs. There was a lack of activities for people to take part in.

The provider had not had robust oversight of the home during a period of changes in the registered manager. Information was not analysed to drive improvement at the home. Information requested by the inspectors was not always readily available.

Medicines were not always safely managed on the intermediate care household.

Not all pre-employment checks had been completed prior to staff starting work.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection in January 2019, while some improvements had been made we found on-going breaches of the regulations relating to the safe management of medicines and good governance. These concerns had been identified at the previous four inspections carried out in May 2015, January 2017, September 2017 and June 2018.

The overall rating for this service is ‘Requires improvement’ and the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 92 people living at the home, across eight units or households (the term used by people living there and staff). The ground floor households were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor, Dove Meadow and Park Acre and on the second floor, Etchells, Clover Field and Stoney Knowll, the latter provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. Stoney Knowll was a partnership arrangement between the provider and Manchester University NHS Trust (formerly the University Hospital of South Manchester).

The home is situated in a quiet residential area of Wythenshawe in south Manchester and set within its own grounds which include an accessible garden area and onsite parking. Bedrooms had en-suite facilities and there were communal bathrooms and toilets on each floor. Each household had its own lounge and dining area and a small kitchen.

The service had a manager who was registered with the Care Quality Commission (CQC) in January 2019. A registered manager is a person who has registered with the CQC 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. This registered manager had been previously registered with CQC and managed another of the provider’s services.

The care home had had a series of different managers over the last five years. The lack of continuity had had an impact on the governance of the service. This was evidenced by poor audit processes, improvements not being sufficiently robust and established to ensure the provider and registered manager effectively monitored the quality of care provided. This meant people were at risk of harm and we found examples to support this.

Since the last inspection in June 2018, the provider had not taken sufficient action to ensure adequate improvements had been made and sustained. We found similar concerns regarding medicines management on the nursing households and the intermediate care household.

The provider did not have sufficient oversight of how the intermediate care household was managed. This household was operated as if separate from the other households of the care home. Quality monitoring checks were not carried out by the provider. This meant people were at risk of harm because the quality of care provided was not checked.

The new registered manager had implemented various improvements within the home since starting in November 2018 but these needed more time to become embedded.

Medicines were not managed safely within some of the households. This meant people were at serious risk of harm because the proper and safe management of medicines was not always followed.

The home was kept clean and staff were knowledgeable about and demonstrated good infection control practices. Regular maintenance and checks of the building and equipment was carried. These checks included passenger lifts, hoists, fire safety equipment and the water system.

There was sufficient and adequately trained staff to support people safely. All relevant pre-employment checks had been completed, to ensure they were appropriate to work with vulnerable people. The provider had suitable systems in place to protect people from abuse including accidents and incidents.

People were supported by staff who had the appropriate skills and competencies. Staff received an induction, mandatory training and shadowed experienced colleagues prior to working unsupervised. Staff had regular supervisions and annual appraisals. Training and professional development helped to ensure staff were competent and equipped to carry out their roles effectively.

People and their relatives said the Peele was a safe environment. Staff were aware of their responsibilities in protecting people from abuse and demonstrated their understanding of the procedure to follow so that people were kept safe. The provider had processes and reporting systems in place to help ensure people were safe from harm and monitored. However these did not always address concerns around medicines management.

Risks to the safety of people and the staff supporting them were assessed and kept up to date. Assessments provided sufficient information to help staff support people safely.

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. The provider had submitted appropriate applications for the deprivation of liberty safeguards to the local authority.

People’s nutrition and hydration needs were met effectively. Where possible, people were supported to shop and prepare their own meals. The service acted proactively to ensure people maintained a balanced diet and that they received relevant health and medical attention as required. This helped to ensure people achieved a good quality of life and wellbeing.

People’s rooms were decorated according to their individual preferences. Since the last inspection the provider had made improvements to the home’s environment to help create a more dementia friendly environment. This would help people living with dementia to orientate themselves more effectively within the home.

People we spoke with were happy and settled living at The Peele and they said the care they received was supportive and kind. Relatives were also happy with the care provided.

The atmosphere at the care home was warm and welcoming. Across all households, we observed good rapport between people, their relatives and the staff.

The care home operated within a diverse and multicultural community and had systems in place to ensure people’s equality and diversity needs were recognised.

People were supported by staff in a friendly and respectful manner. Staff responded promptly when people asked for assistance and we saw people were supported in a patient and unhurried manner.

Care plans contained detailed and adequate person-centred information to guide staff to provide personalised care. These plans were reviewed regularly.

People and their relatives knew how to make a complaint or raise their concerns. There was a clear system in place to manage complaints. We saw records of complaints and responses to these made in a timely manner and in line with the provider’s policy. The service had also received compliments from relatives and professionals about the care provided.

People’s views about the activities on offer at the Peele were mixed. There were a range of activities and events which were meaningful and engaging but more could be done for people living with dementia. During our inspection, we observed activities such as bingo and morning coffee. Photographs evidenced other activities that had taken place at other times.

There were policies and procedures in place and staff met regularly; these helped to ensure staff had appropriate guidance to carry out their roles and an opportunity to speak with their colleagues and managers about the service.

At this inspection in June 2018, we checked and found improvements had been made in the following areas: person centred care, need for consent, training and professional support and recruitment processes. However we found on-going breaches of the regulation relating to the safe management of medicines and good governance which had been identified at the previous three inspections carried out in May 2015, January 2017 and September 2017.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 96 people living at the home, across eight units or households (the term used by people living there and staff). The ground floor households were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor – Dove Meadow and Park Acre and on the second floor, Etchells, Clover Field and Stoney Knowll, the latter provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. Stoney Knowll was a partnership arrangement between the provider and Manchester University NHS Trust (formerly the University Hospital of South Manchester).

The home is situated in a quiet residential area of Wythenshawe in south Manchester and set within its own grounds which include an accessible garden area and onsite parking. Bedrooms were en-suite facilities and there were communal bathrooms and toilets on each floor. Each household had its own lounge and dining area and a small kitchen.

The service had a manager who was registered with the Care Quality Commission since April 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.

The care home had had a series of different managers over the last four years. This lack of stability had had an impact on the governance of the service and was evidenced by audit and improvement processes not being sufficiently robust to ensure the provider and registered manager effectively monitored the quality of care provided.

Previously closed units had been reopened in late April 2018 to accommodate people (male and female) living with advanced dementia. However due to challenges involving staffing levels and staff competencies, these households were divided into male and female units.

The registered provider had not followed their admission process. This had led to significant failings in record keeping and oversight of the newly opened households. This meant people were at risk of receiving care and support that was not responsive to their needs.

Medicines were not managed safely within some of the households. This meant people were at serious risk of harm because the proper and safe management of medicines was not always followed.

Arrangements were in place to ensure hygiene standards were maintained within the home. However these were not systematically carried out in some areas such as the kitchen which compromised food safety and put people at risk of harm.

Staff were knowledgeable about and demonstrated good infection control practices. The home was kept clean though we found some areas were in need of refurbishment. Regular maintenance and checks of the building and equipment was carried. These checks included lifts, hoists, fire safety equipment and the water system.

The provider had made the necessary improvements to the recruitment process; these helped to ensure people were safe because suitable staff were employed to work at the Peele. There were minor aspects of the process which could be strengthened and we pointed these out to the registered manager.

People and their relatives knew how to make a complaint or raise their concerns. There was a clear system in place to manage complaints. We saw records of complaints and responses to these but found some inconsistency in complaints recorded. This meant we could not be sure all concerns raised were managed appropriately and people's needs met responsively. The service also received compliments from relatives and professionals about the care provided.

People were supported by staff who had the appropriate skills and competencies. Staff received an induction, mandatory training and shadowed experienced colleagues prior to working unsupervised. Improvements had been made in the provision of staff training and the scheduling of supervisions and appraisals. Training and professional development helped to ensure staff were competent and equipped to carry out their roles effectively.

People told us they felt safe at the Peele. Relatives confirmed this. Staff were aware of their responsibilities in protecting people from abuse and demonstrated their understanding of the procedure to follow so that people were kept safe. The provider had processes and reporting systems in place to help ensure people were safe from harm and monitored and took necessary action when incidents occurred.

Risks to people’s safety were assessed and kept up to date. These assessments provided sufficient information to help staff support people safely.

The service had made necessary improvements to help ensure it followed the principles of the Mental Capacity Act 2005 (MCA) and sought the consent of people or their legally appointed representative before providing care and support. Appropriate applications for the Deprivation of Liberty Safeguards were made and records kept to ensure the service knew when authorisations were due to expire.

Overall, people told us they had sufficient food and drink of a good standard to ensure their nutritional needs were met. Where people’s health and well-being was at risk, relevant health care advice had been sought so that people received the treatment and support they needed. We saw evidence in care records and most people and their relatives told us the home supported them to access medical attention and health interventions as they needed.

People’s rooms were decorated according to their individual preferences. Since the last inspection the provider had made improvements to the home’s environment to help create a more dementia friendly environment. This would help people living with dementia to orientate themselves more effectively within the home.

People we spoke with were happy and settled living at The Peele and they said the care they received was supportive and kind. Relatives were also happy with the care provided.

The atmosphere at the care home was warm and welcoming. Across all households, we observed good rapport between people, their relatives and the staff.

The care home operated within a diverse and multicultural community and had systems in place to ensure people’s equality and diversity needs were recognised.

People were supported by staff in a friendly and respectful manner. Staff responded promptly when people asked for assistance and we saw people were supported in a patient and unhurried manner.

People told us that on the whole they found their care was good and personalised to their needs. There had been significant improvements in the way activities w

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 69 people living at the home. Only six of the nine units or households (the term used by people living there and staff) were occupied. Households on the ground floor were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor – Dove Meadow and Park Acre and on the second floor, Stoney Knowll – which provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. The intermediate care household was a partnership arrangement between the provider and the University Hospital of South Manchester. The registered manager told us the partnership agreement had expired and there were discussions taking place regarding the future of this collaboration.

People’s bedrooms had en-suite facilities but there were communal bathrooms and toilets on each floor. Each household had its own lounge and dining area and a small kitchen.

The home is situated in a quiet residential area of Wythenshawe in south Manchester and set within its own grounds which include an accessible garden area and onsite parking.

The service had a manager who was registered with the Care Quality Commission since June 2017. 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 told us they were well looked after and that the Peele was a safe environment in which to live.

We found examples where recruitment processes could be strengthened to help ensure appropriate care staff were employed.

Staff supported people to take their medicines safely. There was an updated medication policy which provided easy-to-read guidance to staff who administered medicines. We found that improvements were needed in the management of medicines that are controlled drugs and medicines for thickening drinks. Records of the temperatures at which medicines were stored were poor. This meant people were at risk of harm because the proper and safe management of medicines was not always adhered to.

Staff were aware of their responsibilities in protecting people from abuse and were able to demonstrate their understanding of the procedure to follow so that people were kept safe.

Risks to people’s safety were assessed and kept up to date. These assessments provided sufficient information to help staff support people safely.

Incidents and accidents were recorded and necessary action taken to help reduce the risk of recurrence. Systems in place were effective in helping to ensure people were protected from risk of harm.

Suitable arrangements were in place to ensure hygiene standards were maintained within the home. Staff were knowledgeable about and demonstrated good infection control practices. The home was well maintained. Regular maintenance and checks of the building and equipment was carried. This included lifts, hoists, fire safety equipment and the water system.

People and relatives told us staff carried out their duties well. Training records showed staff had received an induction and we saw some training considered mandatory by the provider in areas such as safeguarding and moving and handling of people had been carried out. There was little evidence to demonstrate what continuing training, if any, staff had undertaken since our last inspection in January 2017. Not all staff had had supervision or appraisals since February 2017. Failure to provide appropriate professional support to staff was a breach of the regulation.

The service did not always demonstrate that it was working within the principles of the Mental Capacity Act 2005 (MCA) to ensure they sought the consent of people or their legally appointed representative before providing care and support. Applications under the Deprivation of Liberty Safeguards had been made. We found that that some authorisations had expired which meant people may have been illegally deprived of their liberty. This was a breach of the regulation relating to need for consent.

People were satisfied with the food and drink on offer at The Peele. They told us staff ensured their nutritional needs were met. This helped to maintain people’s good health and wellbeing. Where people’s health and well-being was at risk, relevant health care advice had been sought so that people received the treatment and support they needed. We were satisfied that the home was proactive in helping to ensure people’s medical and health needs were met as required.

People’s rooms were decorated according to their individual preferences. In light of the home catering to people living with dementia, we found the provider had made insufficient improvements in the home’s physical environment to create a more dementia friendly environment. This would help people living with dementia orientate themselves more effectively within the home.

People we spoke with were happy and settled living at The Peele and they said the care they received was supportive and kind. Relatives were also happy with the care provided.

The atmosphere at the care home was warm and welcoming. Across all households, we observed several positive interactions and good rapport between people and the staff. It was evident to us that staff knew the people they cared for and supported.

People were supported by staff in a friendly and respectful manner. Staff responded promptly when people asked for assistance and were seen to support people in a patient and unhurried manner.

People and relatives told us the service responded to their needs in a person centred way. We identified examples where the provider did not consistently ensure people’s needs were met in a person centred way. We concluded that this did not demonstrate that the hallmarks of a caring organisation.

There were some activities arranged within the home and the community which helped to stimulate people’s wellbeing. However people told us these were insufficient and that they wanted more opportunities to participate in activities outside of the home. We found this to be a breach of the regulation relating to providing person centred care.

People told us they knew how to make a complaint or raise concerns. There were systems in place to manage complaints and we saw these were investigated in line with the provider’s policy and procedures. We noted not all complaints had been recorded in the complaints log.

The care home had had a series of different home managers over the last three years. Staff told us this had been unsettling and destabilising. Audit and improvement processes were not sufficiently robust to ensure the provider and

The inspection took place on 18 and 19 January 2017. The first day was unannounced, which meant the service did not know we were coming.

At the previous inspection in September 2015 we found two breaches of the regulation relating to safe care and treatment. An action plan was submitted on 21 March 2016. At this inspection we checked and saw that action had been taken to remedy the two breaches. However, we found four breaches of regulations at this 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. The Peele had a registered manager who had been in post since May 2016, but was absent on long term leave at the date of this inspection. There was an interim service manager who had been in post since 9 November 2016, who is referred to in this report as the interim manager.

People living in The Peele told us they felt safe and that there were always enough staff on hand to assist them. Each unit had enough staff and there were team leaders who moved between units. There were high levels of agency staff, although many of the agency staff were regularly at The Peele and knew the people well. There had recently been a recruitment drive with a view to reducing the number of agency staff.

There was a new system which enabled people who were at risk of falls to have both call buttons and pressure mats to alert staff if people got out of bed. This was an improvement on the previous inspection.

Proper procedures were carried out when recruiting staff. Staff were trained in safeguarding although some staff needed to update their training. There had been two significant safeguarding investigations during 2016 when the findings included criticism of the service in relation to agency staff and their lack of induction. Measures had been introduced to prevent a recurrence.

We found that careful records were kept of the management and administration of medicines. The Peele was using a new system in conjunction with a new pharmacy, which was working well. The building was well cleaned and smelled fresh.

Since the last inspection The Peele had created personal evacuation plans for use in an emergency and a file of these was kept at the front desk. The fire detection and prevention systems were regularly serviced and the security of the building was maintained.

Mental capacity assessments were not carried out to determine if people lacked capacity to make their own decisions. This meant the service was not adhering to the principles of the Mental Capacity Act 2005. This was a breach of the regulation relating to consent.

The Peele had made a high number of applications for Deprivation of Liberty Safeguards (DoLS) authorisations. We learnt that five applications had been granted although they had not yet been notified to us. The service was awaiting paperwork from Manchester City Council.

New staff completed the Care Certificate. Existing staff received training in core areas, but the uptake of this low. There had been a lack of supervision during 2016, although the interim manager intended to resume supervision during 2017. The low rates of training and the absence of supervision meant that staff were not being adequately supported in their work. This was a breach of the regulation relating to supporting staff.

A new external supplier was delivering food to The Peele. The food was enjoyed, but some people told us they had to choose their meals in advance and could not change their minds. This was a breach of the regulation relating to reflecting people’s preferences. We saw that people who needed help to eat were assisted, and records were kept of food and drink intake, and people’s weight was monitored.

People were able to access healthcare outside The Peele. The home was large but the individual units were a comfortable size. There was evidence that some attention had been paid to creating an environment suitable for those people who were living with dementia.

There was a kind and caring atmosphere within the units and staff, including agency staff, had time to spend with people. We saw examples of kind interactions and of staff encouraging people to maintain their independence.

Staff maintained people’s dignity and privacy, although the layout of each unit meant that staff had to be careful that conversations over the telephone were not overheard. People were given choice in everyday decisions.

The Peele enabled people to stay in the home at the end of life, if that was appropriate. A medical professional commended the home’s approach to supporting people at this stage.

Care plans were detailed but a little regimented because they used the same template. There was scope to include more personal information and make them more specific to each person. People using the service did not recall being involved in writing their care plans, although several relatives did. Although the service provided care for people living with dementia, in one case a document devised to help support staff know people’s needs had not been completed.

Reviews of care plans had lapsed in early 2016 but were now up to date. Daily notes and records of checks were completed.

There was a large activity room which was well used although not everyone took advantage of it. Some people enjoyed watching films or playing bingo. There were four activities organisers who visited the units. A variety of activities had been provided in December 2016.

There had not been residents’ meetings recently, although some meetings had been held for relatives. Formal written complaints had been dealt with appropriately but complaints made verbally needed to be recorded as complaints.

The rating from our previous inspection was not displayed in the home or on the provider’s website, which was a breach of the relevant regulation.

Care plan audits had been carried out in November 2016 but medication audits had lapsed. These were important in view of a history of medication errors at The Peele. This was a breach of the regulation relating to quality monitoring.

There had been four managers in post since our last inspection which created instability. The provider’s senior management team had imposed a suspension of new admissions in May 2016 which was still in place, but there were now plans to lift it. The provider was supporting the interim manager to make changes. Team leaders played an important role within the leadership structure.

The service had learnt from the outcomes of safeguarding investigations during 2016. The service was good at submitting notifications about events that had to be reported to the CQC.

We found five breaches of regulations 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 end of the full version of the report.

We also looked at other standards, and followed up some information we had received from relatives.

At the date of our visit there were 103 people living at The Peele. We spoke with 19 people in different units, three relatives, two visiting professionals and seven members of staff. The registered manager showed us round the building and discussed issues with us. We looked at care plans and other documents.

We considered all the evidence we had gathered and used it to answer five key questions:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found. The evidence supporting these findings can be found under our judgements for each standard.

Is the service safe?

On the two Intermediate Care units people were being encouraged to regain their mobility and their independence so that they could return home or to their previous environment. This meant they were undertaking physical exercises. We observed that there were plenty of trained staff around to ensure these exercises were done safely. We saw one person being encouraged to walk up a staircase, and staff stayed behind him to make sure he would not fall. We spoke with one person on the Intermediate Care Unit who said: "Yes, I do feel safe here."

On the residential units people were looked after in a safe environment. One person told us that they "definitely feel safe".

Staff knew about safeguarding procedures and told us they would have no hesitation in reporting the matter if they had any concerns about a person's safety or felt they were being abused in any way. We saw from our own records that the manager reported safeguarding incidents appropriately.

The CQC monitors the operation in care homes of the Deprivation of Liberty Safeguards (DoLS). At The Peele there was one person for whom a DoLS authorisation had been applied for at the time of our visit. We read the paperwork relating to this and saw that the correct processes had been followed.

Is the service effective?

We spoke with staff who were knowledgeable about people's care and support needs. We looked at a sample of people's care plans and saw evidence which showed, where possible, people had been involved in developing their care plans. This meant they received care and treatment in a way they preferred. The service had developed training for staff working with people living with dementia.

Is the service caring?

One relative had written: "The quality of care given to all the residents never ceases to amaze me, and that is the point: the care, kindness, compassion, warmth and patience to all." Another relative had recorded: "I only have the highest praise for the staff of The Peele. Their selfless effort to care for my father I will always remember."

Is the service responsive?

The manager had responded positively to a number of criticisms in our last report. We saw that changes had been implemented. We saw evidence that the service responded to the needs of individuals. When a person had not been well settled, the manager had recently moved them to a different unit.

A visiting professional told us: "The home is very responsive to meeting people's needs. The staff keep me informed of how people are and will request a review if they feel a person's needs have changed."

Is the service well led?

The registered manager had made a number of significant changes since arriving fifteen months earlier. We saw that there was a good system of delegating responsibility to team leaders, who each managed a group of carers. We spoke to several team leaders who had a good understanding of their role.

The manager had acted decisively in relation to two incidents involving staff behaving inappropriately.

One member of staff told us: "We have very good management ' you can go and speak with them at any time. You get very good support and it is a well led service."

We saw staff being supportive, patient and kind to people living with dementia. We observed staff treat people with respect and maintain their dignity. In particular staff were seen to speak with people respectfully, pleasantly and to preserve their dignity when providing personal care and support.

We found that people were supported by other health care professionals such as psychiatry teams, occupational therapists and speech and language therapists and that both management and staff had good relationships with these health care providers.

We found that many of the records relating to people living with dementia required more 'dementia specific' information recording for example, assessments and personal background information.

We found that staff did not always have time to interact with people on a one to one basis with little cognitive stimulation taking place for people living with dementia.

Sufficient monitoring was not in place to ensure people living with dementia received a quality service.

We found the service was not effectively meeting the full range of needs of people living with a dementia.