Grovewood Residential Home

Grovewood Residential Home is situated in a residential area of Rock Ferry. The home provides personal care for older people. The home is able to accommodate a maximum of 32 people. At the time of inspection there were 23 people living in the home.

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

We conducted a focused inspection of this service looking at the domains of safe and well-led. At this inspection, we found concerns with the management of medicines, record keeping, infection control and governance.

There were a range of provider and manager audits in place, however, a new auditing system had been implemented and not always completed. This meant we could not be certain that certain aspects of the service were being appropriately monitored.

Feedback we received from staff, people and relatives we spoke with during the inspection was mainly positive. We were told by the relatives we spoke with that the care staff communicated with families regularly.

There were enough staff on duty to support people, and staff were recruited safely. Care staff were friendly, and treated people kindly. People’s relatives confirmed this and felt their loved ones were well looked after.

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

Rating at last inspection

The last rating for this service was good (published 03 September 2021).

Why we inspected

We received concerns in relation to concerns received about medicines, safeguarding, infection control and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Grovewood Residential Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines, accurate care planning and record keeping and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Grovewood Residential Home is situated in a residential area of Rock Ferry. The home provides personal care for older people. The home is able to accommodate a maximum of 32 people. At the time of inspection there were 22 people living in the home.

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

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.

People, their relatives and other health and social care professionals gave consistent, positive feedback about the service.

We observed support being provided in the home and saw that this was done in a caring, responsive and patient manner. We saw that people were comfortable in the presence of staff and positive relationships had developed between people receiving support and staff.

Staff were recruited safely and received regular training, supervisions, attended staff meetings and had regular practice checks. Staff we spoke to said that they felt well supported. The registered manager had implemented a number of new processes following learning gained through auditing systems and through the COVID-19 pandemic.

Risks which compromised people’s health and well-being were appropriately assessed, reviewed when needed and contained detailed information. People told us they felt safe with the service.

Accidents, incidents, safeguarding and complaints were managed appropriately and monitored by the management.

Care plans and risk assessments were person centred and they detailed how people wished and needed to be cared for. They were regularly reviewed and updated as required. We saw evidence of how the registered manager and staff ensured people’s beliefs, choices and rights were respected.

Medication administration was managed safely and new quality checks that had been implemented ensured practices were monitored. Staff had regular performance. checks to ensure ongoing safety of people living in the home.

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 (published14 May 2019) and there were two breaches of regulation. 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.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 02 April 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve staffing, recruitment and staff supervision.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Grovewood Residential Home on our website at www.cqc.org.uk.

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.

We found the following examples of good practice.

The service followed safe visiting procedures. Visits were restricted to essential visitors only. However, there were safe measures in place to facilitate visits for people receiving end of life care and where it had been assessed as being in the persons best interest due to their wellbeing. All visitors entered through the nearest entrance. Visits were conducted in the persons own room and visitors were required to wear full personal protective equipment (PPE).

Temperature checks and health screening assessments were completed on all visitors on entry to the home

shielding and social distancing rules were complied with. The environment had been adapted to support social distancing. For example, lounges had been rearranged to facilitate this.

There was a dedicated procedure that accommodated people should they develop COVID-19 or show symptoms.

Safe procedures were followed for admitting people to the service. Virtual assessments were completed, and people were only admitted following evidence of a negative COVID-19 test. On moving into the service people were required to self-isolate for 14 days.

Stocks of the right standard of PPE were well maintained and staff used and disposed of it correctly. The registered manager shared good working practices and updates across the staff team using face to face meetings and electronic means.

People and staff had access to regular testing.

Guidance on the use of PPE and current infection prevention and control (IPC) procedures were clearly visible across the service and available in picture format.

Staff reassured people throughout the pandemic and provided them with the support they needed to maintain regular contact with their family and friends through the use technology. Staff also communicated regularly with families using electronic systems.

People’s experience of using this service:

This inspection found that significant improvements had been put into place by the new manager. People and relatives, we spoke to told us that they had noticed that the home has improved.

During this inspection we found improvements in all areas however additional improvements were required surrounding recruitment, staff supervision and training. However, following the inspection the manager provided us with ongoing evidence that this was continually improving.

We observed support being delivered within the home and saw that people were comfortable in the presence of staff. This indicated that positive relationships had developed between people receiving support and care staff. People told us staff were kind and treated them with respect.

People we spoke with told us that there had been a ‘vast improvement’ since the new manager had been in post and would now recommend the home to others. An external training provider representative also commented on the improvements in the home.

We saw significant improvements had been made to the environment and this was ongoing. We saw the positive impact that this had had on the living conditions for people living in the home. Improvements had been made to the management of the health and safety issues; fire safety, water and building management.

Staff and people spoke very highly of the manager and the work they were doing. Improvements had been made to the management of DoLS and how people's capacity was considered. There were good audit trails of actions taken and why.

People's monitoring of their dietary intake was good, and healthcare was managed well. There were person-centred care plans in place that described what people needed and wanted to keep them safe and well. People told us they felt safe living in the home due to the support they received from staff. Individual risks to people had been assessed and measures were in place to mitigate those risks.

Systems were in place to manage medicines safely and people told us they got their medicines when they needed them.

Systems were in place to gather feedback from people, including meetings or surveys. People and their family members told us they felt confident to be able to raise any concerns they had with the management and that they would be dealt with.

Safeguarding and whistleblowing procedures were also in place for staff to follow. Staff spoken with were knowledgeable about safeguarding procedures and how to raise any concerns they had.

Rating at last inspection: The home was previously rated as Inadequate and was placed into special measures. We had previously found breaches of regulation in regard to consent, safe care and treatment, safeguarding, staffing and recruitment and governance.

Why we inspected: This inspection took place as it was a scheduled based on previous rating.

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

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

The home 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. At this time of this inspection, the home did not have a registered manager.

We inspected Grovewood on 26 and 30 October 2017 and found breaches of Regulations 11, 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to complete an improvement action plan to tell us how they planned to address the breaches of regulations but we did not receive an action plan.

In response to concerns CQC received, and the lack of an improvement plan, we inspected Grovewood again on 28 February and 7 March 2018. We found that all of the breaches were repeated. We asked the provider to complete an improvement action plan to tell us how they planned to address the breaches of regulations, and issued a Warning Notice with regard to Regulation 17. The service was rated inadequate and placed in special measures.

During this inspection we found continued breaches of Regulation 11, 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found breaches of Regulations 13 and 20A, and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

The premises and equipment were not always maintained in a safe condition, and people were not adequately protected from the risk of infection. Some rooms did not have a consistent supply of hot water. A central heating boiler had been deemed unsafe by British Gas in August 2018 and no action had been taken. The home’s fire risk assessment and personal emergency evacuation plans were out of date. We saw a number of areas that were not adequately maintained. We had many concerns over standards of cleanliness and the age and decay of the building and the furniture in it.

The provider had not ensured that robust recruitment procedures were followed including the relevant checks. We asked the acting manager if any new staff had been recruited since our last inspection and we were told that there had not. We then found that four staff members had been recruited. Two did not have adequate references.

Incidents that had put people at risk had not been referred to the local authority for investigation under safeguarding procedures.

Mental capacity assessments were not in place for most of the people living at the home. This included people who were living with dementia; people who had a ‘do not resuscitate’ order which they had not consented to; and people who had devices fitted to their beds to prevent them from falling out of bed.

Staff had not received appropriate support, supervision and appraisal. In two files we looked at we saw that that the staff had been subject to disciplinary action yet both staff members had only received one supervision session in the last six months and neither supervision session referred to the issues of performance where improvements were required. Supervisions and appraisals had been improved since our previous inspection but were still inconsistently offered.

We saw staff meeting minutes that were very confrontational and did not encourage a learning or supportive culture for staff to develop within. We were very concerned at some of the language used and the tone of the communication and did not feel that it was conducive for a positive working environment.

Record keeping across the service had improved but was still not good. For example, during the inspection the acting manager and other members of staff spent a lot of time trying to find documents such as service user guides and complaints records.

The acting manager told us that the provider visited the home about once a month and was always available by phone. We saw records of provider visits in April and May 2018 but none since. We found no evidence of any checking or monitoring by the provider, for example of the staff recruitment and supervision records or the state of the environment.

Some audits were in place to monitor the quality and safety of the service. However, the audits did not identify or address the concerns we found during this and previous inspections. Audits consisted mainly of the acting manager or staff auditing their own work.

Infection control self-audits had failed to identify the issues found by the NHS infection prevention and control inspection in July 2018. Cleaning and laundry daily checklists did not refer to the issues that were clearly visible in the environment.

At this inspection we found that despite concerns raised at our previous inspections, and the action plan we received from the provider, no significant improvements to the overall provision of the service for the people living at the home had been made or sustained. This demonstrated the management systems at Grovewood were inadequate.

The provider did not display their most recent performance rating either in the premises or on their website.

The provider had not notified CQC of safeguarding incidents or of Deprivation of Liberty authorisations for people living at the home.

At our inspections in October 2017 and February 2018 we found that no written information about the service was available for people living at the home and their families or for people interested in going to live at the home. Since then, the manager had produced a ‘Residents Guide’. However we found that this contained misleading information, for example reference to the National Care Standards Commission which was disbanded in 2004.

During the inspection we saw that there were enough staff on duty and people’s requests for assistance were answered promptly. We observed that staff supported people in a friendly, caring way. A programme of staff training had been implemented. The service had a part-time activities organiser and a variety of social activities was provided. The kitchen had a five star food hygiene rating and people appeared to enjoy their meals.

The home’s complaints procedure was displayed and the acting manager had kept records of complaints they had received since our last inspection.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

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.

We had previously inspected the home on 26 and 30 October 2017 when we found breaches of Regulations 11, 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to complete an improvement action plan to tell us how they planned to address the breaches of regulations. We did not receive an improvement plan. In January 2018 we received information of concern from the relative of a person who had been accommodated at the home. These concerns were investigated by the local authority and found to be substantiated. In February 2018 we received further information of concern from a person who worked at the home.

Grovewood is a ‘care home’. 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. Grovewood accommodates up to 32 people in one adapted building.

The home 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. At this inspection, the acting manager informed us that the person registered as manager was no longer employed at the home.

During our inspection in October 2017 we found breaches of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Fit and proper persons employed because the provider had not ensured that robust recruitment procedures were followed including the relevant checks. During this inspection we found that some progress had been made in setting up a personnel file for each member of staff. However, we looked at ten of the personnel files and only two of them contained all of the information needed to ensure that the person was suitable to work with people who may be at risk of neglect or abuse.

During our inspection in October 2017 we found breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment. This was because the premises and equipment were not always maintained in a safe condition; the management of medicines was not safe; people were not adequately protected from the risk of infection.

During this inspection we found that regular in-house health and safety checks, for example checks of water temperatures, had not been recorded recently. When we checked the water temperature in the shower room and bathroom we found it was higher than the safe limit.

During this inspection we found that some parts of the building were unclean and on the first day there was no hot water supply in ten bedrooms and two toilets. There were eight rooms with either no bin, or a bin without a lid. The bins without a lid included one bin that had a continence pad in it. We found unpleasant smells in five areas. The floor and walls in the laundry room needed attention so that they could be cleaned thoroughly.

The medicines room had no hand washing facilities and had an extractor fan that was very dirty. Two people were prescribed a controlled medication and the quantities recorded in the controlled drugs register were incorrect for both of these.

During our inspection in October 2017 we found breaches of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing, because staff had not received appropriate support, training, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

Staff training records had not been maintained since our inspection in 2016 which meant we could not check if everyone’s training was up to date. There were no records to show that new staff employed during 2017 had received any induction training. There was a system of staff supervision and appraisals, however records had not been maintained and we found no records of these being done since our inspection in 2016.

During this inspection we found that a programme of staff training was planned and some staff had attended moving and handling training. However, no records of this were available so we could not identify how many staff had this training. The acting manager told us that the providers had carried out staff supervisions but we found only one record of a supervision in the staff files we looked at. Some staff said they had a supervision but others said they had not.

During our inspection in October 2017 we found a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Need for consent. This had also been identified at the inspection carried out in September 2016.

Six people were sharing a bedroom with someone who was not related to them and we found no evidence that these people had formally consented to sharing a bedroom; that they had the capacity to consent to such a decision; or that a sharing agreement was in place. We were unable to find clear and up to date information about which of the people living at the home had the protection of a Deprivation of Liberty Safeguard (DoLS) or for whom a DoLS application had been made.

During our inspection in October 2017 we found breaches of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Premises and equipment. We saw a number of areas that were not adequately maintained. During this inspection we found that very few improvements had been made. We found maintenance issues in a number of bedrooms, for example nine rooms had poor carpeting, five had damaged furniture, six had damaged radiator valves and six had issues with the call bells.

At our inspection in October 2017 we found that no written information about the service provided was available for people living at the home and their families or for people interested in going to live at the home. The provider said they would make copies available but they had not done this.

During our inspection in October 2017 we looked at the care files for three people who lived at the home. These contained information about the person's needs and preferences and their life histories. The care plans were written in a person-centred style and were sufficient in content to enable staff to look after the person in the way they preferred. At this inspection we saw that the assessments and care plans had not been reviewed and updated since our last visit. The acting manager was in the process of putting the information onto an electronic system. However, we found that the recording on the electronic system lacked the person centred detail we had seen in the paper files.

During this inspection we found no information, assessments, or plans in place for the care of a person who was living at the home and had been there for a month. The acting manager told us that an assessment of the person’s needs had been sent to them by email but during the inspection they were unable to access this information. The staff who were providing care for the person had no information about their care and support needs.

During our inspection in October 2017 we found breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good governance. At this inspection, the acting manager told us that the person registered as manager was no longer employed at the home. We considered that the acting manager, who was previously the deputy manager, was unable to fulfil all of the management and administration tasks that were needed due to the volume of work required. The provider told us they were actively recruiting for an administrator.

We found that record keeping across the service was chaotic. For example, there was no up to date list of people living at the home; there were discrepancies in the personal finance records we looked at for two people.

Staff we spoke with said the acting manager was very approachable and supportive and had created a much more positive atmosphere. However, the acting manager told us she was concerned about staff discipline within the home and had received reports of staff spending time on their phones rather than interacting with the people living at the home.

During the inspection we saw that there were enough staff on duty and people’s call bells were answered promptly. The acting manager told us that since our last inspection there was a member of staff allocated to both cleaning and laundry every day.

Staff we spoke with knew about safeguarding and had reported their concerns.

We observed that staff supported people in a friendly, caring way and people we spoke with said the staff treated them well. The service had an activities organiser and people enjoyed the social activities provided.

The home’s complaints procedure was displayed and had been updated following our last inspection. The acting manager told us that no complaints had been received since our last inspection.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough im

We last inspected Grovewood on 6 and 8 September 2016 when we found that the service was good in four of the five key questions. At that inspection we found a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014 because the home was not fully compliant with the Mental Capacity Act 2005.

During 2017, CQC received a number of concerns about Grovewood. On 18 October the provider informed us that the registered manager was currently not working at the home pending an investigation. Two other staff were suspended. The deputy manager was standing in as acting manager.

During this inspection we found breaches of Regulations 11, 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014

The home had six double bedrooms. We spoke with two people who were sharing a room with other people. Neither could not tell us who the person was that they shared with. One person complained about the person they were sharing with and the other said it was “another patient”.

When we looked at their care plans we found no written consents to sharing a bedroom, and one person’s care notes recorded that they liked their own space. Some shared rooms had no privacy screen and the privacy screens in other rooms were dusty, which suggested that they were not used regularly.

On the first day of our inspection there was no cleaner on duty. We saw a very dirty toilet in the en-suite of one of the shared rooms. We saw an overflowing bin in one of the bathrooms. This had no lid and there were used paper towels all over the floor. Carpets needed vacuuming. One shared bedroom was cluttered with far too much furniture which resulted in the fire exit being blocked.

We saw a number of areas that were not adequately maintained. For example a broken window blind in a bathroom; a bedroom with no curtains; an en-suite toilet cubicle that was smelly and the extractor fan seemed not to be working; two toilets without seats; poor carpets in some bedrooms; and rotting window frames at the back of the property. The laundry room was in the basement. New washing and drying machines had been provided but the floor and walls needed attention so that they could be cleaned thoroughly.

Medicines records indicated that people received what was prescribed for them. However, there were some areas where improvements were needed. The medicines room had no hand washing facilities and had an extractor fan that was very dirty. Handwritten entries on medication administration sheets were not always signed, although most were. There were no administration protocols for medication that was prescribed to be given “as required”. This meant that as required medication may not be given consistently. When we looked at stocks of controlled drugs and controlled drugs records, we found two discrepancies involving small quantities.

The acting manager told us that all staff were well trained, but training records had not been maintained to provide evidence of this. Staff supervision and appraisal records were out of date.

We asked to look at staff files for new staff who had been recruited since our last inspection. The deputy manager told us that files were not in place and she was sending for information, including references and a criminal records checks, which should have been in place before the staff started working at the home.

There was a range of quality assurance systems in place to assess and monitor the quality and safety of the service. These had mainly been completed monthly by the registered manager but had not been effective in identifying areas needing improvement which we found during our inspection. We were concerned about the amount of work the deputy manager was currently having to undertake.

Everyone we spoke with was very happy with the care that people received, with the meals provided, and with the social activities available. Satisfaction questionnaires had been sent out in June/July 2017 and returned positive comments. People told us that their dignity was upheld when personal care was provided and that staff were kind and caring.

Care files contained information about people's needs, decision making ability and preferences. Care plans contained good person centred information. From the care files we looked at, we saw that people's support needs and risks to their health, safety and well-being were assessed and planned for. Records confirmed that people had prompt access to healthcare professionals as required. Deprivation of Liberty Safeguards had been applied for when people’s capacity to make decisions was in doubt.

The acting manager and the providers expressed their commitment to improving the service and told us that the staff team were very supportive.

The home is situated in a residential area of Rock Ferry within walking distance of local shops and public transport. A small car park and garden are available within the grounds. The home is decorated to a satisfactory standard throughout with accommodation provided across three floors. A passenger lift and stair lift enables access to the bedrooms located on the upper floors. Specialised bathing facilities are available and on the ground floor there is a communal lounge, dining room and conservatory for people to use.

During the inspection we spoke with five people who lived at the home, four relatives, three care staff, a catering assistant, the activities co-ordinator, the deputy manager and the registered manager.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

Since our last inspection in 2014, the home has experienced a change in owner (the provider). The previous provider retired and a new provider bought the home is now responsible for the service provided. The new provider still operates as ‘Soundpace Limited’

During our visit, we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014. This breach related to the implementation of the Mental Capacity Act 2005.

We looked at three people’s care files. We saw that care plans contained information on people’s mental health needs, decision making ability and preferences in the delivery of care. Care plans contained good person centred information on what promoted people’s mental well-being and clearly outlined to staff the need to gain people’s consent to their care, before it was provided. We found however that people’s capacity to make important decisions in respect of their care had not always been properly assessed in accordance with the Mental Capacity Act (MCA).

For example, some people had deprivation of liberty safeguards (DoLS) in place that prevented them from leaving the home on their own but their capacity to do so had not been assessed prior to this decision being made. This meant there was no evidence that a deprivation of liberty safeguard application was required or justified and meant that the principles of the MCA and DoLS legislation had not been followed to ensure people’s legal consent was obtained. We spoke to the manager about this. They acknowledged that improvements were required to ensure this legislation was consistently adhered to, in relation to people’s care at the home.

During our visit, we saw that people who lived at the home were relaxed in the company of staff. From our conversations with them, it was clear that people who lived at the home held staff in high regard. Relatives we spoke with also told us they were happy with the care provided and that staff were kind and caring.

We saw that people were able to choose how they lived their life at the home for example, what time they chose to get up / go to bed and what they wanted to eat/drink. A range of activities were provided to occupy and interest people and these activities were well attended. It was clear from what we observed that people enjoyed these activities.

We saw that staff took the time to simply sit and chat to people in addition to supporting them with their personal care needs. Staff were warm, relaxed and kind in all of their interactions with people and their relatives. People were supported at their own pace in a compassionate, unhurried manner which enabled people to be maintain their independence for as long as possible. The atmosphere at the home was homely and social and people’s visitors were made welcome. From our observations it was clear that staff knew people well and that people trusted them.

From the care files we looked at, we saw that people’s needs and risks were appropriately assessed and managed. Two people’s health conditions required further explanation. We spoke to the manager about this and they had already commenced work on this by our second day of inspection. People’s care was planned and delivered in a person centred way. This included ensuring staff had access to information about people and their life prior to coming to live at the home. This gave staff an understanding of the person they supported and a means to connect with the person they were caring for. We also saw that care plans contained information about the person’s emotional well-being and gave staff guidance how to provide person centred support in times of distress or ill-health.

Relatives we spoke with told us staff were good at spotting people’s signs of ill-health, reacted quickly to get people the support they required and kept them fully informed about the person’s progress and care. Records confirmed this and showed that people had prompt access to other healthcare professionals as and when required. For example, doctors, dietitians, district nurses and chiropody services.

We observed lunch and saw that people had a choice of suitably nutritious food and drink. People were offered an alternative if they did not like what was on the menu and people’s special dietary needs and preferences were catered for. We saw that staff provided people with discreet encouragement to eat and drink well.

Medication was managed safely and people received the medications they needed. Improvements in the way medication was ordered were required to ensure that excess stock did not make it difficult to account for the medication administered.

Staff were recruited safely, suitably trained and supported. There were sufficient staff on duty to meet people’s needs. Staff at the home were observed to have a positive relations with both the deputy manager and registered manager, both of whom were ‘hands on’ and acted as positive role models to the staff in how to deliver person centred care.

Staff we spoke with were knowledgeable about types of potential abuse and what to do if they suspected abuse had occurred. People told us they felt safe at the home and they had no worries or concerns. The manager had responded appropriately to any complaints received. Details of who people should contact in the event of a complaint needed to be added to the provider’s complaints policy.

The premises were safe, well maintained and clean. Some parts of the home smelt unpleasant and we spoke to the manager about this. There were a range of quality assurance systems in place to assess and monitor the quality and safety of the service received and to obtain people’s views. For example infection control audits, medication and accidents and incidents audits were all undertaken and a satisfaction questionnaire was sent out to gauge people’s satisfaction with the service provided. We saw that people’s feedback about the service, was consistently positive and the culture of the home was found to be open and inclusive. This demonstrated good management and leadership.

The inspection was carried out by one adult social care inspector and a pharmacist inspector over the course of a day. The focus of the inspection was to answer our five key questions; is the service safe, effective, caring, responsive and well-led?

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

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

Is the service safe?

We found that people using the service were safe because they were protected against the risks associated with use and management of medicines. People received their medicines at the times they needed them and in a safe way. We also found that systems were in place for ordering, administering, recording and storing medicines appropriately.

Risk assessments had been carried out for people who used the service and actions had been identified and implemented to minimise risks to their safety.

Is the service effective?

People who used the service said staff were good at their jobs. Visiting health care staff said staff were helpful and they weren't aware of any concerns about the home.

People were supported to eat and drink to ensure they received a balanced diet.

Is the service caring?

People who used the service said they liked the staff and commented: "The staff are very good" and "The staff are fantastic. I'm so glad I came here". A relative said: "I'm very happy with the care and they call me if my (relative) is unwell".

Throughout the visit we spent time watching how staff cared for people. We observed good interactions between staff and people who used the service.

Is the service responsive?

People's needs had been assessed and considered prior to their admission to the home. Up to date care plans were in place which took account of their needs, and these were reviewed at regular intervals. Staff responded promptly to any concerns they noted in people's health or wellbeing and took appropriate action such as calling the person's GP or specialist nurse. We also saw evidence that the staff enabled people to attend hospital appointments and see the chiropodist and optician regularly.

Staff were knowledgeable about people's life histories, care needs and preferences and took these into account when providing care.

Is the service well-led?

Since our last inspection the registered manager had reviewed the care and support needs and documentation for all the people who used the service to make sure that care plans and risk assessments were up to date and reflected all people's identified needs.

The manager carried out regular checks on medicines and, where discrepancies or concerns were noted, action was taken to address those issues.

A customer satisfaction survey had been carried out to seek the views of the people who used the service and their relatives and all the responses were positive.

A visiting quality assurance officer from the local placing authority said the service had improved since our last inspection.

The inspection was carried out by two inspectors and a pharmacist inspector over the course of two days. They helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People did not always receive safe care and support because their needs had not been appropriately assessed and planned for.

Some people who used the service had not received their prescribed medication on time putting their health, welfare and safety at risk.

Systems which were in place to check on the quality of the service did not identify risks to people’s health, safety and welfare and failed to identify that people had not received the care and support they needed.

Is the service effective?

People did not always receive effective care because staff failed to follow people’s care plans and carry out instructions given by other healthcare professionals who were involved in people’s care.

Systems which were in place to ensure people’s health, safety and welfare were not always effective because they failed to identify that people’s care had not been planned and delivered.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people and also reassured people who were anxious.

People who used the service told us they liked the staff. Comments included: “They’re wonderful. They certainly listen to my requests and try to do what I ask” and “The staff are good. No complaints whatsoever.”

Is the service responsive?

People did not always receive the right care and support because staff failed to respond to significant changes in their needs and staff did not provide appropriate care following instructions given by other healthcare professionals.

The provider failed to submit an action plan within the required timescale, detailing how and when they intended to become compliant with the areas of non compliance which we identified during the last inspection visit.

Is the service well-led?

The service had a registered manager.

Checks carried out by the manager had failed to identify or address ongoing concerns about the management of medicines within the home.

As part of this inspection we spoke with three people who used the service, one relative, the registered manager, a team leader, two care staff and two healthcare professionals. We also reviewed records relating to the management of the home which included, four care records, daily written records, medication records, records relating to the care provided by other professionals, staff files and audits. 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 looked at four staff files to check that information in relation to the recruitment and selection of staff was adequate. We found that appropriate information in relation to staff member's previous employment, identify and suitability to work with vulnerable people had been checked prior to employment.

We looked at the care records of four people who lived at the home. We found each care record contained information about people’s needs and risks but some care plans and risk assessments had not always been kept fully up to date. Care plans also lacked information about how to care for people with dementia. During our observations, we found that care was not always delivered in accordance with people’s plan of care. This meant people were at risk of receiving inappropriate or unsafe care that did not meet their needs.

During our previous visits to the home in July and December 2013, we had concerns about the way in which medicines were managed at the home. At this visit, we reviewed the medication arrangements at the home again. We found that medications were still not being managed safely or appropriately at the home and placed people at serious risk of harm.

We found that some people’s medication was not given at the right time or at the right dose and in some instances people had not received their daily dose of medication at all. Records relating to the administration, storage and disposal of medication were poor and inaccurate and at times false records relating to the administration of medication were made.

We found that staff had little information on how to administer people’s ‘medications such as painkillers that were prescribed to be given 'as required' or guidance on how and where to apply people’s external creams or products. We saw that some medications at the home were passed their expiry date but were still in use; medication was not always stored securely and not always disposed of appropriately.

We had major concerns about the medication practices at the home and discussed these with both the manager on the day of our visit and subsequently with the provider. We have asked the provider to tell us what improvements they will make to ensure that people receive safe and appropriate care. Following our visit a safeguarding referral to the Local Authority was made in relation to people’s medication issues.

Is the service effective?

On arrival at the home, the manager told us the majority of people would be able to talk to us and communicate their views on life at the home. We observed some people at the home displayed behaviours associated with dementia type conditions and some were unable to communicate in a meaningful way. We spoke with two care staff. We found they had a general understanding of people’s needs but lacked an awareness of people’s mental health issues.

The four people whose records we looked at had dementia but there were no care plans to guide staff on people’s dementia care. This meant there was a risk that staff would not know how to communicate or support the person effectively. Two of the care plans we looked at had not been been fully updated in response to changes in people needs or care. This indicated that staff lacked accurate and adequate information about people’s needs and risks and meant people were at risk of receiving care that did not meet their needs.

We have asked the provider to tell us what improvements they will make to ensure that people receive effective care that meets all of their needs.

Is the service caring?

We spoke to three people who lived at the home and one relative. The majority of people we spoke with said they were happy with the care provided. Comments included “Very nice the girls. Food is very good” and “Lovely young girls here, very willing to do extra work. The relative we spoke with told us “All staff have been really, really nice. We are kept really well informed. I can turn up when I want to”.

All the staff we spoke with spoke fondly of the people they looked after. We observed staff supporting people throughout the day. We saw people were spoken to pleasantly and that staff were kind and supported people at their own pace.

Care records were person centred and contained clear information on people’s daily preferences, likes and dislikes and social interests/hobbies. This showed that people and/or their families were able to express their views as to what was important to them in relation to their care.

Is the service responsive?

Two people and the relative we spoke with confirmed that prompt access to medical/professional support for their medical or health needs was organised when they needed it. Records showed that GPs, mental health services, district nurses chiropody and other health professional were involved in people’s care as and when required. We saw that people’s monthly notes kept a record of people’s appointments/visits with other healthcare professionals and documented the advice given for staff to follow.

Is the service well led?

There were systems in place to collect people’s and/or relative’s views on the quality of the service provided. An annual residents/relatives meeting took place and a satisfaction questionnaire was sent out. This year’s satisfaction survey was in the process of being completed at the time of our visit. A small selection of questionnaires had been returned and showed a general satisfaction with the service.

There were some systems in place to monitor and manage risks to people’s health, safety and welfare but some of the systems were ineffective. For example, accident/incident and environmental audits were undertaken and records showed that where issues had been identified these had been addressed. There were no checks however on the quality of the information given to staff in relation to people’s needs and care. This meant there were no suitable arrangements in place to ensure people’s needs were appropriately assessed and care planned.

We found that there were no robust checks on the management of medication at the home to ensure it was safe. The checks undertaken by the manager did not identify any of the serious concerns identified during our visit in relation to poor record keeping, unsafe administration practice, unsecure storage and the inappropriate disposal of medication.

We also saw that the provider visited the home on a monthly basis to undertake a check on the quality of the service provided but their visits also failed to identify quality issues relating to the management of the service or the safety of people’s care for example with regards to people's medication”.

Overall, we found that the service lacked satisfactory management and leadership in the delivery of the service and that this placed people at risk. We have asked the provider to tell us what improvements that will make to ensure that people received effective care that met all of their needs.

We reviewed the provider’s medication arrangements. We saw some improvements to the administration of medication had been made, however the home’s lack of accurate record keeping meant people were at risk of being given their medicines incorrectly. This placed them at risk of unnecessary harm.

At our last inspection, the general upkeep and maintenance of the environment was poor and there were no environmental audits in place to check the home was suitable and safe for people to live in. We saw the provider was now visiting the home on a monthly basis to monitor the quality of the service and regular infection control audits were conducted. On the day we visited, the home was cleaned to a high standard and a number of home improvements had been made. Monthly accidents/incident audits were completed to monitor and prevent further accidents/incidents. This assured us there were systems in place to identify people at risk of falls or risks in the delivery of care.

We looked at the care records of three people. We found care plans were personalised to the individual and gave clear instructions to staff on the personal care required by each person based on their assessment of need.

We reviewed three staff records. We saw evidence staff recieved an annual appraisal and were supported in their job role in order to ensure care was provided to people at an appropriate standard. We saw people were treated kindly and with dignity and respect.

Staff we spoke were knowledgable about safeguarding, the signs of abuse and knew who to report concerns to if they suspected abuse. All staff had received safeguarding training in the last twelve months.

Due to concerns raised during our inspection we reviewed the storage, administration and management of medicines at the home. We found the provider did not have suitable arrangements in place to protect people from the risks of unsafe use and management of medication.

The provider had systems in place to monitor the views of people and/or relatives about the quality of the service provided but did not have suitable systems in place to identify, assess and manage the health, welfare and safety risks posed to people who lived at the home.