Archived: Attwood's Manor Care Home

The inspection took place on the 6 and 7 July 2017 and was unannounced. The previous inspection had been undertaken on 8 February 2017 to follow up concerns found at the inspection in September 2016. The inspection in February 2017 found that there had been some improvements and the overall rating of the service changed from inadequate to requires improvement. At our inspection in July 2017 we found that the improvements made had not been sustained.

The provider continued not to provide a manager registered with the Care Quality Commission (CQC). The home had a manager who had been in day to day charge of the service for a significant period of time but they were not yet registered with the CQC. At the last inspection in February 2017 and at this inspection they told us their application was being processed. However we found no record of this being submitted. 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 premises were not well maintained and there were insufficient controls in place to mitigate risks. For example we found windows without restrictors and the risks regarding legionella were not being managed in a way that protected people. Individual risks to people had been identified but the management plan was not always followed by the staff supporting people. For example we identified issues with the use of moving and handling equipment, catheter care and the management of wounds.

Medicines were not managed safely and we did not have confidence in the auditing process as it had failed to identify some of the issues that we found such as people being given the incorrect amount of medication. We found that the stock did not tally with the records and creams and lotions were not being administered as prescribed.

There were systems in place to calculate the numbers of staff needed to meet people’s needs but we found that the service was dependent on agency staff and staff were not always deployed effectively which meant that people did not receive care when they needed it. The service was in the process of recruiting new staff but the issues that we identified at the last inspection about the robustness of the process had not been addressed.

Staff received training but we were not assured about its effectiveness as staff knowledge in areas such as infection control and dementia did not reflect best practice. There was a system of induction for newly appointed staff but we found that new staff were working without sufficient guidance. Checks were not undertaken on staff competency and understanding of what they had learnt.

Some training had been provided on the Mental Capacity Act 2005 and consent. However staff responsibilities were not well understood and the best interest decisions were not accessible or clearly documented within people’s care plans.

Mealtimes were not well organised and people needed more support with eating and drinking.

People’s nutritional needs were assessed and where there were concerns referrals had been made to dieticians. However, the advice given was not always followed and greater monitoring and oversight of people’s intake was needed.

Staff were well meaning and had good relationships with those they supported. However interactions were largely based around the completion of a task and staff did not always promote people’s privacy and dignity. We were not assured that people always received care that took account of their wishes and what was important to them.

Care plans did not provide sufficient guidance to staff on people’s needs. We identified gaps in how people’s needs were monitored and had concerns that information was not always handed over which meant that issues were not addressed promptly. Documentation was not completed contemporaneously and as a result not always accurate.

Activities were provided to promote peoples wellbeing. There was a policy in place which set out how complaints should be managed however none were recorded as received which was contrary to what people told us. The policy was out of date and we could not see that complaints were used to drive improvement.

This service was operating well below the numbers of people for which it is registered. The local authority has been supporting the service to improve over a long period of time. They had placed a consultant within the service to support the improvements, the provider had continued to employ the consultant for a short period but had not continued with this support. It was a concern that the service has failed to sustain some of the improvements implemented with the support of the consultant.

Staff and people spoke positively about the manager and told us that they were assessable and helpful. There were some audits in place but they were not effective as they had not identified the shortfalls that we found. Overall we concluded that there was a lack of management oversight.

During this inspection we identified a number of breaches 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 back of the full version of this report.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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, they 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.

We carried out a focused inspection to the service on the 19 December 2016 to follow up specific and continued concerns about the management of medication. We found the home were not implementing the steps they had identified in their action plan so were continuing to be in breach of the regulation relating to the safe administration of medication.

At the time of our most recent inspection on the 8 February 2017 there were 36 people in residence. 23 people upstairs and 13 downstairs. The home is registered to provide residential care and we told the provider to address their website which refers to nursing care which is not provided at this service.

The home had a manager in day to day charge but they were not yet registered with the CQC but told us their application was being processed. 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.

Overall we found improvements had been made across the home and people were mostly having their needs met. We took into account the history of the service and recent communication from other health care professionals which would suggest this was not always the case. There were continued concerns about the homes ability to meet everyone’s needs in a safe, responsive way. We have received recent safeguarding concerns and over the last six months there have been quite a number of safeguarding concerns some historical about poor care issues, weight loss management, not getting medicines as intended and delayed referrals to health care professionals. Record keeping and assessments of needs have also been a concern. Equally the home has raised safeguards against other organisations who the home have felt have not always been supportive or acting in a timely manner.

At this inspection we found people had been informed of the concerns there are currently about the home and the channels of communication had improved. Staff were aware of how to raise concerns and felt more comfortable in doing so. Risks to people’s safety were being assessed and steps put in place to protect them from the risk. Care was being provided in a building which was intended to be safe and checks were in place to make sure it was.

Staffing levels were appropriate to the needs and numbers of people currently using the service. The staffing ratios were reviewed alongside people’s needs to ensure they were adequate.

People were now receiving their medicines as intended and there were safe systems in place to support this.

We have made a recommendation about training.

Staff recruitment processes could be strengthened to help them be more robust. Staff training and development was ongoing but was beginning to impact on the quality of service being provided and increased confidence of the staff.

We have made a recommendation about staff recruitment and staff induction

Staff had a reasonable understanding of legislation relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. However we found a lot of Dols applications had lapsed which should not happen.

People were supported to eat and drink enough for their needs and staff were knowledgeable about people’s dietary requirements. People’s health care needs were being monitored and mostly met although we had been advised of a number of concerns since the last inspection but this was an area much improved with improved communication between the health care professionals.

Staff were caring and most people were happy with the service provided. We saw staff knew people well and tried to encourage and facilitate their independence. People and their families were more involved in the running of the service and consulted about their day to day needs.

We found the behaviour of some impacted on others and could not see if this was well managed. We noted several people would go into other people’s rooms, even beds and this was clearly unacceptable and meant people did not have full rights to their privacy.

The staff were responsive to people’s needs because they knew them well and there were systems in place to help ensure records were up to date and illustrated any change in need or unmet needs. The care plans were derived from an assessment of need. Everyone had an up to date care plan but this has only been since recently as everyone has had a review of their care.

Activities when provided were well delivered and people clearly enjoyed the company of the activity staff. It is difficult to engage everyone and some people said they chose not to join in activities. It was less clear how their individual and preferred interests were facilitated by the home as some people would require 1-1 support to access the activities

Complaints were recorded and there was more openness and transparency in the home which meant any concerns would be addressed.

The home is currently running with significantly less people than it’s registered for. It is being well managed and staff are receiving direction and support. However this needs to be sustained in order for us to have confidence in the service and its ability to manage people’s care safely.

We found breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 in some regulations. You can see what action we told the provider to take at the back of the full version of this report.

There is currently no registered manager at the service but an interim manager has been appointed. 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 service is registered for 65 older people who require assistance with personal care but due to the suspension in place by the Local Authority the service had less than 40 people at the time of this inspection.

At this inspection we found a continued breach with Regulation 12, Safe care and treatment. We shall be inspecting the service again shortly.

We last inspected this service on the 11 May 2016 to follow up on areas of concerns raised by a whistle blower and to follow up on a number of incidents the service had not told us about. This was a responsive inspection to assess the safety of people using the service. The service was rated requires improvement in safe and a number of breaches of regulation were identified.

In the last eighteen months we have inspected this service on a number of occasions including on the 14 December 2015 when we found the service required improvement in every key area. In addition we identified three breaches of the regulations. We also inspected the service on the 25 November 2015 because we received concerns about people not receiving their medicines safely. We judged that the service was inadequate in the way in which medicines were managed. Following this inspection we placed two sets of conditions on the providers registration, firstly to prevent further admissions until such time as people were safely receiving medication and secondly to require that the provider made improvements to the administration of medication. When we inspected the service in December 2015 we found they had made improvements in terms of their medicines management and we agreed to allow the service to accept new admissions by removing this condition.

There is currently no registered manager at the service but an interim manager has been appointed in the last four weeks and said they would apply for registration with the Care Quality Commission. 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 service is registered for 65 people and had 49 people residing at the service at the time of our inspection with two people in hospital.

Before this inspection we were aware that the Local Authority were investigating a high number of safeguarding notifications, a number were raised by ourselves during the last two inspections to the service. The Local Authority are closely monitoring and supporting the service to help them improve and keep people safe. Whilst the service implements the changes the Local Authority have placed an embargo on the service which means the Local Authority will not place any one there which they fund.

During our inspections on the 6 and the 9 September 2016 we met with the new manager and discussed some of our concerns with them and the provider who is there most of the week. We found the following: The service had sufficient staff based upon its own assessment but not all demonstrated a sufficient understanding of people’s needs. People did not always receive timely care which we attributed to the poor organisation of the shift and delegation of duties. We had concerns about recruitment practices and how robust they were. This was a particular concern with agency staff members.

Staff received training to help them to be effective in their role but this was not sufficiently robust and staff were not effectively supported to develop and reflect on their practices to adequately meet the needs of people using the service.

The service was not effectively managing people’s needs in terms of their health and safety. We saw poor documentation and inadequate staff’s response to the identification and management of people’s health care needs.

Medicines were poorly organised and poorly managed which meant we were not always assured people would receive their medicines as required.

Infection control practices required improvement there were areas of the home which were unclean and mattresses were not always fit for use.

Staff had some understanding of legislation relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found people were restricted and could not move freely within the care home and its grounds. People were supported to make decisions but the rational for some decisions were not always clearly documented. There was no system in place to ensure that people who do not want to be resuscitated can be easily identified in case of an emergency.

People were not adequately supported with their diet and we were not assured staff always acted on the advice given by other medical health care professionals which potentially put people at risk. People were monitored in terms of their food/fluid intake but this was not evaluated and acted upon when necessary.

People’s health care needs were not being met and not being adequately monitored to ensure people got the right support. For example people at risk of unplanned weight loss were not being closely monitored.

We found staff caring but also found staff did not have enough time to recognise individuals needs and provide care in a way which was individualised and responsive. This meant people’s emotional well- being was not always met and people’s physical care needs were not always responded to adequately. This in turn did not uphold people’s dignity or promote their well- being.

The service has a range of different activities to try and help keep people occupied and stimulated. However this is insufficiently planned for and people are not getting their individual needs met.

Pre admission assessments and care plans poorly describe people’s needs and risks are not adequately evaluated. Not everyone was consistently given an assessment of their needs before moving into the service with a corresponding care plan developed. This resulted in compromised care for some.

Recent changes in the management team have occurred but it is too early to judge how effective this will be. We have found a sustained history of non-compliance with this service which we attribute to poor processes in place to identify, assess and monitor the quality of the service provision. Stability in terms of the management of this service and staff retention has also been a contributing factor. Given its previous history, current information of concern and repeated breaches we have rated the service overall as inadequate.

We found multiple breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 in multiple regulations. You can see what action we told the provider to take at the back of the full version of this report.

Following this inspection the overall rating for this service is 'Inadequate' and the service has been placed 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 the 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.

This inspection was also to follow up a number of concerns we had received about the safety and standards of care people were receiving. Information of concern we received related to people allegedly not receiving their medicines as prescribed, staff shortages particularly at the weekends and people not always receiving their care in a timely way. We followed up at this inspection two significant events that the provider had failed to tell us about at the time as is required by law. The events could have resulted in significant harm to people. We only looked at the Safe key question during this inspection.

The service is registered for 65 people. 54 people were living at the service on the day of our inspection. The service has 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. However the registered manager has had a period of extended leave and was not at the service during the most recent inspections to the service. An acting manager was in post.

We carried out a focussed inspection of this service in in November 2015 and found that the provider was not meeting the requirements of the law as they did not protect people against the risk of receiving care or treatment that was inappropriate or unsafe. We judged the service to be inadequate. Following this inspection we placed a number of conditions on the provider’s registration using our urgent enforcement powers. The first was to prevent them admitting anyone else to the service until they had made the necessary improvements. The other condition imposed stated they must always have competent staff to administer medication as during our inspection in November 2015 we found practices around medication administration were unsafe. We carried out a further inspection to this service in December 2015 and found that improvements to the administration of medicines had been implemented, however the service was failing to meet the requirements in all other areas inspected and required improvement. During this most recent inspection in May 2016 we found some improvements in the management of people’s medicines. However, we remained concerned as to the quality of the care provided. The condition on the provider’s registration preventing further admissions to the service was lifted in January 2016.

During this inspection on the 11 May 2016 we carried out a very detailed medication audit and found that staff administering medication were knowledgeable and competent to do so. A number of minor issues were identified for the provider to address and we have issued a requirement notice as we were not assured that people always receive their medicines as intended.

There were enough staff to deliver safe, effective care on the day of inspection. However staff, relatives and people using the service told us this was not always the case and staff shortages recently had led to compromised care at times.

Risks to people were managed but the service was not always proactive in assessing the risk, therefore we were concerned that people may have experienced unsafe care because insufficient actions to mitigate the risks had been taken to ensure their needs were being met safely.

Staff understood their job roles and were able to undertake tasks and report any concerns they might have about the care and welfare of people using the service. However, we identified three staff with a poor grasp of English. They were not able to demonstrate sufficient understanding of how to keep people safe. In addition we found poor involvement and consultation with people and their families about the service provided and how improvements could be made as a result of people’s experiences. Some people and families raised concerns with us which had not already been raised with the service. The service was not sufficiently proactive in identifying how people were and how their care was being managed.

We found several breaches 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 back of the full version of this report.

We have also made a recommendation about what information should be available for new or temporary staff.

This is what we found:

Is the service safe?

During our inspection we looked round the service and saw that most people were in the communal areas and staff frequently checked on people to ensure they were safe.There were no call bells in communal areas but people in their room had their calls bells in easy reach. The care documentation and risk assessments viewed showed us the service took adequate steps to protect people from unnecessary risk in relation to the prevention of falls, the prevention of unplanned weight loss, dehydration and the prevention of pressure sores.

Mental capacity assessments had not been completed for everyone and we could not be sure that staff always acted in people's best interest as this had not always been recorded. Additional training in this area was being planned for staff.

Medication was administered to people safely and there were systems in place to ensure staff had the knowledge and skills to perform this task. Regular medications audits were carried out which meant the service had a system to assess this outcome and ensure staff error was kept to a minimum and people received their medication as prescribed.

Is the service effective?

Since the last inspection improvement to people's records had been made designed to ensure staff knew how to meet people's needs.However not all records were up to date or reflected recent changes in their needs. We spoke with staff and found they all worked at the service permanently and were knowledgeable about people's needs. We saw examples of how staff were trying to meet people's needs but lacked the necessary guidance to meet them well because guidance was not recorded in the care plan. There was a range of social activities for people but these were not available to everyone who might wish to take part because there were not enough staff to support people with activities.

Is the service caring?

Staff were observed speaking kindly to people and providing assistance to people when they required it. People spoken with told us the staff were nice. However we noted staff were focused on task orientated care and we saw little in the way of social interaction with people. One person said 'staff don't have time to stay for a chat anymore.'

Is the service responsive?

We saw staff responding to people's needs and care plans reflecting people's needs but not all were up to date. We saw all members of staff supported people at meal times which meant people got their meal on time.

Is the service well managed?

The service does not have a registered manager and has had a number of staffing changes which has led to some uncertainty and ambiguity about roles and leadership. The service did not respond appropriately to complaints or learn from these as the complaints procedure did not tell people how their complaint would be acted upon or by whom. No records were kept of concerns raised. During our inspection several concerns were raised with us which were fed-back at the time of the inspection. We saw incomplete records from safeguarding concerns raised so could not see how the service investigated and learnt from events affecting people's safety. We saw a lack of monitoring or involving people who use services which meant we could not see how the service was being run in the interest of people using it. Audits did take place but these related to the environment, equipment and medication. Care and record audits were not provided to us.

Staff supervision was not as frequent as we would expect. The manager said they did two formal supervisions a year and annual staff appraisals. However given the number of changes going on to improve the care delivery we would expect close monitoring of staff performance and evidence of staff's competencies to perform their role.

During this inspection we spoke with staff, people using the service, observed the care being provided and looked at six care plans and associated records.

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

Is the service safe? Is the service effective? Is the service caring? Is the service responsive? And is the service well-led?

This is what we found:

Is the service safe?

Although we found improvements to the service, we identified emerging risks for people which had not been identified by the service. People's care plans were not up to date and we could not see from people's records how staff were delivering the planned care to meet their needs.

There were enough staff on duty to meet people's needs and people received appropriate supervision to ensure their safety. However, during our visit a person fell having not negotiated a small step out on to the patio area. The risk had not been assessed.

Is the service effective?

Assessments and plans of care were in place for everyone using the service. However it was not clear whether the information was accurate or reliable because records had not been reviewed or information was not sufficiently recorded to enable us to see how people's needs were being met.

Is the service caring?

Staff interactions were positive and we saw they regularly engaged with people. We noted that eleven people were outside enjoying the sun and were being encouraged to socialise.

Is the service responsive?

Staff were observed responding to people's needs. However we found that care records were not always updated when a person's needs had changed which meant staff might not be aware of the person's current needs or risks to them.

Is the service well managed?

The service is currently improving how it plans, assesses and evidences how it is meeting people's care needs. However we felt that the manager does not yet have adequate systems in place to evaluate the effectiveness of the care they are providing, or to assess whether it meets people's needs.The manager required more time to improve the standard of record keeping and support staff through adequate training. This would enable them to take more responsibility in terms of maintaining adequate records and providing person centred care.

We considered our inspection findings to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? And, Is the service well led?

Below is a summary of what we found during our inspection:

Is the service safe?

When we arrived at the service staff asked us for our identification and asked us to sign the visitor's book. We saw that the door entry system was in place and people were monitored for their safety to ensure they did not leave the service without staff knowing. This meant that unauthorised access to the service was prevented and people were kept safe.

We found that each person had a care plan which told staff what their needs were and how staff should meet them. However we found the care plans did not provide clear information. They had not been adequately reviewed and did not reflect people's current needs or risks so we could not be assured people were receiving the correct care.

Staff had received training in safeguarding vulnerable adults from abuse. However training methods were limited and meant that staff might not recognise all forms of abuse or poor practice. Not all staff were able to tell us what organisations they might contact if their concerns were not addressed by the service. Care staff had not received training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The manager told us this was planned. Staff were clear about how they supported people with day to day decisions but we were unable to see mental capacity assessments for people and formal applications had not been made where people were deprived of their liberty. This meant that people were not protected.

We spoke with staff about the operation of the premises and found there were systems in place to ensure equipment was tested and maintained in good working order. We saw there were sufficient staff to keep the premises clean and cleaning schedules were in place. However we could not be assured that systems were effective because we found strong unpleasant odours in parts of the service, and some hazards for people's safety.

Is it effective?

We found that care was not effective because staff did not have the skills or training to meet people's individual needs. We found training ineffective because there were not systems in place to assess staff competence to see how they applied their learning. We saw that new staff received a basic induction which did not ensure they had key competencies and skills to meet people's needs. We found a lack of systems which enabled the provider to assess the effectiveness of its service and to ensure people's needs were met. For example we saw unsafe medication practices which put people at risk. We saw people's records were not up to date. Assessments to identify risks were not reviewed to ensure steps had been taken to keep people safe. Staff spoken with were not clear about meeting individuals needs and did not input into the care plans reviews or staff handovers to ensure continuity of care.

We found that there was a programme of activities but these were not suited to everyone and did not promote everyone's well-being.

Is the service caring?

During our inspection we observed some good and poor staff interactions which meant that staff were not always responding consistently to people's needs. We found that some staff were familiar with people's needs but other staff were not able to answer our questions about what people needed. People's care records did not show us how staff were meeting people's needs according to their wishes and preferences and records were generic and not individual to the person. We observed staff talking to people without making eye contact and without making themselves understood. We also saw staff pulling people backwards in their chairs and in one instance catching someone's arm on the door without noticing. This showed a clear lack of respect and staff treated people in an undignified way.

Despite these observations several people using the service and their relatives told us they felt that staff were kind and caring.

Is the service responsive?

The service was not responsive to everyone's needs. We carried out observations and saw that some people were left unoccupied throughout the day. The televisions were on but most people were not watching these. We looked at people's records to see what social activities were being offered and found that some people had nothing recorded so we did not know how their social needs had been met and planned for. We saw that health care professionals were involved with the service. However we found that staff were not always identifying risks to people's health and wellbeing which meant that medical advice was sometimes delayed.

Is the service well-led?

We found the service was well staffed and staff received adequate supervision. We observed staff supporting people at meal times and staff appeared to work in a cohesive way. Staff told us they felt supported and said both the manager and deputy manager were approachable and dealt with concerns.

The manager was not registered with the Care Quality Commission and felt they were not effectively supported in trying to improve the service because they were often expected to work on care shifts. We have not received a registered manager application despite the provider recently being fined for not having a manager. This is a breach of the regulations and means we have serious concerns about how the provider leads the service to ensure quality.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This inspection was carried out to assess what the provider had done in response to the action we had told them to take following our last inspection. This was in relation to the safe management of medicines.

This is a summary of what we found-

Is the service safe?

Although we found improvements in the management of medicines since our last inspection, we found the service was not safe because people were not protected against the risks associated with medicines.

We found the provider had improved arrangements for the administration and recording of medicines, but we found medicines were not always stored safely for the protection of people who used the service.

We found that medication records were in good order, provided an account of medicines used and demonstrated that people received their medicines as prescribed. But we found that the use of prescribed creams was not being recorded properly. We were not assured that suitable arrangements were in place to identify and resolve any medication errors promptly.

On this inspection we did not speak with anyone who used the service about the way their medicines were managed.

We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the safe administration, disposal, recording or management of medicines.

During the course of the inspection, we identified safeguarding matters around the safety of medicines administration. A safeguarding matter is where one or more person's health, wellbeing or human rights may not have been properly protected. We have raised our concerns to the local authority safeguarding adults team. The overall review of this matter has not yet concluded.

The provider did not have appropriate arrangements in place to promote effective performance of the service. The supervision process was not sufficient to ensure that staff were supported in their roles. Staff told us that they felt like they could raise concerns to the manager and that those concerns would be dealt with.

We observed positive interactions between the staff and people who used the service. We saw that staff were kind and considerate to people's needs. Two relative we spoke with told us they felt listened to and that communication was open and transparent at the service. People at the service who do not have a diagnosis of dementia did not always feel supported in promoting their independence and community involvement.

The service currently does not have a registered manager in post. The current manager has been in post for more than one year and will be going through the registration process. The management structure had expanded which has enabled the service to be led more efficiently.

Statutory notifications were reported as required by the regulations. We found that the provider had systems in place to ensure the safe management and administration of medication.

We found that records held by the service were not always, accurate, kept securely and could not be located when required.

We found that the required improvements from our previous visit on 02 November 2012 had been made with the storage of samples in the medication store room. We found that the equipment was being appropriately managed. However we did find a sling that was in poor condition and placed on the hoist for one person. This was immediately removed by the manager.

People told us that the service had much improved since our last visit. One person told us, 'I like that the staff are in the lounge, there is always someone there if we need them.' Another person told us, 'I have lots of different people to talk to now.'

People who used the service told us they experienced good care and their healthcare needs were met. People told us the staff were kind, caring and helpful. One person told us, 'It's not like home, but it's the next best thing.' However one person told us, 'It's not as homely as it used to be. Staff had more time for you when it was smaller. Nowadays staff do what they have to do then rush off, no time for a chat.'

We saw that activities were planned for people who told us they were asked what they would like to do. The activities took place in the four main lounges and people go between each lounge and be involved in different activities if they wished.

We saw that some people in the home were mobile and could go between the lounge areas freely and others required assistance. We saw that staff were not present in the lounges to assist the those who required assistance, some people had to wait to go between the living rooms or get assistance with personal care.

We found concerns with the condition of the slings used for people moving and handling techniques. We found concerns with infection prevention and control in the home relating to the storage of samples.