This inspection took place on the 6 & 7 February 2018. The first day of the inspection was unannounced which meant the home were not expecting us on the first day of the inspection.

Our last inspection of the home was carried out 25, 26 and 31 May 2017. At that inspection we rated the service as ‘Requires Improvement’ overall and for the domains of responsive and well-led. We rated the home as ‘Inadequate’ for the safe domain and ‘Good’ for the domains of effective and caring. At the last inspection we found the home to be in breach of five regulations of the Health and Social Care Act Regulated Activities Regulations 2014. These were Regulation 9, Person-centred care, Regulation 12, Safe care and treatment and Regulation 17, Good governance, Regulation 18, Staffing and Regulation 19, Fit and proper persons employed. At this inspection we found the home had met three of the previous regulation breaches, however were still in breach of Regulation 9 and Regulation 19. We also found the home to be in breach of Regulation 14 meeting nutritional and hydration needs. We have made a further six recommendations for areas needing further improvements.

We saw evidence of enough improvements made to show that the home was no longer rated as ‘Inadequate’ in any of the domains and therefore the home was removed from special measures. The overall rating of the home remains as ‘Requires Improvement’.

The home is situated in Skelmersdale and is easily accessible by public transport. The home provides nursing or residential support for up to 66 people. Nursing care is provided on the top floor of the two story building with the ground floor area supporting people mostly living with dementia. At the time of our inspection there were 56 people living in the home.

Each floor has a lounge and dining room and a smaller quieter lounge used mostly for activities. The kitchen and laundry facilities are on the ground floor of the building and each floor is accessible by a lift and stairs.

Aaron Crest Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

There was a manager in place at the time of our inspection who was in the process of registering. 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 had systems in place to record safeguarding concerns, accidents and incidents and take necessary action as required. Staff had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices.

Risk assessments had been developed to minimise the potential risk of harm to people during the delivery of their care. These had been kept under review and were relevant to the care provided.

Staff had not always been recruited safely and in line with the home’s recruitment policy.

Staff were appropriately trained and supported. They had skills, knowledge and experience required to support people with their care and social needs. However formal support in the form of supervisions and appraisals were not, at the time of the inspection, routinely carried out.

Medication procedures observed protected people from unsafe management of their medicines. However processes did vary between the two floors of the home and needed to be made consistent.

Staffing levels were seen to be sufficient to meet the assessed needs of th

We inspected this service on the 25, 26 and 31 May 2017. The first day of the inspection was unannounced.

The home was last inspected in January 2016 where six breaches to the regulations were identified. Warning notices were issued for Regulation 12, Safe care and treatment and Regulation 14, Meeting nutrition and hydration needs. Four other Regulations were found to be in breach which included issues with the delivery of person centred care, issues with staff support and recruitment of staff and issues with the governance at Aaron Crest Care Home.

The home is situated in Skelmersdale and is easily accessible by public transport. The home provides nursing or residential support for up to 66 people. Nursing care is provided on the top floor of the two story building with the ground floor area supporting people mostly living with dementia. At the time of our inspection there were 56 people living in the home.

Each floor has a lounge and dining room and a smaller quieter lounge used mostly for activities. The kitchen and laundry facilities are on the ground floor of the building and each floor is accessible by a lift and stairs.

Within recent years Aaron Crest has had a number of managers and interim managers, which have impacted on service delivery. At the last inspection the registered manager was on maternity leave and a temporary manager had been in post for nearly a year. Following that inspection the registered manager resigned and after a period a new manager was found who registered with the commission. After a relatively short time in post they also left the organisation for a variety of reasons. For the three months prior to this inspection different regional and quality managers have been in post. More recently an interim manager was appointed to address areas of concern identified by the quality director and until a suitable permanent manager could be appointed. The new manager will register with the commission. As a consequence the home has seen a period of instability which is now being addressed. The provider informed CQC prior to the inspection that they had anticipated more work had been done to meet the requirements of the regulations. The Home's Improvement plan was further developed to account for any ongoing actions. We have been given assurances by the provider’s senior management team that they are working to address concerns and we could see that steps had made in that direction.

At the time of the inspection the home did not have a registered manager. An interim manager was in place whilst the home secured an appropriate manager to register with the 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.

A new management structure had begun to implement systems to better support the staff and ensure the processes and procedures required for good management of the home were followed. This was a work in progress and the instability of previous management teams had led to a staff led culture as opposed to a manager led culture. The senior leadership team were aware of this and were taking steps to address this.

The warning notice issued at the last inspection for the poor management of medication and for not managing and mitigating risks to people had not been met. We found that the management team were aware of the issues around medication management and had implemented protocols, action plans and increased audit to manage the risk. However staff were not following the protocols, implementing the action plans or routinely completing the audits. We saw the management team were taking disciplinary action against the staff involved and in the three weeks prior to the inspection had attempted to identify where a

We inspected this service on the 7, 20 and 21 January 2016. The inspection was unannounced on the 7 January, after the first day the provider knew we would return shortly after to complete the inspection.

The home was last inspected in September 2014 where we followed up on breaches identified at the previous inspection in June 2014. We found the home was meeting the regulations we inspected in September 2014.

The home is situated in Skelmersdale and is easily accessible by public transport. The home provides nursing or residential support for up to 66 people. Nursing care is provided on the top floor of the two story building with the ground floor area supporting people mostly living with dementia. At the time of our inspection there were 61 people living in the home.

Each floor has a lounge and dining room and a smaller quieter lounge used mostly for activities. The kitchen and laundry facilities are on the ground floor of the building and each floor is accessible by a lift and stairs.

The home had a registered manager who had returned from an extended period of leave on the second day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the time of the inspection all people living with dementia had an initial capacity assessment under the Mental Capacity Act 2008. In two files we also saw a number of decision specific assessments to support best interest decisions made to support people with specific support needs. We did find that some of this paperwork was inconsistent and contained some contradictions but steps had been taken to support people under the legal requirements of the Act. The provider assured us a monitoring exercise would be completed to ensure the paperwork was accurate and relevant to the individuals.

We found a significant reduction in formal staff support in the 12 months prior to the inspection. This included formal supervisions and appraisals, team meetings and the structured deployment of staff to support people living in the home. We found systems and procedures had not been followed or effectively monitored for some time which had led to concerns noted in the management of medicines and support for people who may be a risk of falls.

People living in the home had not been effectively supported with their nutrition and hydration with more people requiring support than those identified by the home. We also found some people who required regular eye tests had not had them and half of the people we noted to require glasses for watching television were not wearing them.

Not all the staff that had been recruited recently had all the information in their personnel files required under schedule 3. Schedule 3 identifies the requirements employers registered with the Care Quality commission need to take to safely recruit staff. This included assessments to determine if anyone required additional and suitable adjustments to better support them in their employment.

The home had two activity coordinators who worked to provide group and one to one activities for the people in the home. We saw two group activities taking place over the course of the inspection. Some people told us they would like more to do. We discussed the role of meaningful activity with people living with dementia and the manager told us they had recently completed the Kings fund dementia environment survey and had submitted improvement plans to the provider which considered meaningful activity. Once approved this would greatly increase the quality of people’s life in the home.

We found people’s care plans were written in a person centred way but they were not always reviewed regularly and changes at point of review or as nee

During the course of this inspection we gathered evidence against the outcomes we inspected, to help answer our five key 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. The summary is based on our observations during the inspection, speaking with those who used the service, their relatives, support staff and the manager and from looking at records.

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

Is the service safe?

At the time of our visit to this location, we toured the premises and found the environment to be fit for purpose. It was safe, well maintained, clean and hygienic. The service was consistently monitored and the safety of those who lived at the home was constantly promoted. Therefore, people were not put at unnecessary risk.

People we spoke with told us they felt safe whilst care and support was being delivered and they, or their relatives had been involved in making decisions about the care and support provided.

Is the service effective?

The personal. health and social care needs of those who used the service had been assessed before a placement was arranged. A variety of external professionals were involved in their care and treatment and specialist dietary needs had been identified, where required. This helped to ensure people were receiving the health care support they required.

Policies, procedures and practices adopted by the home supported effective service delivery for those who lived at Aaron Crest. This helped to ensure the staff team delivered appropriate care and treatment in accordance with people's needs.

People's needs were taken into account enabling them to move around freely and safely. It was evident that visitors were able to see people in private and visiting times were flexible.

Is the service caring?

We asked those who lived at the home about the staff team. Feedback from them was very positive. They said staff were kind and caring and we observed members of staff speaking with people in a respectful and friendly manner. People's preferences and interests had been recorded and care and support was provided in accordance with people's wishes.

Is the service responsive?

Staff were seen to be responding to people well by anticipating their needs appropriately. The service worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

In discussion with the managers of the home it was clear the staff team had worked hard to improve the service since our last inspection. Records showed that areas for improvement had been identified by the monitoring processes in place and opportunities to change things for the better were promptly addressed. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the managers of the service. People living at Aaron Crest and their relatives completed annual satisfaction surveys. Where shortfalls or

concerns were raised, these were taken on board and dealt with appropriately.

During the course of this inspection we gathered evidence against the outcomes we inspected, to help answer our five key 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. The summary is based on our observations during the inspection, speaking with those who used the service, their relatives, support staff and the Area Manager and from looking at records.

Some of those who used the service were unable to communicate with us verbally. However, we were able to speak with five of them and two relatives. The responses to the questions we asked were mixed.

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

Is the service safe?

People we spoke with told us they felt safe living at Aaron Crest. Safeguarding procedures were robust and staff had received training in this area. Systems were in place to help managers and the staff to learn from untoward incidents, such as safeguarding concerns.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Applications were in the process of being made. This helped to ensure people were not being unnecessarily deprived of their liberty. People (or their relatives) were involved in making decisions about the care and support provided.

At the time of our visit to this location, we toured the premises and found the environment to be fit for purpose. It was safe, clean and hygienic. Equipment was well maintained and serviced regularly. Therefore, people were not put at unnecessary risk.

Is the service effective?

There was an advocacy service available if people needed it, this meant that people could access additional support, if they needed to. The health and personal care needs of those using the service had been assessed, with a range of people involved in their care and support.

Systems were in place to ensure the service was assessed, so the quality of service provided could be consistently monitored. Records showed and the majority of staff confirmed that a range of training modules were provided for staff, with regular mandatory updates. However, the training matrix displayed a mixture of dates in the future and in the past, which made it difficult to determine who had done which training course.

Is the service caring?

We asked those living at the home about the staff team. Feedback from them was, in general positive. They said staff were kind and caring towards them and helped them to meet their needs.

People's choices and preferences had, in general been recorded. However, although some good information had been documented, the plans of care seen varied in quality. Some were very brief, which failed to provide person centred information or clear guidance for staff about people’s assessed needs, or how these were to be best met. One person staying at the home on respite care did not have a care plan in place and therefore staff had not been provided with clear instructions about the support this person needed. A relative commented, “Most of Mum’s needs are met.”

Is the service responsive?

It was not evident that activities within the home were provided in accordance with people’s wishes and preferences. On the day of our visit most people were sitting in-front of the televisions. However, some were having their hair done and others were having manicures.

The service worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by senior personnel. People living at Aaron Crest and their relatives completed satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately. One relative commented, “It ticks a lot of boxes here, but not all the boxes.”

We undertook a responsive inspection following information received by the Care Quality Commission (CQC). We specifically wanted to look at information to ensure everybody living at Aaron Crest had their support needs appropriately assessed and the home were meeting people’s needs on a daily basis.

We completed two SOFI (Short Observational Framework for Inspection) assessments. SOFI assessments were used to get short snapshots of information around the opportunities someone has to interact with their environment and people around them. The framework assesses the quality and type of interactions people were involved in.

The assessment observed people coughing, clearing their throat and drinking alone. Two people had a risk assessment in place stating they should be observed and supported when eating and drinking. This meant people who were potentially at a risk of chocking were left unsupported.

We looked at peoples care file information and saw that assessment and risk management strategies were sometimes difficult to follow. One person had two moving and handling assessments in their file but none were dated. Each assessment told of differing support needs. The assessments had not been reviewed for some months and as reviews simply stated no change it was difficult to ascertain this person’s current support needs.

Since our last inspection visit to this service, we have been told about a number of concerns and incidents involving the way medicines were handled, administered and recorded. This visit was carried out in order to see how medicines were managed by the service.

We spoke with a senior care worker and the Registered Nurse on duty about how medicines were managed on the two different units.

Nobody we spoke with expressed any concerns about their medicines; however we found errors and discrepancies in the records on the nursing unit that meant people had not always been given their medicines correctly.

Overall we found that people were not fully protected against the risks associated with the unsafe management of medicines.

When we visited the home we observed how staff interacted with the people that lived there. We found staff were helpful to people and took into account each person’s specific circumstances. One person living in the home said, “No-one assumes anything and they (staff) ask every time if and when I need support.”

We spoke with people living in the home about the level of support they required and whether they felt the appropriate level of support was given. One person told us, "The carers are first rate, can’t fault them on anything they do for me. They are there whenever I need them and always have a smile on their face.”

We ate lunch with the people living in the home and asked them how their dietary preferences and needs were met. One person told us, “I don’t like onions and garlic and I’m never given any food that these are in. I’m not allergic to them or anything, I just don’t like them, and it’s never been a problem.”

We spoke to people living in the home about the staff that cared for them. One person told us, “Every member of staff is pleasant and look after me well but (staff member) is something else, they make me feel like they really care for me as if I were a family member, now you don’t get that everywhere.”

We spoke with people about their opportunities to feedback to the manager about how their support was provided.One person said, “I can always get the support I need so don’t ever have any reason to grumble.”

We spoke with seven people who lived at the home, who all provided us with positive comments about what life was like at Aaron Crest.

Those we chatted with told us their privacy and dignity was consistently respected and they were supported to maintain their independence. They also said their needs were fully met by a caring staff team, who ensured their safety was always protected.

Comments received included:

"The staff are just great. They work so hard and such long hours and yet they always have a smile on their faces and a cheery word."

"It is fine living here. I have no complaints."

"They (the staff) are lovely. Nothing could be done any better. It is A1."

"I am totally happy here. Everything is spot on. Put it this way, I wouldn't want to be anywhere else. It is marvelous."

We saw that whilst some people do not have capacity to make informed decisions, staff still take time with them and explain things to them.

People who use the service told us staff treat them with dignity and respect. They told us they take with them and help them with personal tasks. One person told us, “they can’t do enough for us, they are very patient”.

" We always make sure people are up to date with their health checks"

"I am due to have a follow up at the hospital soon, the staff remind me when its due"

" They don’t do anything before they ask me about it, and I am the one who makes the decisions".

" They talk to me about my relatives condition and keep me updated".

“We have training to support people with dementia”

"It can be a strain at times when there are fewer staff on duty".

" We do get stretched at times".

People told us they liked the choice of activities and that the activity co-ordinator was "very good at her job".

"They have a good choice of things going on, if you want to join in you can but if you don’t they leave you alone".

Staff told us they like the new filing system as they can find current information at a glance and know it is up to date for that person. Staff said they are encouraged to look at the information regularly so that they are up to date with any current event affecting that person.

We spoke to the cook who has many years experience, they told us they have many years experience in preparing meals for people in residential care and has a good understanding of the nutritional needs of people.

" I have been doing this for a long time".

"I get all the information I need from the manager and staff, some people are on special diets and I manage those".

"The meals always look nice"

"We have a good choice"

Staff we spoke to told us they have a good relationship with the local doctors, district nurses, and social workers. " We use a local surgery but sometimes people still have their own doctor especially if they are only here for a short period of time".

" Social Workers regularly come in and see their clients, we have a good relationship with them and they are always there for advice".

Staff we spoke to told us they have received training in safeguarding people. "We all get the training, its part of the induction, but then there is more formal training later on" Other staff told us they have received training in safeguarding people and managing challenging behaviour, however they felt they would benefit from training in restraint, as this is sometimes an issue in the dementia unit. " We have a policy to say we can't restrain people, but sometimes its needed especially when residents hit out".

Other information we received told us some people are not happy with the way individual safeguarding issues have been managed and that there has been a lack of communication and notification of information in some instances.

People we spoke to told us they thought the home was very clean and did not have any offensive odours. "They have a lot to do but its always very clean", "I like to flick a duster around my room".

Staff we spoke to told us they have specific duties to carry out in respect of maintaining the homes cleanliness. " I have had training in infection control and we have the policies and procedures to follow".

"We share the cleaning between each floor"

We saw people being given their medication. Staff were following safe practices in the way they administer and record medication.

"I have my tablets given to me by the staff. They wait with me until I've taken them all"

Staff we spoke to told us they have received training in medication practices before they were allowed to administer medication.

People we spoke to told us they like the home, and the way its laid out

" I like my room, I have got everything I need"

" It's very spacious, I can move around easily"

Staff we spoke to said they find it a nice environment in which to work, especially now most of the refurbishment work has been done.

" It's really pleasant to work in, its bright and the furniture is really nice"

Staff we spoke to told us they receive training in the use of various pieces of equipment as part of the induction programme, so that they can use them safely. They also told us they receive training in health and safety.

" We get the training in using the adaptations when we start working here"

People we spoke to said the staff were very courteous and helpful.

"they try and do the best they can", "Some of them have been here for a long time", "I think they are a lovely lot, they are so helpful".

We spoke to some of the staff, they told us they thought in general it was a good place to work. They told us they like the variety of work in the home.

The staff spoke to told us they went through a thorough recruitment check before starting work in the home. They told us they had been interviewed before working in the home and that their previous experience in care had been taken into account.

" I had all the checks done before I started working her"

"we have good access to training and we are encouraged to go on courses"

Staff we spoke to said they felt in general there is a good staff team who work well together. They said each shift has a good skills mix, and that the communication between them is good. "we are told of any changes when we come on shift".

Some staff told us they feel they can be 'stretched' at times.

" Its hard to make sure peoples needs are being met, when we are short staffed"

" Sometimes we have to rush things, and we can't be everywhere at the same time".

People told us they thought the staff team knew what they were doing. They told us they had confidence in the staff, and felt they had the skills to carry out their roles.

We observed instances where staff were engaging with people and saw they had good communication, were sensitive to peoples needs and treated them with respect.

Staff we spoke to told us they felt supported by the management team, and that they received regular supervision and appraisal.

"I had a good induction, which was overseen by the manager at the time"

"I have supervision with the manager and it all gets recorded, I feel really supported"

"We are encouraged to talk to the manager about things".

The staff told us they informally get the views of people just by talking to them. " People usually tell us what they think about the service, sometimes it comes from the relatives"

"Residents with dementia can't express their thoughts, but you get to know when they aren't happy about something, usually by their behaviour"

People we spoke to told us they felt confident they could raise an issue of concern or complaint to the manager if they felt they needed to. "I think if I wasn't happy with something it would get sorted out"

"I have a copy of the complaints procedure, which I would use if I needed to"

Staff told us they are aware of the complaints procedure and make sure people know about it.

Information we received told us some people have not been satisfied with the way the home has investigated complaints and how they have communicated with people.

People we spoke to were aware they had care plans and written information about them.

"the staff talk to me about my care and they write it up so they know what I need"

" We are involved in writing up care plans and other records and we make sure they are confidential so the information is not available to anyone".