About the service: Albany House – Tisbury is a residential care home, registered to provide personal care for up to 19 older people. At the time of the inspection, 15 people were living at the home.

People’s experience of using this service:

At our previous inspection of Albany House – Tisbury, the service was rated as Requires Improvement. There were four breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were because people’s needs were not assessed when they were admitted to the home. Care plans were not developed in a timely manner. The care plans did not include enough information regarding people’s preferences, risk assessments and risk related records, and medicines administration. People had not been consulted with about their care, to gain their informed consent. Mental capacity assessments were not always completed where required. Also, staff training, and supervision meetings were not up to date.

At this inspection we found that there were some continued shortfalls at the service, as well as identifying other concerns. There was a failure to take timely and appropriate action to address concerns raised at previous inspections and to ensure that there was a managerial oversight monitoring the improvements. Because of this, the service is now rated as Inadequate for Safe and Well-Led, and this makes the service Inadequate overall.

The registered manager had a vision for the future of the service, however did not have a plan on how to achieve this. The lack of planning had resulted in continued areas for improvement, which had not been addressed. The registered manager felt they had been working in an insular manner and that they needed some peer support to understand how to better manage the service. The registered manager did not take accountability for their legal responsibility to lead improvements at the service. They shifted blame to staff and to the nominated individual. However, they had not discussed with staff or the nominated individual a plan of action and who should be accountable for what.

There were quality assurance systems in place to monitor different areas of the service, however these were not being used at all or utilised effectively. The registered manager had a quality assurance system to monitor the whole home. They informed us they had read the information however we saw that the audits involved had not been completed or followed up.

There were records of accidents at the home. However, a monitoring system to identify patterns and trends was only implemented after this was raised with the registered manager on day one of the inspection. One incident was not recorded in the accident log, and this meant that any overview would not give an entirely accurate picture of the service.

Medicine administration records contained gaps in records, without reasons for this recorded. Medicine audits were in place but were not being completed consistently. This meant that previously identified shortfalls had continued, and improvements were not always sustained.

The medicines fridge was not locked. The medicines policy and CQC guidance states that this should be locked and stored in a locked room. The room was accessed by staff who are not responsible for medicines administration. There was potential for people living with dementia who may not understand the risks associated with medicines stored in the fridge. We saw that the room was unlocked and open at times where no staff were present. The fridge temperatures were not consistently recorded daily to ensure creams and insulin were stored at safe temperatures.

Staff continued to not receive supervision meetings with their senior or the registered manager in a timely manner. The registered manager told us they aim for each staff member to have six supervision meetings per year. Supervision meeting records evidenced that this was not being achieved and some staff did not receive more

At the last inspection in May 2016 we found breaches of legal requirements. We asked the provider to take action to make improvements to key questions that relate Safe, Effective, Responsive and Well Led. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Regulations 9 Person Centred Care, Regulation 11 Consent to care, Regulation 12 Safe care and Treatment, Regulation 17 Good Governance and Regulation 18 Staffing.

This is the second consecutive time the service has been rated Requires Improvement.

Albany House supports up to 21 older people and some of whom were living with dementia. At the time of the inspection there were 19 people living at the service.

This inspection was unannounced and took place on 8 and 9 November 2017.

A registered manager was 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.

Medicines administration systems were not safe. Procedures were not in place for medicines to be taken “when required” (PRN). Medicine Administration Records(MAR) showed people were having PRN medicines. Medicine care plans for some people included people’s preferences on how they liked their medicines to be administered. Medicine administration records (MAR) charts were signed by staff to indicate the medicines administered.

Risks were not always identified and there was no guidance to staff on how to minimise potential harm to people or to help them take risks safely. Risk management procedures were not up to date. The risk assessments were not updated for people who fell frequently and there was no action taken to prevent further falls for example, referrals for specialist support such as falls clinic. Where people were refusing food and fluid there were no formal systems to assess their deteriorating health. We found monitoring charts were not consistently completed or analysed and risk assessments were not developed on supporting these individuals with hydration.

Formal arrangements to assess and monitor service delivery were not in place. Quality assurance systems were not in place. Records were not up to date and staff acknowledged that the recording of information needed to be improved. Policies and procedures were outdated and were based on legislation that had been replaced. Accidents and incidents were documented but not analysed to identify trends to help staff prevent a reoccurrence of the accident.

Where people had cognitive impairments their capacity for care and treatment was not assessed. Relatives and friends without Lasting Power of Attorney (LPA) had consented to care and treatment. Where it was documented that LPA was in place the type was not identified. Covert medicines were being administered without the appropriate framework being in place. The staff knew the day to day decisions people were able to make.

People’s needs were not assessed before their admission to the home. Care plans were not developed on how to meet people’s needs and lacked person centred approach. We saw where staff had documented they were supporting people with personal care but care plans were not developed. People were not supported to develop plans about their future wishes for their end of life journey.

The staff knew the types of abuse and the expectations placed on them to report abuse. However, the training certificates showed only two staff had attended safeguarding training.

Staffing levels were well maintained but there were staff vacancies which meant agency staff were being used.

Arrangements were in place to maintain a clean environment and we found the home

Albany House – Tisbury provides care and support for up to 21 people some of whom may be living with dementia. At the time of the inspection, 19 people were resident at the home.

The inspection took place on 4 May 2016 and was unannounced. We returned on 5 May 2016 to complete the inspection.

The service had a registered manager who was responsible for the day to day running of the home. 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 did not follow the requirements set out in the Mental Capacity Act 2005 when people lacked the ability to give consent to living and receiving care at Albany House.

Staff did not receive sufficient appraisal and supervision to support them to carry out their work as effectively as possible.

Staff members said they felt sufficiently trained. However the registered manager did not have a training record in place, which meant some staff training had not been updated.

People’s care plans did not always contain the most up to date information to enable staff to be responsive to people’s needs. Information within care plans was sometimes contradictory and associated risk assessments had not always been completed.

The registered manager of the service worked as part of the care team on a daily basis but this left little time for managerial duties. The service did not have fully effective systems in place to evaluate and improve the quality of the service.

People and their relatives spoke highly of the care at Albany House. Comments included “We like everything about this place” and “We are blessed. The staff are always lovely.”

People and/or their relatives said they were able to speak with staff or management if they had any concerns or a complaint. They were confident their concerns would be listened to and appropriate action taken.

People were protected from the risk of harm and abuse by trained staff who knew how to recognise abuse and what actions to take, to keep people safe.

People’s medicines were managed and administered safely. Medicines were securely stored in line with current regulations and guidance. We found prescribed creams and lotions were not always recorded, when applied.

Staff were genuinely concerned about people’s well-being. Staff knew the people they were caring for including their preferences and personal histories. People were supported to follow their preferred routines.

We looked at five people's care records. We found the provider had improved each section of the records. People had relevant risk assessments appropriate to their needs. Care plans were person centred and overall included sufficient information for staff to provide safe, effective care.

We spoke to staff who were confident in their knowledge of people's needs. We observed the care described was in line with people's plans of care.

The provider had implemented a new system for recording essential patient information staff needed to be aware of. For example changes in a patient's health or specific care instructions. This ensured staff were responsive to changes in people's care and were able to implement guidance provided by other healthcare providers such as GP's.

We spoke to seven people who used the service. We did not ask the same questions of people because some of them had dementia which made it harder for them to express their views. At the time of the inspection there were 19 people living in the home.

We observed and were told people were involved in decisions about their care. We were also told consent was obtained before care was given. Staff worked in the best interests of people with diminished capacity in line with guidance from the Mental Capacity Act 2005.

People we spoke with told us they were satisfied with their care. One person said " it's wonderful. They're very willing to help. They're very good." We observed staff who were patient and caring. They were knowledgeable about the people they looked after.

We found all areas of the home were clean. People we spoke with were satisfied with the cleanlines of their rooms. Staff wore clean neat uniforms and appropriate personal protective equipment as necessary.

We saw the provider had an effective system to ensure people received appropriate support and care provided by other health care services.

We found people did not have plans of care which reflected their identified needs. The care records did not provide sufficient detail to enable staff not familiar with people to provide safe effective support. We found specific assessment of risk for example risk of pressure ulcer development had not been reviewed regularly for people identified as high risk.

We carried out this inspection to review improvements following our visits of 4 January 2012 and 8 May 2012.

When we visited in January 2012 and May 2012, there was no manager in place. A new manager had now been in post for seven weeks, and we found significant improvements in the way the service was run. The manager is now registered with us.

Three relatives told us how pleased they were with the improvements made by the manager. People who used the service told us they were pleased with the new activities provided and liked the new choice menu.

The manager had reorganised the system for holding people’s money with proper recording and audit.

The manager had looked at the appropriate use of bedrails. We saw records of consultation with the person and relevant healthcare professionals.

We saw from the manager’s quality audits of the service and facilities, together with an action plan, that progress was being made to address improvements for people who use the service.

Following our inspection of 8 May 2012 we took enforcement action against the provider for breach of Regulation 23 (1): Supporting workers. This was because the provider had not made suitable arrangements to ensure that persons employed received appropriate training and supervision in relation to their responsibilities to deliver care to people safely. The provider wrote to us to say a new manager had been appointed and four training courses had been arranged.

We saw, from the manager’s action plan, staff meeting minutes, supervision notes and supervision diary, suitable action had been taken to address the breach. Members of staff told us they felt very well supported by the manager and told us about the training they had undertaken recently.

We haven’t been able to speak to all of the people using the service because some of them had dementia which made it harder for them to express their views. To find out what daily life is like for people who had dementia at Albany House - Tisbury we used the short observational framework for inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

People who did speak to us told positive things about the service and the staff. We were told “this is a wonderful home”. “The staff are very very good”. “The carers are lovely girls”. “I would not want to live anywhere else”.

People had their needs met in friendly and caring way by the staff. We saw staff spending time listening to people and talking to them in a warm manner.

People benefited because they each had a care plan that showed in basic detail what support they required to meet their needs. However the care plans did not fully show how to meet people's needs. The care plans failed to include guidance information about how to support people with specific mobility needs.

People were being cared for by staff who kind and supportive in their manner. However the staff were not being properly supported and supervised in their work. Staff were also further hindered in their work by a significant lack of any suitable training and development opportunities to help them improve their skills. During our visit we saw evidence that staff did not have the right skills’ and knowledge to care and support people effectively.

Before we carried out our review of the home we had been made aware of concerns that had been raised about the service. We did not directly investigate the concerns because the powers given to us by parliament do not include the statutory authority to carry out investigations into complaints. However, we used the information to help guide the process we followed to carry out our inspection of the home. We also used the information to inform our judgments of the overall quality of outcomes for people who use the service.

Everyone we spoke with said that they were very happy with the care and support provided. One person told us "they are very good with attention. I press the call bell if I need to. If I'm not very well I tell them. I've been taken to the clinic. I'm very well looked after. I have a bath when I want, when they are available." Another person said us "I like it here. We get treated very well. I'm looked after very well. The food's very good, we are very well fed."

The registered manager had been on compassionate leave since the beginning of December 2011 and resigned following our inspection. Although the deputy manager was over seeing the day to day running of the service, they were only working part time. The provider was making weekly visits.

The care plans and other records had not been regularly reviewed during the manager's absence. The quality assurance audit only looked at questionnaires to people and their relatives. There was no action plan and no recent audit of all the systems and services provided.

Training and supervision had not been carried out since the manager's absence.

Members of staff engaged very well with people and it was clear from talking with people who use the service that good relationships were established.