This unannounced comprehensive inspection took place on 13 and 15 September 2017.

When we inspected the service in June 2016, there was not always sufficient numbers of staff to support people safely, and mental capacity assessments were generic and did not always identify what specific decisions the assessments related to. Additionally, staff did not feel supported, valued and listened to. At this inspection we found improvements had been made and the service provided to people was now safe, effective, compassionate and of good quality.

The service provides care and support to people with a range of care needs including those with chronic health conditions, physical disabilities, dementia, learning disabilities and mental health conditions. At the time of the inspection, 38 people were being supported by the service.

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

People were safe because the provider had effective systems to keep them safe, and staff had been trained on how to safeguard people. There were individual risk assessments that gave guidance to staff on how risks to people could be minimised. People’s medicines were managed safely and administered in a timely way by trained staff. The provider had effective recruitment processes in place and there was sufficient numbers of staff to support people safely.

Staff received effective training, support and supervision that enabled them to provide appropriate care to people who used the service. The requirements of the Mental Capacity Act 2005 were now being met because people’s ability to make decisions about their care and support was appropriately assessed. People were supported to have enough to eat and drink, and to access various health services when required.

Staff were kind and caring towards people they supported. They treated people with respect and as much as possible, they supported people to maintain their independence. People were happy with how their care was provided and they valued staff’s support. People made decisions and choices about how they wanted to be supported and staff respected this.

People’s needs had been assessed and they had care plans that took account of their individual needs and preferences. Care plans were reviewed regularly or when people’s needs changed. Staff were responsive to people’s needs and where required, they sought appropriate support from healthcare professionals. The provider had an effective system to manage people’s complaints and concerns.

There was now stable leadership of the service, and staff felt well supported and their contributions recognised. The provider had systems to assess and monitor the quality of the service and they explored ways of further improving the quality of the service in order to enhance people’s experiences of care. They also encouraged feedback from people, relatives and staff to enable them to continually improve the service.

We carried out an unannounced inspection on 9 June 2016.

The service provides care and support to people with a range of care needs including those with chronic health conditions, physical disabilities, dementia, learning disabilities and mental health conditions. At the time of the inspection, 41 people were being supported by the service.

During our inspection in May 2015, we had found the provider needed to improve the cleanliness of the home and equipment, and their quality monitoring processes had not always been used effectively to drive continuous improvement. We found they had made the required improvements during this inspection.

There was no registered manager in post, but a new manager had started the process to register 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.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised. There were systems in place to safeguard people from risk of possible harm. The provider had effective recruitment processes in place, but some staff said that there was not sufficient numbers of staff to support people safely. They felt that they had to rush how they supported people and were not able to spend quality time with each person.

Staff received regular supervision and they had been trained to meet people’s individual needs. They understood their roles and responsibilities to seek people’s consent prior to care being provided. However, staff did not always ensure that the care of people who did not have capacity to consent to their care or make decisions about some aspects of their care was managed in line with the requirements of the Mental Capacity Act 2005 (MCA).

People were supported by caring, friendly and respectful staff. They were supported to make choices about how they lived their lives. People had adequate food and drinks to maintain their health and wellbeing. They were also supported to access other health services when required.

People’s needs had been assessed, and care plans took account of their individual needs, preferences, and choices. They were involved in reviewing their care plans and were supported to pursue their hobbies and interests.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people who used the service, their relatives, staff and other professionals, and they acted on the comments received to improve the quality of the service.

The provider’s quality monitoring processes were now being used effectively to drive continuous improvements. Although staff told us they had seen positive changes in how the service was being managed, they did not feel well-supported and valued.

We carried out an unannounced inspection of this service on 5 and 14 November 2014. A number of breaches of legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to providing person centred care, dignity and respect, the need for consent, safe care and treatment, safeguarding people from abuse and improper treatment, ensuring people had sufficient to eat and drink, staffing and good governance. We undertook this inspection to check that they had followed their plan and to confirm that they now met the legal requirements.

The service provides accommodation and nursing care for up to 68 people living with physical needs, mental health care needs, dementia, and learning disabilities. The service is divided into five units, four of which are on one site and the fifth unit, Atwell House, is located a five minute walk away. At the time of the inspection, there were 47people being supported by the service.

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

Some areas of the home had not been cleaned to an appropriate standard.

Staff had received further training so that they appropriately recognised and reported concerns about people’s safety. There were detailed risk assessments in place that gave guidance to the staff on how risks to people could be minimised.

People’s medicines were managed safely and administered in a timely manner.

People were asked for their consent before care was provided.

Staff supervision, support and training had improved to enable them to support people well. Further training had been given so that staff had the skills and knowledge to support people with complex needs. However, this needed to be embedded so that the improvements were sustained.

People were supported to have sufficient food and drinks in a caring and respectful manner. They were also supported to access other health and social care services when required.

People’s needs had been assessed, and detailed care plans were now in place and they took account of people’s individual needs, preferences, and choices.

People were supported to pursue their hobbies and interests.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people or their representatives to improve the quality of the service.

People’s care records were now held securely within the service.

There were improvements in the provider’s quality monitoring processes. However, these needed to be fully embedded, understood and implemented by all the staff. This was necessary so that improvements made were sustained.

During this inspection, we identified a breach 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 the report.

During our visit to Alicia Nursing Home on 8 April 2013, we observed a friendly environment, with positive interactions between staff and residents. People looked relaxed and well cared for, and we saw staff took time to talk with people.

We spoke with five people living at the service, one relative and five staff on duty during our visit on 8 April 2013. Due to some people's dementia needs, not everyone was able to tell us about their experiences. We therefore used a number of methods to help us understand the experiences of people using the service, including observation and talking with people's relatives and care staff. The relative that we spoke with told us, " I can't fault it. They provide great care. It's second to none."

We found that people's capacity to consent was recognised where appropriate and where people lacked capacity, this was identified appropriately and formally recorded. One person told us, " I'm free to enjoy myself in my own way, staff give me a choice and ask what I want."

We saw there were careplans and relevant risk assessments in place and these were updated or reflective of the care delivered in practice. This meant that people were consistently receiving the support that they needed.

We saw that staff had a good awareness of the Safeguarding of Adults and knew the correct process for reporting any issues or concerns they had. We noted that this practice was backed up with formal training and education.

During our visit to Alicia Nursing Home on 19 December 2012, we spoke with people about the care and support they were given. People told us they were happy with their environment, the care provided and support they were offered. One person told us," I am happy living here, it's good and the staff are kind to me." Another resident said, " I like being here, I am given time to do what I want and to make my own choices, I love it."

Due to the complex needs of some people, we also spent some time observing people and saw that they were actively engaged in activities of their choice and at a level that was appropriate to them. On the day of our visit, some people had been supported to attend the day centre to participate in making Christmas cards or engage in art and craft activities. One person said, " I really enjoy what is on offer."

Staff were respectful in their approach to people and treated them with dignity and respect, addressing people in a manner that was appropriate to them. People told us that they were content with how staff treated them and that there was a friendly atmosphere within the home. Relatives were encouraged to be involved in people's care reviews and were kept updated with any changes in conditions. There was evidence of joint working within care planning so that individual and cultural needs were respected.

During our visit on 19 January 2012 people told us that they liked living in the home as the staff support them to be as independent as possible. They said that the staff always treated them with respect and kindness.People told us that they were involved in the reviews of their care plans and they had been involved in the initial assessments prior to them moving to the home.

One person told us that they were involved in the stakeholders group which discussed issues relating to the running of the home. They said that they often showed people around the home when they came to look around with a view to moving in themselves or when looking for somewhere for a relative to move to. They had also been involved in the recruitment of new staff.

We spoke with a family member who was visiting and they told us that they were very happy with the care provided to their relative. They said that the staff kept them informed about how their relative was and that they always obtained medical care for them when it was needed. One person told us that, "The staff are all really good, I would tell the manager if they weren't but I have never had to in six years". Another person told us, "The staff are lovely, we don't have to wait long when we ring the bell".

People also told us about how much they enjoyed the activities organised at the day centre which was situated within the home. Each day a programme of activities was available for people to join in if they wished to. They told us about a range of activities that had included trips to Blackpool, the London Eye, local wildlife parks. In addition to this there had been 'themed days' with celebrations of different cultures.

We carried out an unannounced inspection at Alicia Nursing Home on 5 November and 14 November 2014.

At our last inspection on 08 April 2013 we found the service was meeting all the expected standards of care.

Alicia Nursing home provides accommodation with nursing and personal care for up to 68 people with physical and mental health care needs including dementia, learning disabilities and ongoing mental health needs. At the time of our inspection there were 62 people living at the service. The home is divided into five units, four of which are on one site, and the fifth unit, Atwell House, is located a five minute walk away.

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

People were not protected against the risks of receiving care that was inappropriate or unsafe and care was not planned or delivered to meet people’s individual needs. Medicines were not administered safely.

There were sufficient numbers of staff on duty but they did not all have the skills and experience to support people’s needs well.

People were not protected from abuse because staff failed to recognise and report concerns appropriately. Risk assessments failed to provide information on how to reduce the risks and promote people’s independence.

The induction process was not effective, staff training was not all kept up to date, and many staff lacked the skills and knowledge to support people’s complex needs.

People’s nutritional needs were not met. Sufficient quantities and choice of suitable food was not always available. Staff did not consistently provide dignified, appropriate assistance to people during meal times.

People’s dignity and confidentiality were not upheld and they were not asked for their consent before care was provided. Many staff did not demonstrate respect for people. People’s individual needs were not always recognised and met. This was particularly the case for people who had complex needs or who were unable to communicate their wishes verbally.

The manager understood the requirements of the Mental Capacity Act (2005) and the associated Deprivation of Liberties Safeguards.

Systems to assess and monitor the quality of the service were not effective and leadership in the home was not effective. People’s records were not held securely.

During this inspection we found the service to be in breach of several of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.