The inspection took place on 25 April and 2 May 2018. The first day of the inspection was unannounced. This meant that the provider and staff did not know we were coming.

We last inspected the service on 16, 21 August, 18, 19 September and 2 October 2017 and at that time identified breaches in nine of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were related to safe care and treatment; person centred care; dignity and respect; safeguarding people from abuse and improper treatment; premises and equipment; good governance; fit and proper persons: directors; requirements where the service provider is a body other than a partnership and requirements relating to registered managers.

During this inspection we found improvements had been made and most of the matters we identified at the previous inspection had been addressed. As a consequence of these improvements the service remained in breach of only one regulation relating to good governance.

Allison House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Allison House accommodates 38 people in one purpose built building. At the time of our inspection there were 29 people using the service.

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.

Risks to people were assessed and plans put in place to reduce the chances of them occurring. Regular checks were made of the premises and equipment to ensure they were safe to use. Accidents and incidents were monitored to see if improvements to people’s safety could be made. Plans were in place to support people in emergency situations. Infection control practice had improved.

Policies and procedures were in place to safeguard people from abuse and any safeguarding referrals were now being made appropriately.

The registered manager monitored staffing levels to ensure enough staff were deployed to support people safely. The provider’s recruitment process minimised the risk of unsuitable staff being employed.

Systems were in place for the management of medicines so that people received their medicines safely. Arrangements were in place for recording the administration of oral medicines however, some further improvements were needed in the guidance for covert administration and the records and guidance for medicines prescribed ‘when required’.

A programme of redecoration and refurbishment had begun around the service. Improvements had been made to make the environment more suitable for people living with dementia.

People’s nutrition and hydration needs were met and special dietary requirements were appropriately catered for. People were given more support to make choices at mealtimes. Staff plated up meal choices and showed these to people so they could make their choice.

The majority of staff were up to date with all mandatory training and staff were supported with regular supervisions and appraisals.

People were supported to maintain their health and wellbeing. People's care records contained evidence of visits and advice from a variety of health professionals.

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.

Relatives were very happy with the care their loved ones received. Staff treated people with dignity and respect.

Care plans were based on people’s assessed support needs and preferences. This included information

This inspection took place on 16, 21 August, 18, 19 September and 2 October 2017. On some visits the staff and people using the service did not know that we would be carrying out an inspection of the service. In order to obtain the information we needed for other visits we announced that we would be visiting.

The service was previously inspected in June 2016 and was not meeting two of the regulations we inspected. These related to staff training and good governance. We took action by requiring the provider to send us action plans telling us how they would achieve compliance. When we returned for this inspection we found some of the issues identified had been addressed but others had not.

Following the first two days of this inspection we had a number of concerns which were shared with the provider. We invited them to submit an interim action plan but this was not received. During our visits we were also alerted by the local authority and Clinical Commissioning Group (CCG) to concerns they had following a joint visit. In response to these concerns we carried out a third day of inspection on 18 September which was unannounced. The registered manager was not available on 18 September and some information was inaccessible therefore we returned on 19 September 2017. Following our visit on 19 September 2017 we wrote to the provider outlining our findings and the concerns they raised. We again requested an action plan and following receipt of this, two inspectors visited the service on 2 October 2017 to review progress and complete the inspection.

Allison House provides accommodation, nursing care and support for up to 38 people living with dementia. The service is single storey and purpose built around a secure central garden and seating area. There are a number of communal areas around the building including four lounges and three dining rooms.

The service had 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.

Staff training had improved since our last inspection. Staff were up to date with most training, however, 20 out of 54 staff were in need of refresher training in dementia awareness.

The system of audits in place was still not effective. The issues we found during the inspection had not been picked up by the checks being undertaken by the manager and senior staff.

We looked at the arrangements in place for the management, storage, recording and administration of medicines. There were discrepancies and unexplained gaps on people’s medicine administration records and prescribed creams were not being marked with a date of opening. Records relating to covert administration of medicines were not clear.

The service had safeguarding and whistleblowing procedures in place. Staff knew how to identify signs of abuse and told us they would report anything they were concerned about. However, incidents of a safeguarding nature were not always reported to the local authority or the Care Quality Commission.

Checks of the building and maintenance systems were undertaken however when repairs were needed these were not always undertaken in a timely manner. Fire doors and emergency lighting that were identified as faulty were not replaced or repaired as a matter of urgency with some remedial work taking up to five months. We observed a window in one of the bathrooms had no restrictor in place. This was a large window which was very easy to access and opened wide enough to climb through. The manager told us they would ensure restrictors were fitted to all windows and when we returned to the service we found this had been done.

Individual risk assessments were not in place for all recognised areas of risk and some recor

We inspected Allison House on 8 and 22 June 2016. The first day of the inspection was unannounced which meant that the staff and registered provider did not know that we would be visiting. We informed the registered provider of the second day of the inspection. The service was last inspected in July 2014 and was meeting the regulations we inspected at that time.

Allison House provides care and accommodation for up to 38 people and / or older people living with a dementia. The home is purpose built and offers all ground floor accommodation. The service is built around a quadrangle with a large garden and seating area in the centre, which people who used the service can access safely and securely. At the time of our inspection visit there were 38 people who used the service.

The home had 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.

We looked at the arrangements in place for quality assurance and governance. Quality assurance and governance processes are systems that help providers to assess the safety and quality of their services, ensuring they provide people with a good service and meet appropriate quality standards and legal obligations. We were shown numerous checks which were carried out. However from looking at the health and safety inspection we could not determine the actual checks that were taking place. Staff had identified areas for improvement, however we could not determine if action had been taken. The care plan audit did not include looking at the care plans of all people who used the service. The medication audit was insufficiently detailed as it didn’t include a check on systems and although the service did an annual assessment of infection control there was no other auditing in-between.

Records looked at during the inspection indicated that not all of the staff were up to date with their training and that some staff had not received training in areas such as behaviour that challenged since 2012.

Staff had not always consistently received supervisions and appraisals were out of date. However, the registered manager had developed a plan to address this.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. People subject to DoLS had this clearly recorded in their care records and the service maintained a good audit of people subject to a DoLS so they knew when they were to expire. However, mental capacity assessments were not decision specific. Best interest decisions were recorded in some care plans but not all.

Systems were in place for the management of medicines so that people received their medicines safely. However, the room in which medicines were stored on occasions was too warm. If medicines are not stored at the correct temperature they can lose effectiveness.

Care plans were varied and some contained more information than others. The registered manager told us they were in the process of reviewing the care plans of all people who used the service.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People were weighed and nutritionally screened. The service used the Malnutrition Universal Screening Tool (MUST) to assess people. This is an objective screening tool to identify adults who are at risk of being malnourished.

There were systems and processes in place to protect people

Some of the people who used the service had dementia and other conditions which made it difficult for them to express their opinions or recall recent events. Because of this we observed the way staff and people interacted. We also spoke to six relatives and five of the home’s staff, to help us understand what it was like for people living at the service.

Are services safe?

The service had systems in place to assess risk and monitor health and safety. This included risk assessments related to the care of individuals and health and safety checks related to equipment and premises. People were also protected by incident and accident analysis and monitoring, which helped to identify trends and any actions needed to maintain people’s safety.

Systems were in place to ensure that medication was stored safely and that people received the medication they needed. However, we identified some areas for improvement relating to the recording of some medications.

Staffing levels were safe and maintained at levels appropriate to the needs of the people living at the service.

Are services effective?

People told us that they were happy with the care delivered. Comments made to us included “Generally very good, my (relative) is always clean and tidy” and “They try to make (relative) look nice, do their hair and nails.” We observed that people looked cared for. Where needs had been identified in people’s care records we were able to see that these were being met by staff. For example, the use of pressure relieving equipment to help maintain skin integrity.

Are services caring?

We saw that people looked cared for and observed staff treating people kindly. One relative told us “They always have time for you.” Another said “They all know my relative, you can tell they are paying attention.” Staff we spoke with demonstrated a good awareness of dementia care and were able to tell us how they tried to meet people’s individual needs.

Are services responsive to people’s needs?

People’s needs had been assessed and care plans put in place which detailed people’s needs and preferences. These records provided guidance to staff on what care and support was needed. The records we looked at also showed that people’s needs were regularly reviewed, to help identify any changes to their care needs.

We observed staff responding kindly to people’s requests for assistance during our visit. This included responding promptly to the call bell or sensor alarms, when people were spending time in their bedrooms.

Are services well-led?

The home had a registered manager, who was supported by the Trustees and the provider’s administrative systems. Audits and checks were completed regularly to monitor the quality of service provision. There was also regular input from the Trustees, including visits to the service.

Relatives and staff told us that they were able to talk to the staff and management and felt they were listened to. One relative commented “The staff are so nice and they always have time to talk to you.” Another relative commented “If you have any problems they listen to you and sort it out.”

We carried out this inspection because the last time we visited Allison House we had concerns about the privacy and dignity of people. We were concerned that people were not encouraged to make choices. For example people were not asked if they would like drinks, given a choice of drinks, asked when they wished to go to the toilet or where they would like to sit. Additionally we found that a significant number of staff were not up to date with their mandatory training. This meant that there was an increased risk that people who used the service could come to harm, or receive inappropriate care and support.

At this inspection we found that people were encouraged to make choices for themselves and encouraged to remain as independent as possible. People were also treated with respect and their dignity maintained.

Staff who worked at Allison House had been provided with a number of different training opportunities to enable them to complete their mandatory training. All staff had undergone supervision recently and further regular and frequent supervision sessions were scheduled.

People who used the service received care which on the whole met their physical and mental health needs. Pre placement assessments were carried out and risk assessments and care plans were written and reviewed regularly to ensure that they contained up to date information.

There was sufficient well maintained equipment in the service to ensure that people’s independence and safety were maintained.

The service carried out audits and had a quality assurance process in place, which involved people and their relatives to ensure that quality standards were maintained.

Staff who worked at Allison House were not up to date with all of their mandatory and specialised training. Additionally, they were not receiving regular supervision every two months as specified in the organisation policy.

Staff who worked at Allison House did not always ensure that they maintained the dignity of people. People were not always given choices about aspects of their daily lives and staff sometimes made assumptions about what people wanted without first asking. Additionally, some staff did not communicate with people, empathise with them or explain to them what they were doing when delivering care. This meant that sometimes people became distressed unnecessarily and staff did not react appropriately to manage the distress.

People who lived at Allison House received care and support which protected their safety and welfare because their needs had been assessed and care plans devised to manage risks. Where people were deprived of their liberty, this had been done following correct procedures and best interest decisions were properly documented.

Records relating to people had improved and on the whole, were accurate and had been reviewed regularly. There were still some improvements needed in the recording in daily records but other records contained enough detail to ensure that people were cared for appropriately.

Most of the equipment used within the service was checked, maintained and serviced regularly to ensure its safety however there were a number of pieces of electrical equipment used within the service which had not had annual electrical testing carried out.

We spoke with one relative during our inspection. She told us that the staff and the manager were very supportive and always listened to any concerns she had. She also told us that she was always kept up to date with the condition of her relative. She said “I’ve had nothing to complain about and I’ve always found that there are enough staff and I know she is getting well looked after.” She added, “She’s always clean and always nice.”

Because people with dementia are not always able to tell us about their experiences or express their opinions, we have used a formal way to observe people’s experiences of living in the home and their interactions with each other and with staff. We call this the Short Observational Framework for Inspection (SOFI). We also spent time observing activity within Allison House where we did not use the formal structure of SOFI. Both of these methods allowed us to understand better the experiences of people who lived at Allison House.

Throughout our observations we saw people being treated with dignity, respect and courtesy. We saw that staff were able to communicate with people who used verbal and non verbal communication. Staff smiled at people and asked them how they were. They also waited for people to respond and then acted according to their responses. We observed that one lady responded that she wanted to go home and became agitated. Staff comforted the person and also tried to engage her in activities as a way of distracting her. We saw that this helped the lady.

We observed staff during meal time in one of the dining rooms. Over the lunchtime we saw that people were given choices with food and drinks. We also saw that staff noted when people hadn’t eaten much of the meal they had chosen and offered alternatives such as sandwiches with different fillings and fruit.

In addition, we saw that some people needed assistance with their food and three people needed staff to feed them. We saw for two people, one member of staff sat and took time to engage with the person they were helping. They encouraged the person and made eye contact often. Both they and the people they were assisting were focussed on each other and the food. This was positive and showed that the members of staff knew how to engage with the people they were assisting and made sure that they had good experiences.

We did however observe another person being assisted to eat, but two different care staff took turns to help. On this occasion the experience for the person being assisted was not positive and staff were not focussed on giving assistance or encouragement.

During our observations we saw that staff engaged with people and tried to encourage them to take part in activities. We also saw that staff explained to people what was happening to them and were discreet when helping people with personal care needs. We saw that staff had a good rapport with the people they provided care for and knew them well.

We spoke to the relatives of three different people using the service. They told us, “The home is smashing. I’m very pleased with the home. The ambience feels right, it feels like home.” Relatives also told us, “The staff talk to me all the time about what’s going on with my relatives care. I’m able to talk to staff about any changes to care that are needed.”

Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people’s experiences of living in the home and their interactions with each other and the staff. We call this the ‘Short Observational Framework for Inspection' (SOFI). We undertook a period of observation in the lounge of the Aspen unit during the morning and in the dining room of the Willow unit over lunch.

Throughout the observation, we saw staff treat people with respect and courtesy. We observed staff taking the time to talk to people using the service and engage them in pleasant conversations. Some staff frequently smiled at people to offer reassurance and spoke clearly and at a steady pace with people. They held or touched people who were distressed and disorientated and this seemed to provide comfort to people.

However, we saw some interactions that staff could have handled more appropriately. On one occasion, two staff members asked a person using the service to come with them. They did not explain where they were going, and did not reassure the person when they became distressed and agitated at not understanding the request. We also observed some staff members feeding a number of people at the same time over lunch. This meant they did not focus on the individual needs of the person they were assisting. In addition, staff did not always explain what they were going to do, before they did it. This meant they did not always provide appropriate support, encouragement and assistance to help the person eat and drink.