This inspection took place on 8 May 2018 and it was unannounced. We last inspected Alma Green on 20 February 2017. At that time we found five breaches of the Health and Social Care Act Regulations 2014. These were in relation to; need for consent; safe care and treatment around the management of medicines and the control of risks; safeguarding service users from abuse and improper treatment; meeting nutritional and hydration needs and good governance.

Following our last inspection we asked the provider to complete an action plan to show us what they would do and by when to improve the key questions safe, effective, caring, responsive and well led to at least good. At this inspection we found the provider had made the improvements required in accordance with their action plan, so the key questions of caring and responsive were found to be rated good. However, during this inspection we found two breaches of the HSCA 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment and good governance. Therefore, the key questions of ‘safe’ and ‘well-led’ remained as, ‘Requires improvement.’ There were several recommendations made in the area of ‘effective’ and therefore this key question also remained as ‘Requires improvement.’

Alma Green Residential Care Home (Alma Green) 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.

Alma Green is located in the village of Upholland. It provides accommodation for up to 29 people, who require help with their personal care needs. At the time of our inspection there were 23 people who lived at Alma Green. All bedrooms are of single occupancy with en-suite facilities, consisting of a wash hand basin and toilet. A wet room is available and there are a variety of bathrooms located throughout the home, which provide assisted bathing facilities.

There are a variety of amenities within the village itself, such as public houses, shops, a library, a church and a post office. The surrounding areas of Southport, Ormskirk, Liverpool, Wigan and Skelmersdale are all within easy reach by public transport. Some parking spaces are available at the front of the premises.

There was a registered manager in place. The registered manager assisted throughout the 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.

We toured the premises and found several areas of risk, which needed to be addressed. Infection control practices were poor. The kitchen and kitchen equipment were dirty and needed to be thoroughly cleaned. We noted the kitchen was being used as a thoroughfare for staff, who were not wearing Protective Personal Equipment (PPE). The storage of food in the fridge did not meet food hygiene standards. This could have put people at potential risk of consuming contaminated food.

The cleanliness of the premises throughout was poor and the environment was in need of updating and modernising. We noted some mattresses were longer than the bed bases and could pose a risk to people if they sat on the end. We noted some concerns around fire safety in relation to seating areas beneath stairwells and the lack of relevant information provided on the Personal Emergency Evacuation Plans (PEEPS).

During the inspection we observed staff transferring people on two occasions. One manoeuvre was by the use of a hoist. This was conducted in a competent and safe manner. The second transfer was with the use of a lifting belt for a person who was unable to weight bare. This manoeuvre was not safe and could have potentiall

We last inspected this service on 10 September 2015, when we found the service to be in breach of four regulations.

During this inspection we reviewed the action taken by the provider to meet the requirements of the regulations, these included; medicines management, environment safety and infection control. Person-centred care, Need for consent, Meeting nutritional and hydration needs and good governance.

At this inspection we found the provider was still in breach of Regulation 12 safe care and treatment, in relation to medicines management and Regulation 11 Need for consent. The provider was no longer in breech of the other regulatory requirements highlighted at the last inspection. However, we found the provider to be in breach of other regulations at this inspection, these included; Person centred care and Safeguarding service users from abuse and improper treatment. .

Alma Green is located in the village of Upholland. It provides accommodation for up to 29 people, who require help with their personal care needs. All bedrooms are of single occupancy with en-suite facilities, consisting of a wash hand basin and toilet. A wet room is available and there are a variety of bathrooms located throughout the home, which provide assisted bathing facilities.

There are a variety of amenities within the village itself, such as public houses, shops, a library, a church and post office. The surrounding areas of Southport, Ormskirk, Liverpool, Wigan and Skelmersdale are all within easy reach by public transport. The bus stops very close to Alma Green and there is a railway station nearby. Some parking spaces are available at the front of the premises.

At the time of the inspection there were 26 people who lived at the service. There was a registered manager in place. The registered manager assisted throughout the 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.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found that staff had received training in safeguarding adults and demonstrated a good understanding about the meaning of abuse. However, we found that the service had not always made safeguarding referrals in line with their policy and procedure. For example, one person’s care records showed that they had been physically assaulted by another person who lived at the service. A safeguarding referral had not been made, risk assessments had not been reviewed in relation to the incident and the registered manager told us that they had not been informed about the incident.

We looked at people’s care records in relation to the prevention of accidents and injuries. We found examples of when people who lived at the service had fallen. However, their care plans and risk assessments for falling had not been updated to show how the service had assessed and mitigated the risk for further accidents to prevent injury.

During the inspection we observed staff using a hoist for a person who had fallen in their bedroom. We asked staff if the person had been assessed for the use of a hoist and staff could not confirm if an assessment had taken place. Staff assisting the person were unable to clarify what size hoist sling the person needed. This placed the person at risk of injury. We informed the registered manager who took immediate action.

Risk assessments were in place for the premises and these were audited on a regular basis.

We found variances in stocks of medicines. This suggested that medicines had not always been administered as prescribed. The service did not have a robust monitoring system in place to highlight when medicines had not been administered. We found that the servi

Alma Green is located in the village of Upholland. It provides accommodation for up to 29 people, who require help with their personal care needs. All bedrooms are of single occupancy with en-suite facilities, consisting of a wash hand basin and toilet. A wet room is available and there are a variety of bathrooms located throughout the home, which provide assisted bathing facilities. There are a variety of amenities within the village itself, such as public houses, shops, a library, a church and post office. The surrounding areas of Southport, Ormskirk, Liverpool, Wigan and Skelmersdale are all within easy reach by public transport. The bus stops very close to Alma Green and there is a railway station nearby. Some parking spaces are available at the front of the premises.

We last inspected this location on 10 February 2014, when we found the service to be compliant with all five outcome areas we assessed at that time.

This unannounced inspection was conducted on 10 September 2015. The registered manager was on annual leave when we visited Alma Green. She had managed the day-to-day operation of the service for several years. 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 of the Health and Social Care Act and associated regulations about how the service is run.

Some areas of the premises had been recently decorated. However, other areas of the home were in need of upgrading and redecorating. Infection control practices could have been better.

Medications were not being well managed. This did not promote people’s safety and could have potentially put people at risk of harm.

People were helped to maintain their independence. Staff were kind and caring towards those they supported. Assistance was provided for those who needed it in a dignified manner and people were enabled to complete activities of daily living in their own time, without being rushed. However, the provision of leisure activities could have been better, so that people who lived at Alma Green were supported to maintain an interest in a variety of hobbies or pastimes.

The planning of people’s care was based on a thorough assessment of their needs, with information being gathered from a variety of sources. The care plans we saw were well written, person centred documents. A range of health and personal care assessments had been conducted. However, the hydration needs of one person were not being appropriately monitored and another person was not enabled to make their own decisions about their care and treatment, despite being assessed as having the capacity to do so.

There were sufficient numbers of staff on duty to meet people’s needs. Staff members were well trained and had good support from the management team. They were confident in reporting any concerns about a person’s safety and were competent to deliver the care and support needed by those who lived at the home. The recruitment practices adopted by the home were robust. This helped to ensure only suitable people were appointed to work with this vulnerable client group.

Equipment and systems had been serviced in accordance with the manufacturers’ recommendations, to ensure they were safe for use. This helped to promote people’s safety.

Staff we spoke with told us they received a broad range of training programmes and provided us with some good examples of modules they had completed. They confirmed that regular supervision sessions were conducted, as well as annual appraisals.

Staff spoken with told us they felt well supported by the registered manager of the home. They spoke in a complimentary way about her management style and described her as being, ‘approachable’ and ‘caring’.

We found the service to be in breach of several regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in respect of safe care and treatment, good governance, need for consent and meeting nutritional and hydration needs.

You can see what action we have asked the provider to take at the end of this report.

During our visit to this location we spoke with six people who lived at the home and three visiting relatives. Everyone provided us with positive comments. They told us their needs were being met by a kind and caring staff team. They felt the home was well managed and they were able to make decisions about the care and support they received.

Comments received included:

"They (the staff) are more than helpful. I cannot grumble about any of them."

"They are excellent. They always put themselves out for us."

"I don't get bored. They bring singers in sometimes to entertain us. We are playing bingo this afternoon."

A relative commented, "It is fab here. This is not like a care home. It is like a family home. The staff are very kind, caring and helpful."

At the time of this inspection we looked at how people's needs were being met and how they agreed to the care and support provided. We also assessed the management of medications, recruitment practices and methods used for monitoring the quality of service provided. We did not have any concerns about any areas we assessed on this occasion.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined joined by a practising professional and an Expert by Experience who has personal experience of using, or caring for someone who uses this type of service.

We also 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 using the service told us they were satisfied with the care and support they received at Alma Green. We found they were treated with dignity, their independence was promoted and privacy respected. They told us, “It’s lovely and clean. They clean everyday", “Our visitors can come anytime and we go to my room for some privacy” and “If you tell the staff anything it gets done straight away”. However, some people said they were bored and would like more activities and entertainment.

Some people told us they liked the meals provided at the Alma Green. However a few were dissatisfied with menu and the choices offered. People’s food preferences were known and consideration was being given to people's individual nutritional needs. Although there was no evidence of risk from a lack of nutrition, we found the catering arrangements did not fully respond to people’s needs and preferences.

We found there was mostly enough staff to provide care and support. People were content living at Alma Green; they knew what to do if they had any concerns and were confident they would be dealt with.

One person recently admitted to Alma Green Care Home told us that she had been visited prior to admission and asked about her needs and requirements. This person also said that the “care is very good” and that she felt “quite settled and happy here”.

People living at the home who we spoke with told us that they were aware of their person care plan and that staff did discuss with them how their needs could be best met. We were also told by one person that staff, “Always help you when you need it, you need to feel safe and I do, I am quite happy with everything”.

During the course of the visit we spoke with five residents and one relative. We also spoke briefly with a number of other people living in the home in a communal area of the home. Without exception people using the service and the relative all spoke very highly of the care and support provided at Alma Green. We were told that, “I like living here, I am well looked after, we are looked after very well” and “The care here is very good, I am quite happy with everything”. Another person said, “Staff are very good, excellent with us. Joanne (Registered Manager) sets a high standard that staff have to follow; staff go beyond their bounds of duty”.

People living at Alma Green stated that they enjoyed the meals served and the variety of the foods provided. One person said, “It’s good food, I don’t think I leave anything”. Another person said “I enjoy the food. You only need to say that do not like or want the menu choice of the day and they ask you what you would like instead. Nothing is too much trouble”.

One person living at Alma Green told us, “They are definitely good at getting the doctor out if you don’t feel well, they do something straight away”.

People living at Alma Green that were spoken with, all stated that they felt safe living at the home and had no concerns. We were told that people were confident that if they did have any concerns this would be swiftly acted on. There was however a lot of praise for the staff team and the level of care and support offered at the home. One person told us “There is no place like home, but the nearest is here”.

People living at the home told us that the internal environment was always kept clean and tidy. One user of the service told us that “The cleaners are very good, they keep our rooms clean. This is one of the best homes, always clean and sweet smelling”.

One person said that she was quite happy for staff to administer her prescribed medication.

People spoken with that live at the home described Alma Green as ‘homely and comfortable’. Another person told us that she really enjoyed the walk in shower and confirmed that her privacy and dignity was always respected. This same person went on to say, “I don’t mind any of them they are all respectful” (the staff group).

One person told us that following her admission, a specialist bed had been purchased by the home to assist with her breathing. This had been much appreciated and had helped to ease the condition for this person.

A person living at the home stated, “I am very happy here, the staff are wonderful”. A member of staff spoken with confirmed that a thorough recruitment process had taken place prior to her taking up employment at the home and that “A very good service is provided, I think it is excellent. Joanne (registered manager) does her up most to make people’s lives easier and happier, staff and residents”.

Two members of staff spoken with stated that in their experience, there was always a sufficient number of staff on duty to meet the assessed needs of people living at the home. This was also confirmed by residents with one person telling us “There is always enough staff we never have to wait long”. Staff spoke positively about the training provided.

Without exception people spoken with, including the relative, were very pleased with the care and support provided and stated they had no need to make a complaint about anything. One person living at the home said, “My son made a good choice with this home, is 5* in more ways than one”. Another person said, “I know how to make a complaint and there is a post box if I want to write anything down but I have never made a complaint or needed too. If I did need to I would just speak with a member of staff or Joanne (Registered manager). Staff would always respect and respond to what I said”.