About the service:

Alston View Nursing and Residential Home is a care home that accommodates up to 49 older adults, some who may be living with dementia or mental health needs and require nursing care. At the time of the visit there were 45 people who lived there.

People’s experiences of using this service

People told us that they received safe care and treatment. People and their relatives spoke positively about the care and support provided. However, our findings showed improvements were required to ensure the care delivered was consistently safe, reliable and person-centred.

In the majority of cases people’s needs had been assessed and planned for and people’s outcomes had been identified. However, we found shortfalls in the care records and risk assessment for people who had been admitted for a short term stay or as part of a hospital discharge plan. Risk assessments had not been adequately completed and reviewed. The registered manager took immediate action to address this.

The registered manager and the registered provider had ensured the premises were maintained and any faults rectified. They had also completed audits to monitor the safety and quality of care provided.

Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. However, individual risks to people and the environment had not been adequately monitored to ensure measures were put in place to manage them and minimise the risk of avoidable harm occurring. Risks associated with falls and malnutrition had been managed. However, post falls observations had not been carried out. The infection prevention and control practices in the home needed to be improved.

Governance arrangements were in place to check, monitor and improve the care delivered. However, we found the audits and quality checks had not been adequately implemented to support the registered manager and the provider in identifying shortfalls.

While people’s medicines were safely managed, improvements were required to the safe storage and management of topical medicines such as creams.

Staff had received a range of training and support to enable them to carry out their role safely. However, staff training had not been consistently monitored. There were shortfalls in the provision supervision, appraisals and competence checks to staff.

Consent records were completed, and people told us they were always offered choice and control over the care they received. However, authorisations for restrictions on people’s liberties had not been considered or applied for where required. The registered manager took action after our inspection.

While staff showed a motivation to deliver care in a person-centred way, we found some practices in the home did which did not consistently support a dignified and person-centred approach. This was because people’s preferences for getting up and washing and dressing in the morning were not always followed.

People received support to maintain good nutrition and hydration and their healthcare needs were understood and met.

People and family members knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly.

The leadership of the service promoted a positive culture within the staff team. People, family members and staff all described the registered manager as supportive and approachable. The registered manager showed they were committed to improving the service and displayed knowledge and understanding around the importance of working closely with other agencies and healthcare professionals where needed.

Rating at last inspection: At the last inspection the service was rated good (published 22 July 2016).

Why we inspected: This was a routine planned comprehensive inspection.

Enforcement: We identified four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around the m

Alston View is registered to provide accommodation, nursing and personal care for up to 49 people and is owned by MPS (Investments) Limited. At the time of our inspection on 14 March 2016 there were 39 people living at the home: 21 people requiring nursing care and 16 requiring residential care. The home is located in the village of Longridge where access to local facilities are within walking distance. Alston View is a modern home with accommodation on three floors. All of the bedrooms are en-suite with the exception of two single rooms. A small car park is available for visitors. There are communal lounges and a dining room as well as toilets and bathroom facilities. A kitchen and laundry are located on the ground floor.

Alston View is required to have a registered manager. At the time of our inspection there was an acting 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. Our records showed that the acting manager's application to be registered with the Commission had been received, and was being processed.

During our last inspection on 30 September 2015 the service was rated as inadequate and was placed in 'Special Measures'. We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Safe Administration of Medicines for which we issued the provider with a warning notice in respect of this breach.

During this inspection we found improvements had taken place in the way medicines were administered and managed. Medicine audits were now effective. Incidents and accidents were now properly monitored, and when these needed to reported to external agencies, we found that this had taken place. The home now had a staff member who took overall responsibility of infection control measures. Staff now received sufficient training and supervision in order to perform their work effectively. People’s needs were being met, and these needs were reflected in their improved care records. Management record keeping was improved, and the governance systems operated within the home were now a lot more robust. The systems and processes to record, assess, analyse and mitigate risks and promote people’s well-being were now being followed.

The service had made improvements in many areas including the way they reported on, responded and dealt with safeguarding incidents and risk.

Employees were asked to undertake checks prior to employment to ensure that they were not a risk to vulnerable people; records relating to these checks were complete. Risks associated with, infection control and cleanliness, and environment factors were assessed.

The service had policies in place in relation to the Mental Capacity Act 2005 (MCA) and depriving people’s liberty which were put into practice. The building was found to be in a good state of repair, and the environment was found to be fit for purpose. The service had procedures in place for dealing with allegations of abuse. Staff were able to describe to us what constituted abuse and the action they would take to escalate concerns.

People were able to express their choice in relation to meals and how they spent their time. The menu offered people a choice of meals and their nutritional requirements were met. People knew how to access the complaints process, and knew who to talk to if they wanted to raise a concern.

There was a wide range of policies and procedures in place which provided staff with clear information to guide them on good practice in relation to people’s care. We found written evidence to show that the acting manager had an appropriate system in place used to assess and monitor the quality of the service. Surveys were sent out to all th

The lead inspector for the service undertook an unannounced inspection to the home after we received information of concern from a whistle blower. The information we received raised concerns about staffing levels at the home, and the welfare and safety of people living there. The whistle blower suggested that due to the staffing levels, service users were potentially being put at risk, as staff were not always able to respond to people's needs. When undertaking the inspection we observed practice within the home, spoke to the home's manager, and reviewed a number of records relating to the operation of the service. We also spoke at length with four members of staff regarding the role and the operation for the service. We looked to gather evidence to help answer five questions: Is the service safe, caring, responsive, effective and well-led?

Is the service safe? People who use the service were not always protected from the risks associated with unintentional poor practice, because the provider had not taken reasonable steps to identify the possibility of unintentional poor practice taking place. The registered person did not have an effective system in place to identify, assess and manage the risks relating to the deployment of the staff team, and how this deployment impacted on the health, welfare and safety of service users.

Is the service caring? Although it was clear that the staff approach to their work was positive, and they had positive relationships with the service users, they believed they were at risk of providing an inconsistent service to people.

Is the service responsive? Care and treatment was not consistently planned and delivered in a way that was intended to ensure people's safety and welfare. Although there were enough qualified, skilled and experienced staff employed by the service, there deployment at different times of the day was sometime ineffective to meet people’s needs.

Is the service effective? We found that service users did not always benefit from safe, quality, care and support that was based on effective decision making and the management of risks to people’s health, welfare and safety.

Is the service well-led? The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service. Although the majority of people living at the home received a quality service, some did not, and the management systems at the home were not robust enough in identifying potential shortfalls in care practices.

At our last inspection in March 2014, we found this service to be non-complaint in the way it delivered some aspects of care and support. We found that improvements had been made. Our inspection team was made up of an inspector, who looked for evidence to answer the following questions. Is the service caring, responsive, safe, effective and well led? Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe? People are treated with respect and dignity by the staff. People told us they felt safe. Safeguarding procedures were in place and staff understood how to safeguard the people they supported. Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. The service was safe, clean and hygienic. Equipment was maintained and serviced regularly therefore not putting people at unnecessary risk. Recruitment practice is safe. Policies and procedures are in place to make sure that unsafe practice is identified and people are protected.

Is the service effective? There was an advocacy service available if people needed it, this meant that when required people could access additional support. People’s health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs. People’s needs were taken into account with signage and the layout of the service enabling people to move around freely and safely.

Is the service caring? People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People at the home said that they felt their needs were very well met by the staff. One relative said that the staff were very helpful, and knew their relative very well. They added that the staff were quick to respond to requests for help. We observed the staff work with people in positive ways, giving them time to think, treating them with care and respect, and responding to their requests for help and support. People living at the home said that they felt safe and secure. One person said that they knew they could always turn to a staff member for help and reassurance. A relative said that they believed their loved on lived in a very safe and caring environment.

Is the service responsive? People completed various activities in and outside the service. People knew how to make a complaint if they were unhappy.

Is the service well-led? The service worked well with other agencies and services to make sure people received their care in a joined up way. The service had a quality assurance system, records showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and wanted to ensure it was implemented.

During this inspection at Alston View Nursing and Residential Home we looked at Records where we last found non-compliance in October 2013. We found that improvements had been made and the issues highlighted in the last report had, on the whole, been addressed.

We found that input from health professionals such as Speech and Language Therapists was clearly documented and staff were aware of relevant changes. We found that nursing staff had received guidance to ensure care planning documents were kept up to date and time had been allocated to staff to allow this to happen.

However, during our inspection we found that on occasions, the care provided did not ensure the welfare of the people who used the service. One person told us, “I don't want to go downstairs because you get left there for hours. I’d like to have my lunch there but no-one brings you back because they are too busy, so I just stay in my room.” We also saw and were told that during busy periods some people have to wait for call bell's to be answered.

During the inspection we spoke to a number of people as well as their visitors and relatives. The comments were unanimously positive. People said; "Matron is lovely." and; "The nurses are great." and; "They are very good."

Relatives and visitors said; "I never have to complain, the nurses are great."

and; "The staff are friendly and helpful."

and; "It's absolutely wonderful. Really well run. The staff are kindness itself."

and; "Previously, (my wife) was on medication that made her sleep. When she came here they took her off it. Best thing they have ever done."

We observed staff giving care and support in a sensitive and friendly manner. They took steps to preserve people's dignity and support their choices. There were effective systems in place to reduce the risk and spread of infection.

People were able to describe what they would do if they had a comment or a complaint. One person said; "I would go to matron, she is lovely. She is very approachable".

The care records of eight people were reviewed. Seven of the care plans for nutrition and hydration did not fully reflect the outcome of an assessment and report by the speech and language therapist. One record contained contradictory information about whether a person could be given food and fluids orally or not. This means that people may be at risk of unsafe or inappropriate care or treatment because accurate and appropriate records were not maintained.

During the inspection we spoke with a number of residents and visiting friends and relatives. There were a lot of people visiting, some who were planning to stay to eat and watch a choir who were due to perform. One relative commented, ‘’I visit every day. I look forward to coming and I always feel welcome.’’ Another told us, ‘’They really make the effort here. There is always a buffet or some occasion.’’

Everyone that we spoke with gave very positive feedback about the home and spoke highly of the manager and staff. Comments included;

‘’They are a fantastic bunch – nothing is too much trouble!’’

‘’Matron is wonderful! She knows every single resident and she asks me every day if I am happy with things.’’

‘’The staff here go above and beyond!’’

‘’I love Matron. She is super and so very kind!’’

We observed staff going about their duties and providing support in a kind and pleasant manner. We noted that staff, although busy, responded to residents requests and took time to check that people were comfortable. We heard one resident chatting with staff, mention that he fancied a drink of beer. We saw that a carer arranged this for him straight away.

We looked at a number of areas during the inspection, which included how the home promoted the care and welfare of people using the service and how they safeguarded people from abuse. We found that the service was compliant in all the areas we assessed.

The people that we spoke with during our visit told us that they were treated well by staff and were encouraged to make choices and decisions about how they spent their time. Comments included, "I can get up when I please. I like to get up early but staff don't bother, they help me when I want" and "They know I like female staff to look after me".

People told us 'resident' meetings were held. They told us they were kept up to date with any changes and were able to influence how the home was run. Comments included, "You can raise anything", "We are told about any changes that affect us" and "We have meetings and they listen to us".

People told us they were concerned about being asked to pay for additional services. We discussed this with the manager who told us that people would be provided with the correct information about any additional payments.

People who we spoke with told us they were happy with the care and support that they

received. However, we found that the care plans did not always include enough detail about how people liked to be looked after. People told us they were consulted about their daily routines and had access to different activities and entertainments. They said, "I am happy with the care" and "It's a grand place, I am always well looked after". They said they were often asked if they were comfortable and happy and would be able to raise any concerns with the staff or management.

People told us there were enough staff. Comments included, "There are enough staff, I press the buzzer and they come straight away", "Staff always pop in to see if I need anything" and "If they can't get to you straight away they pop in and tell you how long they will be".

Alston View is registered to provide accommodation, nursing and personal care for up to 49 people and is owned by MPS (Investments) Limited. At the time of our inspection on 30 September 2015 there were 37people living at the home: 21 people requiring nursing care and 16 requiring residential care. The home is located in the village of Longridge where access to local facilities are within walking distance. Alston View is a modern home with accommodation on three floors. All of the bedrooms are en-suite with the exception of two single rooms. A small car park is available for visitors. Accommodation is provided over three floors (including the ground floor) with lift access between the floors. There are communal lounges and a dining room as well as toilets and bathroom facilities. A kitchen and laundry are located on the ground floor.

We previously inspected the home in May 2015, and found the home required improvement in the following areas. People who used the service did not have their medicines well managed and that the infection control measures were not consistently adequate to protect people from the spread on infection. Staff training and supervision was not always carried out in a timely manner to ensure staff were properly supported to undertake their work. Staff were not confident in their knowledge and use of the Mental Capacity Act 2005. In some instances, care records and assessment were very narrowly based on clinical issues, and not focused on the whole person. People were not always supported to take part in a range of activities whilst staying at the home. Quality assurance and governance systems were in place; however they were not always followed and implemented. The staff communication systems were sometimes ineffectual. Staff were found to be caring, but some were not given support to reflect on practice through appropriate supervision.

We carried out a series of unannounced inspection visits in July 2015. On 15 July 2015, our inspection was undertaken as part of a joint visit with representatives from Lancashire County Council Social Services Department and the Police Public Protection Unit. Our visits were made after Social Services were alerted to the death of a service user, who had been found to be gravely ill when attended to by a visiting healthcare professional. We undertook subsequent inspection visits on 17, 21 and 22 July 2015 in order to collect further evidence of how the service was operating.

In July 2015 we found that that people were not kept safe from harm as staff had not received up to date training in safeguarding and allegations of abuse were not always recognised or reported. There was a lack of meaningful activities for people, although people told us they enjoyed the outside entertainers who visited. People’s care was not always planned or delivered in a way that met their individual needs and preferences: care records were not robust and people’s needs had not been comprehensively assessed. Medicines were not managed safely and properly: stock balances did not reconcile.

Staff had not received training in, and lacked understanding of, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Feedback from staff and information held within the records showed that the registered provider had not provided appropriate and sufficient support, training, professional development, supervision and appraisal to enable all staff members to carry out the duties. Care and treatment was not provided by suitably qualified, competent, skilled and experienced staff: the home relied on nursing care from registered mental nurses (RMNs), when clinical input from registered general nurses (RGNs) would have been more appropriate.

The data relating to the number of deaths at the home in the past 12 months differed across a number of agencies: CQC, the Local Authority and the Clinical Commissioning Group were all found to hold a different number. It was clear that the service provider had not correctly notified external agencies as required to do so. There was a lack of quality assurance systems and those that were in place were ineffective and had been used to effectively identify service deficits such as concerns around staff training, staff qualifications, care assessment and planning activities and notifications.

We revisited the home on 30 September 2015, and found that some improvements had been made. The care records were found to be well organised, making information easy to find. We were pleased to note that RGNs had now been appointed, rather than relying purely on the clinical input from RMNs. The RGNs had more suitable qualifications, experience, skills and knowledge to provide the care and treatment for those who required a higher level of nursing intervention. Staff spoken with were able to discuss the needs of those who lived at the home well.

The area manager advised that some progress had been made in recruiting new staff and that this was on-going. This meant the service were able to reduce their use of agency staff, which had previously been an issue, which was noted on the staff rotas.

Alston View is required to have a registered manager. At the time of our inspection there was an acting 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. The service provider has given the Commission assurances that the acting manager will applied to be registered.

We found errors in the way medicines were administered and managed. These issues were similar to those found in May 2015 and July 2015, and this put the care and welfare of people living at the risk. Medicine audits were not effective. Not all the staff had received appropriate fire safety training. Incidents and accidents were not properly monitored, and when these needed to reported to external agencies, we found that this had not always taken place.

Some areas of the home were found to be in need of a deep clean, and the home did not have a staff member who took overall responsibility of infection control measures. We have made a recommendation about this.

We did not have assurances that staff members had adequate knowledge to undertake their work, as many had not received sufficient training and supervision in order to perform their work effectively, although we noted that the home had an action plan to tackle this issue, and were working through the plan. Some areas of the home were in need of repair, and needed to be properly maintained.

Although people’s needs were being met, and these were reflected in their improved care records, staff were sometimes slow to respond to people’s requests for support, and the home did not always provide appropriate social activities.

Management record keeping was poor, and the governance systems operated within the home were not robust or effective, although we noted that some improvements to the systems had taken place. Systems and processes to record, assess, analyse and mitigate risks and promote people’s well-being were not being followed.

We found five breaches of the HSCA 2008 (Regulated Activities) Regulations 2014 in relation to Person Centred Care, Safe Medicines Management, Safe Care and Treatment, Staff Training and Supervision’, Safeguarding, Safe Premises and Good Governance.

We found two breaches of the (Registration) Regulations 2009 in relation to notifications of deaths and notifications of other incidents.

We recommend that the service provider consults and implements best practice guidance on injection control measures.

We identified a number of breaches in regulations and the Care Quality Commission is considering the most appropriate regulatory response to resolve the problems we identified. The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special Measures'. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

You can see what action we took at the end of this report