What life is like for people using this service:

Since the previous inspection the registered provider has made improvements, however further improvements were required.

Processes for checking the quality and safety of the service had improved since the last inspection, however further improvements were required because they were not always effective in identifying areas of improvement.

Service leadership, management and governance was not always effective. Statutory notifications regarding incidents and events which occurred at the home were not always submitted to the Care Quality Commission (CQC) as required by law.

Some concerns about the safety of the environment were identified during the inspection; these were discussed with the interim manager and immediately responded to.

We have made a recommendation about the safety of the environment.

Medication management procedures had improved since the last inspection. However, further improvements were needed so that medication administration records (MARs) were appropriately completed.

People were protected from harm. Staff understood safeguarding and whistleblowing procedures and knew how to report any concerns as and when they presented.

Staffing levels had improved since the last inspection. People received care and support from the right amount of staff in a responsive, timely and considerate manner.

Recruitment was safely managed. Staff had undergone the appropriate recruitments checks and provided the right care and support to people.

The registered provider complied with the principles of the Mental Capacity Act (MCA) 2005. People’s level of capacity was appropriately assessed and measures were in place to ensure people received support in the least restrictive way possible.

We received positive feedback about the quality and standard of food. Staff were familiar with people’s dietary needs as well as their likes and dislikes.

People received care and treatment in a dignified and respectful manner. We received positive feedback about the quality and safety of care people received.

There was a complaints process and policy in place. People and relatives knew how to make and a complaint and felt confident that any concerns would be responded to accordingly.

More information is in the full report below.

Rating at last inspection: Requires Improvement (report published 28 December 2017) This is the third consecutive time the service has been rated Requires Improvement.

About the service: Alt Park is a ‘care home’ that provides nursing and personal care for up to 35 older people living with dementia. At the time of the inspection 25 people lived at the service.

Why we inspected: This was a planned comprehensive inspection based on the ratings at the last inspection.

Please refer to the end of the report for the action the registered provider needs to take.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. We will meet with the registered provider to discuss how they plan to address the issues identified during this inspection.

The focused inspection took place on 30 July 2018 and was unannounced.

Alt Park is a ‘care home’, registered to provide accommodation and nursing or personal care for older people. The care home is registered to provide support for up to 35 people. At the time of the inspection there were 30 people living at the home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Alt Park is a purpose-built care home situated in Gillmoss, a suburb of Liverpool. Accommodation can be found over two floors, there is an available passenger lift and stairwell, as well as a lounge/dining area and garden areas located around the home.

At the time of the inspection the was no registered manager in post. A registered manager is a person who has registered with CQC 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 and how the service is run. The registered provider had appointed a manager in April 2018 but they had not submitted the relevant documentation to CQC.

At the previous comprehensive inspection which took place in November 2017, the home was rated as ‘Requires Improvement’. This focused inspection was carried out due to notifications of concern which CQC received in relation to the clinical support people received, particularly in relation to effective wound care management.

This focused inspection was carried out to ensure people received effective care and the registered provider was meeting all legal requirements. The team inspected the service against two of the five key questions we ask always ask: is the service effective and is it well-led?

Consent to care was not obtained in accordance with the Mental Capacity Act (MCA) 2005; records did not indicate that principles of the MCA were being followed and it was not clear to see if people were involved in the decisions which were made in relation to the care provided.

Quality assurance systems were not always effectively assessing, monitoring or identifying areas of improvement and development. Audits and checks were not identifying the areas we identified during the inspection and were not effectively monitoring the safety and quality of care people received.

We recommend that the registered provider reviews the quality assurance systems which are currently in place.

During this inspection we looked at the clinical care people received in relation to wound care and the management of vulnerable skin. We did this in order to assess whether relevant risks had been effectively assessed by nursing and care staff. People’s vulnerable skin conditions were clearly recorded and staff followed specific care and treatment plans to support the risks that presented.

We reviewed clinical support processes that were in place manage and mitigate risk. These included repositioning charts, topical (medicated) administration records, waterlow assessment tools and pressure relieving equipment. The clinical support measures which were in place helped to provide an evaluation of the care provided and demonstrated how risks were assessed and monitored.

The day to day support needs of people living at Alt Park were being met. We found staff liaised with external health and social care professionals at the appropriate time to optimise people’s health and well-being.

Staff received regular supervision and were supported with their learning and development. Staff told us they felt supported and were able to develop the necessary skills and competencies to deliver effective care. Relatives also told us that staff were well equipped and trained to provide the care which was expected.

The overall governance of the home required im

This inspection took place on 1 and 2 November 2017 and was unannounced.

Alt Park is a purpose built care home situated in Gillmoss, a suburb of Liverpool. Alt Park provides nursing and personal care for up to 35 older people who have dementia. There is a car park to the front of the building and accommodation is located on two floors, with access to all areas of the home by a passenger lift. During the inspection, there were 28 people living in the home.

At the last inspection in May 2017, we found that the provider was in breach of Regulations in relation to the safety of the environment, risk management, medicines management, recruitment, staff training, consent, care planning, feedback systems, audit systems, policies and procedures and submission of notifications. The service was rated as inadequate and placed in special measures. This inspection looked to see whether sufficient improvements had been made to ensure the provider was meeting the fundamental standards of care.

At the last inspection we found that medicines were not always managed safely. There were gaps in recording, PRN (as and when required) protocols and plans for covert (hidden in food or drink) medicines were not detailed. During this inspection we found that some improvements had been made and plans were now detailed. However, we found that one medicine was not given as prescribed as minimum times between the doses were not always maintained and not all stock balances were accurate. The provider was still in breach of regulation regarding this.

In May 2017, we found that people’s personal emergency evacuation plans (PEEPs) were not detailed and risk assessments were not always completed accurately. During this inspection we found that risk assessments had not all been completed accurately and provided inconsistent information about risk to people. Information within care plans was not always clear or consistent to ensure staff had relevant information as to how best to support people. We also found that planned care was not always evidenced when provided and PEEPs had not all been updated. Risk was still not assessed accurately for people and the provider was still in breach of regulation regarding this.

At the last inspection we found that consent was not always sought in line with the principles of the Mental Capacity Act 2005 (MCA). During this inspection we found that applications to deprive people of their liberty had been made appropriately, however mental capacity assessments were not always completed when required. When assessments were in place, they had not all been completed in line with the principles of the MCA. The provider was still in breach of regulation regarding this.

In May 2017 we found that the audit system in place was ineffective. During this inspection we saw that the provider had implemented a new audit system which was comprehensive and identified areas that required improvement. Many of the actions highlighted had been addressed, however, due to the limited time since the new provider took over, not all of the actions had been completed.

Many of the concerns identified at the last inspection had been addressed, but not all had been fully addressed. It was evident that the provider had made a number of improvements but they needed further time to complete all of the required actions. The provider was no longer in breach of regulation regarding this.

During the last inspection we found that the provider failed to notify CQC about incidents that had occurred. During this inspection we found that notifications had been submitted regarding events and incidents that the provider was required to inform us of. The provider was no longer in breach of regulation regarding this.

In May 2017, we found that new staff were not fully supported in their roles. During this inspection we saw that all staff had completed an induction in line with the requirements of the care certificate; had regular supervision and an annual apprai

This inspection took place on 22 and 23 May and was unannounced.

Alt Park is a purpose built care home situated in Gillmoss, a suburb of Liverpool. Alt Park provides nursing and personal care for up to 33 elderly people who have dementia. There is a car park to the front of the building and accommodation is located on two floors, with access to all areas of the home by a passenger lift. During the inspection, there were 32 people living in the home.

At the last inspection in March 2016 we made a recommendation regarding staff training and induction. During this inspection we checked to see that improvements had been made. Records showed and staff told us that they had not completed all of the training considered mandatory. The training records provided by the registered manager did not reflect all of the staff employed.

Records showed that staff were provided with regular supervisions and an annual appraisal to support them in their role. Staff felt they had received a sufficient induction; however this did not meet the requirements of the Care Certificate.

External contracts and internal checks were in place to help maintain the safety of the building and equipment; however we found that the building was not always safely maintained. Window restrictors were fitted to the windows on the first floor; however they did not meet current requirements. Chemicals were not always stored securely appropriate lighting was not always maintained.

We saw that risk assessments regarding people’s health and wellbeing had been completed. These assessments had been reviewed regularly; however they were not always completed accurately. This meant that people’s risk may not be accurately assessed and mitigated.

We looked at how the service managed fire safety and found that risk regarding fire was not effectively managed. Fire doors were not adequately maintained and appropriate equipment was not available to assist people to evacuate the home in the event of an emergency. Personal emergency evacuation plans (PEEPs) had been completed, but not all contained sufficient information as to how people should be supported to evacuate the home. Not all staff had completed fire safety training. We shared our concerns with Merseyside Fire and Rescue Service.

Records showed that staff had their competency assessed to ensure they administered medicines safely. We found however that medicines were not always managed safely. There were gaps in the recording of medicine administration and plans to inform staff when to administer PRN medicines (as required) were not all in place. Those that were in place did not provide sufficient information to ensure people would receive their medicines when they needed them. One chart we viewed showed that a medicine had not been administered as prescribed.

The personnel files we viewed all contained two references and a Disclosure and Barring Service (DBS) checks. However two of the files we viewed contained gaps in the staff member’s employment history and one file did not contain any photographic identification as is required.

DoLS applications were made appropriately, however not all staff were aware who this applied to in the home and not all staff had completed training in this area.

Consent was not always sought in line with the principles of the Mental Capacity Act 2005. Mental capacity assessments were completed but best interest decisions were not always clear. Records showed that only two staff had completed mental capacity training.

Care plans were specific to the individual person and most were detailed and informative. We found however, the plans did not always contain up to date information regarding people or their needs.

We saw that planned care was recorded as provided, however not all records were completed accurately.

There were some systems in place to gather feedback regarding the service, though these systems had room for further improvement. We made a recommendation regarding th

This unannounced inspection was conducted on 29 March 2016.

Situated in North Liverpool and located close to public transport links, leisure and shopping facilities, Alt Park Nursing Home is registered to provide accommodation for up to 35 people with nursing and personal care needs. The location is a two storey property with a passenger lift giving access to the upper floor.

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.

People’s medication was generally stored and administered in accordance with good practice. However we saw that administration instructions relating to the use of covert medicines were lacking in detail and some records relating to topical medicines (creams) were not complete.

Staff were not always suitably trained and skilled to meet the needs of people living at the home. The staff we spoke with confirmed that they felt equipped for their role. However the training records that we saw showed that not all training had been completed or refreshed according to the home’s schedule.

During discussions with staff we found that not all people were able to demonstrate that they had the necessary language skills to communicate effectively with people living at the home, relatives, colleagues and healthcare professionals.

We have made a recommendation regarding staff training and support.

We asked people and their relatives if they felt safe living at the home. All of the people that responded told us that they felt the home was safe.

Staff knew how to recognise abuse and discrimination and were seen to intervene in a timely and appropriate manner when people showed signs of distress. This reduced the risk of behaviours escalating and reduced people’s anxiety.

People living at the home had detailed care plans which included an assessment of risk. Each of the care records that we saw contained risk assessments relating to; nutrition, use of bed rails, falls, pressure area care, smoking, balance, eyesight, choking and moving and handling. These were subject to regular review and contained sufficient detail to inform staff of risk factors and appropriate responses. We saw that risk assessments had been reviewed and care plans amended following recent incidents.

The records that we saw showed that the home was operating in accordance with the principles of the MCA.

We saw staff engaging with people in a positive and caring manner. Staff spoke to people in a respectful way and used language, pace and tone that was appropriate to the individual.

Throughout the inspection we saw people moving around the building independently and engaging in activities of their own choosing. We saw that people declined care at times during the inspection and that staff respected their views.

People’s privacy and dignity were respected throughout the inspection. We saw that staff were attentive to people’s needs regarding personal care.

People’s preferences and personalities were reflected in the décor and personal items present in their rooms. Important items and photographs were prominently displayed. All the bedrooms we saw were personalised.

We observed that care was not provided routinely or according to a strict timetable. Staff were able to respond to people’s needs and provided care as it was required.

Information regarding compliments and complaints was clearly displayed and the provider showed us evidence of addressing complaints in a systematic manner. All of the people that we spoke with said that they knew what to do if they wanted to make a complaint.

Each of the people that we spoke with told us that the registered manager was aware of the day to day culture of the home. We saw that the regis

An adult social care inspector and an expert by experience carried out the inspection.The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? As part of this inspection we spoke with three people who used the service, the Registered Manager, four of the care staff and five people who were visiting relatives who lived at the service. We also reviewed records relating to the management of the service which included staff files and records relating to infection control. Below is a summary of what we found, the summary describes what people who use the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

People who lived at the home told us they were treated with respect and dignity by staff. People told us they felt safe and that if they had any concerns they would raise these with staff or with the manager.

The service was managed in people's best interests and the manager was aware of her responsibility to refer to external professionals if it was felt that a person may be being deprived of their liberty. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to residential services and care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Records we reviewed confirmed that staff had been trained to understand the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People’s health, safety and welfare were protected in how the service was provided. People got the support they needed when they needed it and risks to people’s safety were appropriately managed.

Our observations and the records we looked at, assured us that the equipment used to support people living at Alt Park Nursing home, was clean and well maintained to ensure that each piece of equipment was safe for people to use.

Is the service effective?

People received the care and support they required to meet their needs and maintain their health and welfare.

People were supported by kind and attentive staff. We saw staff were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and in their own way. Our observations confirmed this.

Is the service caring?

People who lived at the home told us staff were caring and respectful. Staff told us they were clear about their roles and responsibilities to promote people’s independence and respect their privacy and dignity.

Some of the people who lived at the home had done so for many years and we saw that staff showed warmth and familiarity when supporting people. People comments included: “The staff are a good bunch, we’re treated well” and “I am happy here, the carers are good and I have everything I need.”

Is the service responsive?

The service worked well with other agencies and services to make sure people received their care in a joined up way. GPs and other health professionals were referred to promptly when people required support with their health care needs.

People who lived at the service and their relatives told us they felt listened to and included in day to day decision making. We found that people who lived at the home were listened to and their views were acted upon. People were asked to give feedback on their experience of the service. This was done through the use of surveys and meetings with people who lived at the home. This feedback was then used to make improvements to the service.

Is the service well-led?

The provider had a system in place for checking on the quality of the service and this involved seeking the views of people who lived at the home on a regular basis. We reviewed records which confirmed that actions had been taken to make improvements to the service based on people’s feedback.

The service was managed in a way that ensured people’s health, safety and welfare were protected. The service was managed in the interests of the people who lived at the home.

We had previously inspected this service on 22 May 2013 and at this time we found that the service did not have appropriate arrangements in place for the management of medicines. During our visit we found that there had been improvements at Alt Park to the way in which the medicines were managed.

We used a number of different methods to help us understand the experiences of people living at Alt Park because some of the people using the service had complex needs which meant they were not able to tell us their experiences. During our inspection we observed staff being respectful, kind and caring in their interactions with the people they cared for. We were able to speak with relatives of people who used the service who told us the care their family members had received at Alt Park had been “excellent” and that “the home has a warm and friendly atmosphere whenever you call in”. We found people were given support to have their say in how they wanted to be helped and were supported to do the things they wanted to do.

There were enough skilled and experienced staff to be able to meet the needs of the people who lived at Alt Park in a timely manner and there were appropriate procedures in place to deal with complaints. However, during our inspection we found that appropriate arrangements were not in place for the management of the medicines.

People were not able to tell us their experience of living at Alt Park so we used a variety of formal and informal observation methods in order to see how people and staff interacted, and see how care was provided. Our observations showed us that people received a good level of support with their personal care needs. Throughout our inspection we saw that staff interacted positively with people. We saw that staff at the home spoke to people in a kind and respectful way and had a clear knowledge of people's individual likes and preferences. Relatives we spoke with commented:

"All the staff here are very good".

"The food is wonderful".

"She feels safe here, it is her home".

"She's always clean and tidy".

We spoke with two relatives of people living at Alt Park. We asked them how they were involved in decisions that needed consent. Both were very positive regarding care and the service generally. They said they feel involved and are kept up to date by the staff. They said the staff were very approachable and always give them time.

On the day of the site visit we spent some time observing the care. We saw staff attending to people in wheelchairs and assisting people to feed. The dependency of people living in the home can be very high and those visitors we spoke with said that there was good communication and staff were very competent when carrying out care and using equipment.

People looked clean and well presented showing that staff paid good attention to standards around personal hygiene.

Generally we observed people to be relaxed and mixing well with staff. One person observed was clearly agitated on occasions, but staff responded well and seemed aware of care needs. We spoke with one visitor who said ‘The staff look after residents very well’.

Those people spoken with and observed were very relaxed around staff and said that they were listened to so that any concerns could be addressed. Residents, when asked, said that they felt ‘safe’.

We spoke with people about the staff. They told us that staff were competent and were easily identifiable. We received positive comments about staff and their approach. This helps people to feel safe in the home.

People told us that they are consulted about the care and about aspects of the running of the home. Interviews confirmed that the general running of the home is consistent.

We spoke with social service contracts and safeguarding team who place some people in the home and who responded to an incident involving an altercation between two people living in the home; the result of which was hospitalisation of one of the people concerned.

An investigation by the safeguarding team raised a number of concerns around the way people with more challenging behaviour are cared for.

• Care plans were not suitable to reflect the action staff are to take, nor do they identify triggers or interventions in relation to the aggression.

• An 'incident book' was seen which records a high number of such incidents in the home. None of these have been reported to us [the Care Quality Commission] or to Safeguarding so that proper reviews could be instigated.

• There was concern that in the absence of the manager there was no leadership in the home and therefore nobody to cover the home.

• Safeguarding felt that a ‘culture of acceptance’ of challenging behaviour had resulted in inappropriate action being taken.

• Staff records evidenced that staff may not have been recruited properly and therefore might not be suitable to work with vulnerable people.

We also spoke with an investigating social worker who had looked at two incidents and had ongoing concerns about the way the home managed people with challenging behaviour. He looked at two incidents involving residents and concluded that incidents of physical violence were happening with out correct reporting or review. These include physical assault and sexually inappropriate behaviour.

When we spoke with safeguarding we learnt that because of these concerns they were having ongoing input into the home and that currently the home are not admitting [voluntarily] any new people. The team have been working with and monitoring the home since then.

We undertook a site visit to Alt Park and we spoke with some of the people who live there and also to three relatives and visitors. Of the people who live in the home only a few were able to give any sort of informed opinion as most have some mental impairment. We were told by one person that they could speak freely to staff and that staff did consult them on a daily basis about aspects of their care and they were also always informed when a medical review [for example] was due and what this would be about.

We spoke with three relatives who told us that the manager and staff work well with them and keep them informed and up to date re aspects of the care and treatment. For example one relative said that they had ‘worked well with the staff’ to get medication reviewed on behalf of their relative and this had been very positive. The staff had been very supportive. Another relative informed us that they had been involved with decisions around making an ‘end of life plan’ [plan for the eventuality of any decline in health] and that this had been completed together with the doctor who had visited the home. The relatives understood that both the staff and they were working to act in the person’s best interest and that they were consenting to treatment.

We asked people whether they were involved in reviewing and contributing to the care plans drawn up by staff. All confirmed that they had no involvement in this. We spoke with the manager about this aspect of involvement as the care plan is the key peace of documentation that coordinates the care in the home and although there is evidence of consent and inclusion in many areas of the care this is a key area that should be developed.

People who live in the home who were able to express an opinion said that they were well cared for. They enjoyed living in the home and said that staff were supportive of their needs. One person said that staff spent time talking and said:

‘I love it here. It’s very busy and there’s a lot of people about – it keeps me going’.

Those spoken with said that they were treated with respect by the staff.

We observed staff working and supporting people. We saw staff assisting people to feed. The pace of care during this period [middle of the day] seemed well paced and relaxed. Interactions were warm and friendly.

These observations were supported by interviews with relatives / visitors who said that the home was always welcoming. Relatives said that people always looked well cared for.

We spoke with a visiting health care professional who told us that the manager and staff work well to support a person with particularly challenging behaviour and they make good use of any advice and are flexible in their approach to care.

This provides evidence that people feel their health and welfare is generally managed in the home.

The people we spoke with, who could give an opinion said that they felt safe in the home and that staff could be trusted. Relatives spoken with on the site visit also expressed confidence in the staff and said that they were always kept informed of events.

Some of the comments by visitors raised concerns about the numbers of staff on duty at times. Some comments were that given the needs of the people in the home and the lay out of the building there may not be enough staff on occasions to ensure people are safely observed. One comment was:

‘Staff can be stretched at times. I feel overall staffing is not enough to keep an eye on everybody given layout of the home and also there are some difficult residents’.