The inspection took place on 26 and 27 November 2018 and was unannounced. Alton Manor Care Home is registered to provide accommodation and personal care for up to 34 older people including people who may be living with dementia or other mental health conditions.

Alton Manor Care Home 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. Alton Manor Care Home is situated in a residential area. The accommodation is arranged over three floors of a large, converted Victorian building with stair and lift access to all floors. At the time of our inspection there were 31 people living at the home.

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.

We previously inspected Alton Manor Care Home on 10,11 and 26 May 2016 and rated the service as Good. At this inspection we found evidence that demonstrated risks or concerns. This was because risks to people were not assessed, monitored and mitigated effectively and medicines were not managed safely. We also had concerns that the principles of the Mental Capacity Act (MCA) 2005 were not followed and the requirements of the duty of candour had not been met. The provider did not have effective quality assurance processes in place to identify these concerns. The overall rating of the service has changed since our last inspection to ‘Requires Improvement’.

Risks to people were not always managed effectively. Clear plans and records were not in place for people at risk of choking, falls and risks associated with specific health conditions. This meant staff did not always know about risks to people and how to manage or mitigate them.

The administration of medicines was not managed safely. This had not been identified by the service because effective checks had not been undertaken.

There was not a robust quality assurance process in place. Systems to assess the quality of service provision were ineffective in identifying some of the improvements needed. The provider had not followed legislation that required them to act in an open and transparent way when people came to harm.

Staff sought verbal consent from people, before providing support, but did not always follow legislation designed to protect people’s rights when making decisions on their behalf. Care plans lacked mental capacity assessments and there was no record that people had consented to their care at Alton Manor Care Home. All people with the exception of one had a Deprivation of Liberty Safeguard (DoLS) applied for when necessary. Staff were not aware of who had a DoLS in place in the home.

Care plans contained information about how to support people but areas of these needed to be more personalised and detailed to ensure people received support in a person centred way. We have made a recommendation about this.

People’s communication needs were recorded in their care plans. However, we have made a recommendation that the service consults guidance to further develop their practice in accordance with the Accessible Information Standard (AIS).

People had access to external healthcare professionals such as GPs and nurses when needed but were not referred to the falls prevention team or speech and language therapists when risks were identified in these areas. This meant appropriate guidance was not always sought to safely support people.

Accidents and incidents were recorded and monitored to determine if any trends were occurring for individuals but accidents and incidents were not analysed at a service level w

Alton Manor Care Home provides accommodation, personal care and support for up to 34 people living with dementia. We conducted an unannounced inspection of this home on 10, 11 and 26 May 2016. The accommodation is arranged over three floors of a large, converted Victorian building with stair and lift access to all floors.

At the time of our inspection, there were 32 people living at the home. There were 17 care workers, six domestic, maintenance and kitchen staff, one senior care worker, one deputy manager and a registered manager. 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 had a good understanding of how to keep people safe, identify signs of abuse and report concerns appropriately. Staffing levels were sufficient to meet the needs of people living at the home. Robust processes were in place to recruit staff, which ensured people were cared for by staff who had the appropriate checks and skills to meet their needs.

There were systems in place to ensure medication was administered safely.

There were procedures in place to identify, assess and mitigate any potential risk to people's health and wellbeing. However, actions following risk assessments in relation to skin integrity were not fully applied in every day practice. External health and social care professionals were involved in the care of people and care plans reflected this.

Where people were legally deprived of their liberty to ensure their safety, appropriate guidance had been followed and where people were unable to consent to their care the service had adhered to the Mental Capacity Act 2005.

Staff received an induction and ongoing training to ensure they had the knowledge and skills to carry out their role effectively. They were supported by the registered manager with supervision and appraisals.

People were encouraged to eat and drink enough to promote and maintain a balanced diet. People who had specific dietary requirements were supported to manage these.

People were supported to access healthcare professionals, but this was not always in a timely manner.

Staff involved people and their relatives in the planning of their care. People's privacy and dignity was respected and people spoke positively about their care experiences. Staff were caring and considerate when they were supporting people within the home.

People’s care plans were personalised and met the individuals’ needs. People were involved in their care planning, which was reviewed regularly and care was delivered according to the person’s preferences and wishes. People knew how to complain about their care, and complaints were logged and dealt with in a timely manner and according to policy.

People, staff and relatives spoke highly of the registered manager. There was an open and supportive culture promoted by the registered manager.

Staff told us that they felt able to go to the registered manager with any concerns or worries and they would be listened to. There were robust auditing and management systems in place to monitor and improve the quality of care provision within the home.

We made a recommendation that the service review the outcome risk assessments that come from Waterlow assessments with a high risk and take action to improve the clarity in such assessments as to what steps are taken on a case by case basis.

Alton Manor Care Home offers personal care to up to 34 people with dementia. On the day of our inspection there were only 32 people using the service. During our inspection of Alton Manor Care Home we spoke to seven people who used the service, three relatives of people who used the service, three members of staff and the registered manager.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

Is the service safe?

People told us they felt safe living at the home. One person told us “There’s nothing to worry about”.

Effective safeguarding and whistleblowing polices and systems were in place to ensure people were protected against the risk of abuse. People were protected against risks associated with their medicines and people's medicines were safely and appropriately managed by the home.

The home had a policy and procedure in place in relation to the Mental Capacity Act. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. At the time of our inspection applications were not being submitted to review whether the arrangements for people's care and treatment in the home amount to a deprivation of their liberty because there was no one living at the home that was having their liberty deprived.

Is the service effective?

People told us they were happy with the care and support they received. People's needs were assessed and updated regularly and care plans were person centred and reflected their individual needs and preferences. It was clear from what we saw and from speaking with staff that they understood people's care, support and communication needs and they knew them well.

People's relatives told us they were involved in developing the care plan with their relatives. One relative told us, “I was involved in the care plan”. “They ring me up when medication changes or if [the person] is poorly and we will come in”.

Is the service caring?

People told us staff were friendly and kind but could sometimes be sharp with their responses and be uninterested. One person told us, “Sometimes people make a fuss and they have to be spoken to sharply”. Another person told us, “Staff look after me very, very well, they are brilliant and they make sure I eat to keep well”. “The food is good and there are ample cups of tea”, “I go to bed happy and content”. A relative told us, “[The person] gets on famously, nothing is perfect but I can walk in and feel that it’s her home although it is sometime tense.”

We saw on occasions some staff spoke to people in a direct and abrupt manner and when they interacted with people they did not give people the time to respond. However we observed staff talking to people who used the service and they seemed very comfortable and made good eye contact. We spoke to the registered manager who told us they would look into this and speak with staff.

Is the service responsive?

The service had quality assurance processes in place. However people’s comments were not always acted upon. Relatives and people who used the service stated they would like more activities to take place in the home. During the inspection we did not see any activities being carried out and people who used the service remained asleep, watching the television or completing a wordsearch for most of the day. One person told us “when I am sitting here I calculate what I’m going to do tomorrow”. Another person told us, “There wasn’t much entertainment, I can’t remember the last time”

Those people who needed a ‘mental capacity assessment’ or best interest decision’ had these made by the right people. Staff were trained on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Is the service well led?

There was a registered manager in post and they were present at the time of our inspection. Management arrangements provided leadership and there was an open culture. Staff told us they felt supported and could raise any concerns with the registered manager.

All staff we spoke with told us they knew who the manager was and who would be responsible if the registered manager was not available. One relative told us “the manager is very dependable”.

The service had effective processes in place to monitor and deal with complaints, accidents and incidents and learn from them.

We spoke with four people who use the service, the relatives of two people and one person's visitor. We reviewed six people's care plans and we spoke with the provider, the manager and staff. People told us they were supported by staff who respected their decisions about their day to day care and treatment. People's mental capacity to make decisions about their care and treatment was assessed in relation to their individual care needs.

We found that people's care was based on an individual needs assessment and planned and delivered to ensure their safety and welfare. A person told us "the staff are excellent, I need a lot of help and they are good at it". We found that staff demonstrated a good understanding of people's needs and preferences. A person's relative said "I have no qualms that my relative's needs are catered for".

We found that the home was well maintained and procedures were in place to ensure the home was safe, clean and comfortable. People we spoke with told us that they were satisfied with the standard of the premises.

We found that staffing levels were sufficient to meet people's needs and that training was provided to ensure staff were suitably knowledgeable and skilled to meet people's needs.

There was an effective system in place to assess, monitor and manage risks to people's safety and welfare. People and their relatives were asked for their views on the quality of care provided by the service and their comments were acted on.

We spoke with three relatives and they told us the place was clean and tidy. Members of staff told us they received regular training and there were systems in place to ensure the standards of cleanliness were kept.

We found that where people did not have the capacity to consent, the provider had sought consent from relatives but had not followed the principles of the Mental Capacity Act 2005 in full. People we spoke with told us they chose what they wanted to do during the day.

We looked at six people's care records and found that care plans did not include all the information staff would need to support the person effectively. Care plans had not been updated and we saw that these were not always followed by staff. People told us that staff were nice and they liked living in the home.

We found that people were not protected against the risk of developing infections because of poorly managed cleaning procedures.

We saw potential hazards to people's health and safety. These included split and damaged flooring which had lifted in places, mould in the shower room and a lack of procedures to assess for hazards to the environment.

We found that staff were supported effectively and received appropriate professional development. We spoke to four staff who told us they were supported, they were comfortable to talk to the manager and were confident they would be listened to. Staff we spoke to confirmed the home conducts a robust recruitment process.

People were able to express their views about the service and their care, however the home did not have an effective system in place to assess, monitor and manage risks to people’s health, safety and welfare.

People we spoke to told us they were well looked after and they enjoyed living at Alton Manor. People told us the staff were fabulous and thought they were kind, patient and caring. People who live at Alton Manor have different levels of dementia and therefore not everyone was able to tell us about their experiences.

People said that they did not have any concerns or complaints but would raise these with the staff or the manager if they did.