Annabel House 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.

Annabel House is in a residential street in Weston Super Mare, close to local amenities and with onsite parking. Accommodation is offered over two floors and there is a mixture of single and double bedrooms. Communal spaces include two lounges and a kitchen-dining area, the garden is accessible and there is a decking area for people to use on the first floor.

The home is registered to provide nursing and personal care for up to 30 people.

During our inspection there were 23 people living in the home.

This inspection of Annabel House was carried out on the 10 July 2018 and was unannounced.

We last inspected Annabel House on the 7 and 8 July 2016 and during this inspection a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

The manager had made improvements to the service to ensure that the requirements of this regulation were met. Two activity coordinators were now working in the home and they had introduced meaningful and varied activities; people’s areas of interests were identified and activities designed with those in mind. Improvements made regarding the management of medicines and pressure care have been sustained.

The Care Quality Commission is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLs) and to report what we find. We saw that when people lacked capacity to make decisions for themselves that staff understood the requirement to work within the Act.

People were supported to ensure that they had enough to eat and drink. There was a choice of food available and people spoke positively about the food. When required, food and fluid intake was recorded accurately.

People received care and support from staff who were safely recruited and benefited from training and supervision to enable them to meet people’s needs.

Staff treated people with kindness, respect and ensured that people’s dignity was protected. Preferences, likes and dislikes were recorded and these were understood by staff.

People’s health and social care needs had been identified and risk assessments and care plans developed to guide staff in meeting these needs.

People, staff and relatives spoke positively about the manager and were well supported. Frequent team, staff and relative meetings were used to ensure that communication remained open and honest and contributed to positive outcomes for people.

The manager ensured that staffing levels were maintained at a safe level to ensure that people’s needs were met, this included managing the types of staff required e.g. nurse/care assistant in relation to the needs of people living at the service.

There was a programme of quality audits in place and these were used effectively by the manager to identify themes, create action plans and make changes.

Prior to our inspection, we looked at the service’s website to check that the most recent rating was being displayed. There was a link to the inspection report however the ratings were not displayed on the website.

This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20A.

The most recent inspection report was not being displayed in the service. We brought this to the attention of the manager. They informed us that they were unsure where the report was and that it had been displayed at some point.

Annabel House is registered to provide nursing and personal care for up to 32 people. Accommodation is provided in single rooms over two floors. Communal lounges and dining room are also on the ground floor. The gardens are easily accessible to people using the service. The home is situated in the town of Weston Super Mare and close to local amenities. There is a car park for visitors and staff. At the time of this inspection there were 18 people resident at the home.

We last visited Annabel House on the 11 and 13 January 2016. Breaches of legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Regulations breached were Regulation 12 ,safeguarding service users from abuse and improper treatment. Regulation 13, Safe care and treatment. Regulation 19, Fit and proper persons employed. Regulation 18, staffing. Regulation 11, need for consent. Regulation 14, Nutrition and hydration. Regulation 9, person centred care. Regulation 17, Good governance.

This inspection of Annabel House was carried out on the 7 and 8 July 2016 and the first day was unannounced.

At this inspection, we found the new manager had taken action to improve consent to care, dignity and respect, training and supporting staff, care planning, pressure care, medicines management, making sure staff knew how to support people properly and quality assurance processes. However sustained improvements were needed to ensure the provider was fully compliant with regulations.

There was a registered manager 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. However, the provider had appointed a new manager since the last inspection wo had started the Care Quality Commission process to be registered as the manager for the service. The current registered manager was in the position of deputy manager.

We found improvements had been made with the management of medicines and pressure care. Quality assurance systems had been introduced to support the manager to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using the service and others.

Risk assessments relating to people’s care had improved and staff were familiar with the needs of people at risk of poor nutrition, falls, and pressure ulcers.

People received a balanced diet and special diets were catered for. The charts used to monitor people’s nutritional and hydration intake were being used effectively and this resulted in people having their nutritional needs consistently met. However, we did find some issues in recording of dietary needs.

Information sharing between staff had improved and we found records used by staff to review people’s needs were now completed.

There had been an increase in staffing levels and people using the service, relatives and staff told us this had been beneficial to them. People did not have to wait for assistance when they needed staff support.

Infection control within the service was good. The home was clean and odour free and there had been an increase in domestic hours to maintain cleanliness.

Training was being provided to support the staff to deliver safe and effective care and support. Staff training needs was being routinely assessed and planned for, and staff received regular supervision.

Staff we spoke with were aware of the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safe Guards (DoLS) and best interests decisions. The manager was familiar with the process to follow and had taken action to apply for DoLS following people’s cap

People we spoke with were positive about the care they received. People's representatives were involved in the care arrangements and had an opportunity to comment on the care people received. Practices in the home promoted people's rights and respected decisions people made.

Assessments of need and care planning identifying how need could be met had been completed. These provided staff with the necessary guidance to meet identified care needs. The provider had processes in place to make multi disciplinary best interest decisions. A moving and handling technique was being used which placed people's health at welfare at risk.

Staff had completed safeguarding training. They demonstrated a good knowledge of the nature of abuse and how to respond to any concerns about possible abuse.

Staff were very positive about the support they received and told us they found management approachable. Core skills training had been provided to all staff. There were good arrangements in place for the one to one supervision of staff.

We found that since our last inspection improvements had been made in the consistency and frequency of quality monitoring. However there remained some shortfalls in auditing arrangements.

On our last inspection on 29 August 2012 we found serious concerns regarding the management of medicines. We also found concerns regarding the home’s lack of effective monitoring systems for the management of medicines. We served a warning notice regarding the management of medicines and gave a compliance action for the monitoring of medicines. This was a follow up inspection to check compliance of the warning notice served.

We also checked some of the home’s newly implemented monitoring systems during this inspection. However, time is needed to judge if these systems are effective over a period of time. Therefore we will review their quality monitoring systems for medicines in the near future.

During our inspection we found the home was now complying with management of medicines.

It was not necessary to speak to people who used the service during this inspection.

During our inspection we found we had serious concerns regarding the management of medicines within the home.

We found staff felt supported and attended regular meetings to encourage good communication within the home. Staff showed a good understanding of how to protect vulnerable adults from abuse and what action they needed to take if they were concerned.

People who lived in the home told us they were very happy at Annabel House Care Centre. One person told us what they thought of the care staff. They said “the staff are quite good, they try to look after you”. One of the relatives we spoke with told us “mum’s totally happy here whenever I visit”.

During our visit we used the Short Observational Framework Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We carried out our observation in one of the lounges and observed four people. We found when staff interacted with people we saw that interactions with people were patient and kind. We saw staff on two occasions did not take the opportunity to interact and make conversation with people.

The purpose of this review was to check that improvements had been made to achieve compliance with outcome 20. During our visit to the service in November 2011 we found that the manager/ provider had not been reporting safeguarding incidents between people who lived in the home either to us or the local authority, and some staff were unware of the requirements and process for reporting this information.

During this review we did not visit the home , but we reviewed the information sent to us from the provider/ manager and we spoke to the local authority about information they had received.

We found Annabel House care centre to be compliant with this outcome

The purpose of this review was to check that improvements had been made to achieve compliance with this outcome. The service cared for older people, many of whom were in an advanced stage of dementia. On this occasion we did not speak to people who lived in the home. On our previous visit we spoke with them as far as they were able. At both this visit and our previous visit we observed care and support delivered to people and reviewed the information held about people and plans for their care and talked with members of staff.

We carried out this review to check that the concerns we had raised at our previous visit in August 2011 had been addressed. We did not speak with people who use the service as they are not all able to engage in conversation due to, dementia, Alzheimer’s disease or other mental health condition.

We observed staff encouraging people and assisting them. Where people appeared unsure where they were going, staff took the time to ask what people wanted to do and direct and assist them as required.

We saw that people were having individual sessions with the activities co-ordinator and that during the afternoon staff joined in with singing in the lounge area. At this visit we spoke with four staff, all of whom told us they had received an update for manual handling from a member of the trained staff.

During our review of incident forms we noted that there were occasions when people who use the service had been involved in altercations and incidents with each other. We had concerns that these incidents had not been reported to the relevant authorities or CQC as required.

We found evidence that staff did not have access to information and guidance required to enable them to undertake some care assessments such as for risk of pressure sores.

The service cares for older people, many of whom are in an advanced stage of dementia. We were therefore not able to talk with people in any great depth about their care. We observed care and support delivered to people, reviewed the information held about people and plans for their care, and talked with members of staff. Relatives told us that generally they felt they were kept up to date with the care of their relative.

People who use the service told us they enjoyed their meals. We saw that people had been given a choice of hot meal at lunchtime and one person using the service was able to tell us what they were going to have to eat. People who use the service receive care and support from staff who undergo induction training and other relevant training.

People’s needs are not always assessed and documented to reflect a change in the care and support they require. Administration of medicines is not always carried out in a safe way. There is no evidence of medication monitoring in place.

The provider has not provided us with sufficient evidence of the quality assurance and monitoring systems they use, to ensure the service meets people’s needs.

Annabel House Care Centre provides accommodation for people who require nursing and personal care for up to 32 people. On the day of inspection there were 19 people living at the home. Most residents were living with dementia so were unable to express their views regarding the support they receive. The accommodation is arranged in one building over two floors. The main offices are located in the basement of the home and the nurses’ office is located between two living spaces.

At the last inspection, we found breaches in the home because staff were not receiving supervision in line with the provider’s policy and there was a shortfall in training. Staff had not read care plans and were not delivering care in line with what was in the plans. We found the home was not well led because there were gaps in the audit systems and they had not identified all the shortfalls we found. Since the last inspection, the provider and registered manager have been sharing changes they had made in the home. Although there had been some improvements, we found there were still concerns.

This inspection was unannounced and took place on the 11 and 13 January 2016

The home had been working towards the Butterfly Project in conjunction with Dementia Care Matters. This is an approach of working with people with dementia where you accept the world as they see it. Staff did not wear uniforms, they had name badges and positive interactions with people are encouraged. There are four lounges set up for different stages of dementia.

A clinical lead nurse supported the registered manager. A registered manager is a person who has been 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 told us they felt safe but there were risks to their safety around pressure care, risk assessments, moving and handling and medicine management. Where staff had identified pressure related wounds, plans had not been put in place to manage them. Medication procedures were not always following best practice and this was putting people at risk. People who required support were not always transferred between chairs following best practice and their risk assessments were not detailed enough to tell staff what to do.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef provided alternative options if people did not want what was on the menu to ensure their preferences were met. However, there were times people’s weight was not being monitored and people were not receiving the correct food supplements.

Staff were receiving regular supervisions in line with the provider’s policies and there had been some improvements with the training staff received. However, the staff did not get all the training they needed to carry out their duties.

The staff were aware of their responsibility to protect people from avoidable harm or abuse and most staff had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home and they knew whom to contact externally. The recruitment process did not always follow good practice, which meant people were put at risk from staff who had not had the correct checks from the provider.

The provider and senior management had an understanding about people who lacked capacity to make decisions for themselves. There had been some improvements into recording decisions made in a person’s best interest. However, care plans had not made the consultation process clear when people lacked capacity or had decision specific assessments. When they had decided to prevent people leaving the home for their safety the correct processes had been followed. But they had not always completed the correct process when bed rails were put in place to keep people safe. As a result, there were breaches of people's human rights.

The registered manager and provider had followed their legal obligations to notify CQC of other incidents. The registered manager and provider had regular meetings including one to review audits completed in the home. The audits were up to date and on occasions had been identifying shortfalls and recorded improvements. However, the systems were not identifying all shortfalls in the home or where some had been identified no actions had been taken. When we were told actions had been put in place to reduce the risks in relation to safeguarding these had not been completed.

The nurses and activities coordinator were in the process of updating and rewriting all the care plans. Where care plans had been updated there was evidence of people or relatives being involved. However, some people’s care plans were not complete or were not person specific. Not all the care plans had a person centred approach to them.This meant people were not central to their care and decisions they made for themselves or that were made for them. Staff had some knowledge about the care plans, but explained they had not had time to read them all.

Staff supported people to see a range of health and social care professionals to help with their care, but sometimes referrals were not been made in a timely manner. Staff supported and respected people’s choices and they knew how important this was.

People and their relatives thought the staff were kind and caring; we observed mainly positive interactions, but some were to fulfil tasks. The privacy and dignity of people was respected most of the time and people were encouraged to make choices throughout their day.

People knew how to complain and there were good systems in place to manage the complaints. The registered manager and provider demonstrated a good understanding of how to respond to complaints.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.  We are currently considering the action we are taking.