This inspection took place on the 20 and 22 June 2017 and was unannounced on the first day.

We last inspected the service in January 2016 when we rated the service as requires improvement. At that time we found the service was in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, these related to safe care and treatment, person centred care, premises and equipment and governance.

This inspection was to check improvements had been made following the last inspection and to review the ratings.

Appleton Manor Nursing Home is run by HC-One. The home is situated on the borders of Brinnington and Bredbury near Stockport. It is a purpose built two storey building which provides nursing and residential care for up to 58 older people. The home is split into two areas nursing care is provided on the ground floor for up to 25 people. Residential care and support for people living with dementia is provided for up to 33 people on the first floor. Appleton Manor Nursing Home is close to local amenities and there is convenient access to public transport and motorway networks. Car parking is available at the front of the home.

At the time of our inspection there was no registered manager in place as the previous registered manager had left the service in May 2017. However a temporary manager from another HC-One home located on the same site as Appleton Manor was in place pending the recruitment of a new manager. The provider advised us that steps were being taken to recruit a suitable manager within a reasonable timescale.

Systems to make sure the safekeeping and administration of medicines were followed and monitored were in place and reviewed regularly. Medicines were stored safely and administered by designated trained care workers and nurses. Any specific requirements or risks in relation to people taking particular medicines were clearly documented in people’s care records.

We saw people were supported by sufficient numbers of care workers and nurses. Care workers and nurses told us they had undergone a thorough recruitment process and had undertaken employee induction and training appropriate to their job role. This helped to make sure the care provided was safe and responsive to meet people’s identified needs.

During both days of the inspection we saw positive and caring interactions between care workers, nurses and people who used the service which helped to make sure people’s wellbeing was promoted and their dignity was respected.

People lived in a clean and well maintained environment. We saw that the home was decorated to a high standard; there was a warm and relaxed atmosphere throughout the home. Appropriate equipment and health and safety checks were carried out to help maintain a safe environment for people to live in.

People who used the service and their relatives were complimentary and positive about the care and support provided and the attitude of the care team and management. They felt that the overall care provided was very good and the environment was furnished and maintained to a high standard.

Complaints were addressed and recorded appropriately by the management team. People who used the service and their relatives told us they knew how to make a complaint and felt confident to approach any member of the staff team if they had any concerns.

Accurate and complete records in respect of the care and treatment provided to people were being maintained. Systems were in place to monitor the quality and safety of the service provided to people living in the home.

This inspection took place on 7, 8 and 14 January 2016. Our visit on the 7 January was unannounced.

The service was last inspected on 5 August 2014 when no breaches of regulations were found.

Appleton Manor Nursing Home is a nursing home managed by HC-One. It provides 24 hour nursing care and support for up to 58 older people including people with dementia. It is situated on the borders of Brinnington and Bredbury near Stockport. It is close to local amenities and there is convenient access to public transport and motorway networks. The home is a modern two storey building; people with nursing needs are accommodated on the ground floor, with a residential unit upstairs accommodating up to 33 people. On the day of our inspection there were 54 people accommodated.

When we visited the service a registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission (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 about how the service is run. The manager of the home had recently been appointed, but not yet registered with CQC, and was present throughout. The previous registered manager, who had moved to become a peripatetic manager for HC-One homes was also present during our inspection. The appointment of the new manager had been well received. One visitor told us “We are seeing lots of improvements. She’s got the passion for it

We identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Not all care plans were written in a person centred way and this could place people at risk of receiving unsafe or inappropriate care.

There was a strong offensive odour that permeated throughout the first floor of the home originating from a person’s bedroom. Although there was an appropriate cleaning schedule this had not helped to remove these odours.

People who used the service had risk assessments relating to their health and safety on their care files, but these had not always been fully completed and reviewed regularly to make sure the identified risks were mitigated.

Care plans contained out of date information and rooms did not display people’s names which increased the risk being of people being given the wrong care and treatment.

Care plan reviews did not take into account specific issues which could result in poor outcomes for people, such as skin integrity needs, continence support needs and dementia needs.

Staff we spoke with were confident about their duties and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and had received training in this topic.

People who used the service, who we asked, told us that Appleton Manor was a safe place to live and felt they were well looked after. People we saw looked well cared for and comfortable in their surroundings. We had brought our inspection forward following concerns raised with us about recruitment and retention of staff and safeguarding issues. When we inspected we saw that where allegations of abuse and issues of concern had been brought to the attention of the provider action had been taken to minimise the effect on people who used the service. Staff shortages led to an over reliance on agency staff, and the home had halted new admissions into the home until staff could be recruited and given appropriate training. When we spoke to the home manager about this, she informed us that nine new starters had been recruited to commence training the week following our visit.

Staff understood their role in making sure they safeguarded vulnerable people from harm and had undertaken training in adult safeguarding.

The staff training records sh

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

As part of this inspection we spoke with the area manager and the nurse on duty. No-one living on the unit we visited was able to speak to us about their medicines; however no-one expressed any concerns. We also reviewed records relating to the management of medicines within the home. This included medication administration records (MARs) and other records for ten people living in the home. Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people using the service were safe because they were protected against the risks associated with use and management of medicines. People received their medicines in a safe way.

Is the service effective?

We found that systems were in place for managing medicines appropriately. Staff had clear guidance available to them to make sure that people received their medicines correctly. The morning medicines round took a long time to complete and this meant that some people were at risk of not getting their medicines when they needed them.

Is the service caring?

People were supported by kind and attentive staff. We saw that the nurse on duty was patient and gave encouragement when supporting people to take their medicines. People were able to do things at their own pace and were not rushed.

Is the service responsive?

Records showed that people’s condition was monitored closely. Where changes had been made to people’s medicines, we saw that these had been put into place quickly and accurately.

Is the service well led?

We saw that regular audits, or checks of medicines, were done to assess the way medicines were managed.

Our inspection team was made up of an inspector who addressed our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service safe?

Some of the people who were living at Appleton Manor were living with dementia and could not always give their verbal opinions on the service they received. However, we observed during our visit that people were treated kindly and with respect. We were also able to understand from the people we spoke with that they were happy with the care provided.

From the records we looked at we saw that people who lacked capacity were protected when decisions were necessary regarding their health and personal care needs.

At the time of our inspection we noted that the home was clean, tidy and free from unpleasant odours.

At the time of the inspection staff moving and handling training was taking place at the home to protect the people who lived there. Training such as safeguarding adults and health and safety helped to make sure that the staff team had the qualifications and skills to meet people's needs. National Vocational Qualifications (NVQ) had been undertaken by the staff team in Health and Social Care. Fire awareness training had been provided at the home for the care workers.

We looked at two staff recruitment records and saw that the provider had carried out the appropriate pre-employment checks before they started working at the home.

Is the service effective?

From the four care plans that we looked at we saw that there was clear written information which helped to make sure that people received appropriate care to meet their needs. We saw records to confirm that healthcare professionals such as GP’s and district nurses also visited the home as requested. Notes were made of the visits on the person’s care plan.

Appleton Manor was purpose built to meet people’s individual needs. All bedrooms had en suite facilities and were situated on the ground floor and first floor of the home. The first floor could be accessed via a passenger lift. We saw there was equipment available such as a hoist, assisted baths, wheelchairs, pressure relieving mattress and cushions to meet people’s needs.

The manager told us that most of the staff were established and had worked at the home for a number years.

Is the service caring?

Five people spoken with said that they had no concerns about the care provided. People spoken with said that they had no complaints and that the staff were good. One person said the staff were “All very nice”. They also told us that they felt well supported and cared for by the staff.

All of the people we saw on the day of the inspection looked clean and comfortable and they were smartly dressed.

We saw staff showing respect to people when delivering their individual care and in a way that promoted their privacy and dignity.

Is the service responsive?

During this inspection we used a short observational tool (SOFI). It helps us to look at the mood and engagement of people using the service and the quality of staff interactions during the inspection process. It is one form of evidence that we use when making a judgement about compliance with the appropriate regulations.

We saw that people's needs were assessed before they were admitted to the home to help make sure that their needs could be met. We saw that comprehensive care plans were in place that reflected the person's care needs to help make sure they received appropriate care.

We saw that necessary individual risk assessments to guide staff in managing individual risks were in place. We saw that these records were checked regularly to help make sure that people's changing needs were being met.

We saw that staffing levels reflected the number of people who were living at the home and the level of their care needs. The people we spoke with said there were always enough staff at the home to meet their needs.

A person spoken with told us that the GP was called as and when necessary and their medication was always given appropriately.

Is the service well-led?

At Appleton Manor a registered manager was in charge of the day to day management of the home. The manager was on duty at the time of the inspection. The organisation’s quality manager was also present at the home during the inspection.

We saw evidence in the form of completed service user satisfaction questionnaires which confirmed they had been completed by people who used the service.

Healthcare professionals and people’s relatives were also provided with a questionnaire to obtain their views and opinions about the service.

We were told by people who used the service that they could talk to the manager if they had any concerns about the care being provided.

Prior to this inspection we were made aware of some concerns about the staffing levels within the home. We looked into this and found that there were adequate staff in place to meet the needs of the people in the home but that there was a need for the management team to improve communication with the staff regarding job roles and which tasks these included.

During our inspection we spoke to five people who lived in the home. They were all very happy with the care that they were receiving. One told us; "The staff are lovely and they work very hard." Another person said; "This place is lovely and the food is beautiful." We also spoke to two relatives who were very happy with the home and the staff who worked in it. One said; "It's been very unsettling with all the management changes but it seems better now and the current manager is good."

We looked at the medication procedures in the home and saw that the manager and quality assurance manager had introduced more robust checks to ensure that medication was administered appropriately and safely.

We looked at the complaints procedure and saw that it had recently been updated and was made available for people who lived in the home and their relatives. We also saw that no complaints had been made since the previous inspection.

We undertook this visit to see if concerns found on our previous inspection in October 2012 had been addressed.

We spoke with three people who lived at the home. One told us; "I always feel safe here." The other said "The food is good here and I like the snacks tray." We also spoke to a relative who had previously been concerned about the care provided at the home. They told us; "There has been a huge turnaround since the current manager came here, everything has improved."

We also spoke to the GP who visits the home every week. He told us; "Communication between staff and myself has improved considerably. The manager and the clinical lead nurse work closely together and with me to make sure that the resident's needs are met."

Our observations, documentation we reviewed and the staff we spoke to assured us that the home had made significant improvements to the care it was providing. People were experiencing care and support to meet their needs. Staff also said that they had confidence in the manager and that the improvements would continue. Some staff expressed concerns about the lack of activities in the home for the people who use the service. The manager showed us an action plan to address this issue.

We found that action had been taken to address the concerns raised at our October 2012 inspection and that people's needs were now being met.

We spoke with two people who lived at the home. One told us; "The girls are good, kind and help me." The other said; "The staff work hard and could do with more help." Prior to our inspection we received information from relatives who were concerned about their family members and other people living at the home. One relative said; "We see many people stuck in their rooms all day with nothing to do and no stimulation." Another said; "I am very concerned about how people at the home deteriorate and are losing weight. My relative is only Ok due to the extra food the family brings in."

Our observations, documentation we reviewed and the staff we talked to assured us the home had sufficient staffing to meet people's needs. Staff also said they had confidence in the new home manager. However, we found people had not experienced care and support that met their needs. People spent too long in their rooms and there was insufficient specialist equipment to enable people to mobilise as they wanted. We also found that people were not asked for their consent or properly assessed prior to the installation of bed rails.

We found that action had not been taken to address concerns relating to nutritional needs which we had identified during our July 2012 inspection and that people's nutritional and hydration needs were not being met.

As a result of all these concerns we did not have confidence in the robustness of the providers quality assurance and monitoring systems.

This was the first Care Quality Commission inspection visit since the service was registered in October 2011.

A registered manager was not in place at the time of our visit. The home was being managed by an acting temporary manager who will remain in post until the new manager starts in August 2012.

We spoke with six people who used the service, four visiting relatives and four members of staff. We were told that people were happy living at the home and staff helped them when they needed it.

Some of the comments received were: “I am treated with respect,” I can do what I want here,” “I get well looked after” and “Of course they (the staff) help me if I need it.”

The relatives we spoke to were all positive with regards to the care their family members received. Some of their comments were: “We have no concerns about care,” “We are very happy with the care,” “We have never seen or heard anything that concerns us,” “We feel happy that they are well looked after” and “The staff are vey friendly and helpful.”

As part of this review process we contacted Stockport adult social care quality team who monitor the care of the people who had been placed at Appleton Manor by Stockport Local Authority. They told us that since the previous manager retired in December 2011 some concerns had been raised that appeared to be related to the lack of a permanent Manager. However since then there has been an acting manager in post who is to remain at Appleton Manor until the new manager starts in August 2012.