About the service:

• Appletree House Residential Care Home is situated in Lancing, West Sussex. It is a residential ‘care home’ registered for up to 15 older people, some of whom are living with dementia or frailty and other associated health conditions. At the time of the inspection there were 12 people living in the home.

People’s experience of using this service:

• People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and procedures in the home did not support this practice. Staff continued to lack understanding about mental capacity so made decisions for people rather than with them.

• Although improvements had been made, for example, people now had the equipment they needed, there were continued concerns about the oversight of the systems and processes within the home to ensure people received high-quality care.

• Shortfalls found at the inspection had not always been identified by the registered manager.

• Potential risks to people had not always been considered or lessened.

• Staff recruitment practices did not always comply with guidance or the provider’s policy to help ensure staff were suitable to work with people.

• Staff did not always have access to learning and development that the provider considered essential for their roles.

• People told us they were happy living at the home and there was a relaxed, friendly and homely atmosphere.

• People were treated with dignity and respect. They told us staff were kind, caring and compassionate. One person told us, “They’re lovely, they normally give me cuddles.”

• People could plan for their end of life care.

• There were sufficient staff to meet people’s needs.

• People had access to healthcare services and had their medicines when they needed them.

• Infection prevention and control was maintained and the home was clean.

• People told us that they were happy with the food. One person told us, “We are lucky with the food, it is beautiful, such a treat. The food is lovely, very nicely prepared.”

• People had their own rooms and access to communal spaces so that they could spend time alone or with others.

• People received care that met their physical, social and emotional needs.

• People told us that they enjoyed the interaction with staff as well as the activities that took place.

Rating at last inspection:

• At the last inspection the home was rated as Requires Improvement. (Published on 11 December 2018). This home has now been rated as Requires Improvement in the last three consecutive inspections.

Why we inspected:

• This was an unannounced comprehensive inspection. At our last inspection, on 27 September 2018, the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action against the provider and gave them a date to meet the Regulations by. This inspection took place to check that improvements had been made and that they were now meeting the Regulations.

Enforcement:

• The provider had met the Warning notices that had been issued following the previous inspection on 27 September 2018.

• Although improvements in some areas had been made since the last inspection, which included the provision of equipment and the oversight of the service, we continued to have concerns.

• Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up:

• We will continue to monitor the intelligence we receive about this home and plan to inspect in line with our re-inspection schedule for those services rated as Requires Improvement.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Appletree House Care Home 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.

The home provided care for older people, some of whom were living with dementia. The home had 14 rooms and was registered to care for up to 15 people. Two people shared a room. At the time of the inspection there were 15 people living within the home.

The home had a registered manager, who had been in post for 2 years, at the time of the inspection. 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 inspected Appletree House Care Home on 27 September and 1 October 2018. We brought this comprehensive inspection forward, due to information of concern we had received. This information related to the safe care and treatment of people within the home. We had received concerns relating to the suitability of staff, staffing levels and a lack of activities, the availability of food, the facilities and the management of the home.

When we completed our last inspection, on 14 November 2017, we found breaches of the regulations relating to the mismanagement of risks, due to unsafe equipment. We also identified that the provider had failed to provide meaningful activities for people and there were insufficient staff. There was a lack of oversight of the home and quality assurance systems had not improved the care people received. The provider sent us an action plan, after this inspection, detailing the changes they were making to improve the service. However, at this inspection concerns continued about the care people received and the running of the home.

At this inspection there were not enough suitably trained and competent staff available to ensure people received safe care. On the first day of the inspection the staff on duty did not have the required experience. The provider had not ensured all staff had the required pre-employment checks to ensure they were suitable to work within the care industry. Training was not up to date and had not ensured good standards of care were maintained. However, staff did receive supervision and told us that they felt supported by senior staff.

Medicines were not always delivered in a safe and consistent way. Not all staff felt confident in the delivery of medicines and this meant that some people did not receive their medicines at appropriately spaced intervals. There was a medicine procedure and audit in place, but this had not ensured medicines were always stored appropriately.

Appropriate infection control measures were not always followed and the facilities within the home did not always provide for people’s needs. At this inspection the lift was still out of action, although it has since been mended. The risks relating to the use of the chair lift had been managed, as people who were less mobile had been moved to downstairs rooms. However, other environmental risks had not been addressed in a timely manner. Due to the size and age of the property the facilities were limited and if things broke, this impacted on the people within the home. The facilities also impacted on people’s privacy and dignity.

Personal risk assessments and care plans were not always updated, in a timely fashion and actions were not always completed. Staff did seek the advice of health-care professionals but the documentation around decisions was not always completed thoroughly. Staff did not always anticipate the needs of people who were approaching the end of their lives. People did not always have choice in relation to their food and strategies, to ensure peopl

The inspection took place on 14 November 2017 and was unannounced. At the last inspection in July 2015, concerns were identified in relation to the oversight that the provider had of the service and how they could be assured of the quality of care delivered. A recommendation was made in relation to this that supervision methods should be put in place to support the registered manager. At this inspection, whilst the registered manager received support and supervisions from an ex-colleague, these were not sufficient in maintaining the quality of the service provision.

Appletree House Residential Care Home provides accommodation and residential care for up to 15 people living with dementia, mental health needs and frailty of old age. Communal facilities include a sitting room with dining area and access to outside space. All rooms are of single occupancy, except for one room, which is shared by two people. Appletree House Residential Care Home 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.

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.

Risks to people had not always been identified or assessed appropriately. Some care plans lacked detail or guidance for staff. One person had sustained a number of falls during the year, but no referral had been made to the local authority’s falls team for advice and support. Premises were not always managed to ensure people’s safety. The lift was out of commission and a stair lift had been installed for people to access the first floor. However, the stairs were steep and some people were too nervous or unable to use the stair lift which meant they could not come downstairs. A commode chair was used to transport one person, which was unsafe. Some topical creams and bath lotions had been left on the windowsill of a communal bathroom and not stored safely. The provider had failed to ensure that risks to people, the use of equipment and premises were managed appropriately.

Staffing levels were not sufficient to ensure people were supported safely. For 15 people who lived at the home, care was provided by two care staff, although the registered manager and cook occasionally helped out during the week if required. The provider had failed to ensure there were sufficient numbers of staff to meet people’s care and support needs safely.

People’s preferences were not always identified or taken account of in relation to the care they received. One person persistently told staff they did not like vegetables, but every day they were served with them. People and/or their relatives were not involved in reviewing their care. Activities in the home were limited and did not relate to people’s likes or interests. There was a lack of meaningful activities for people to engage with and no outings into the community.

There were no systems in place to measure and monitor the overall quality of the service and no means of identifying areas that required improvement. The culture of the home did not promote person-centred, open or inclusive care. Issues we identified at this inspection had not been picked up through the audits we looked at. Relatives were not asked for their feedback about the service. The provider had failed to establish systems or processes that operated effectively to assess, monitor and improve the quality of the service. The registered manager was unaware of the new Key Lines of Enquiry which the Care Quality Commission introduced from 1 November 2017.

As part of this inspection we spoke with three members of staff and four of the ten people who lived at the home. We also spoke with the relatives of two people.

The registered manager was present for the inspection.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe? Is the service caring? Is the service effective? Is the service responsive? Is the service well led?

This is a summary of what we found

Is the service safe?

People who lived in the home said they felt safe because “Staff are lovely”. Staff told us the service was safe because it was a “Small home” which meant they had time to get to know people well and gain their trust. They said this meant people living in the home could talk to them about things that were worrying them.

The home did not have appropriate procedures in place to support people who could not make decisions about their care and treatment. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw the home had not made applications for DoLS and staff had no understanding of this and how it impacted on people. Staff had not been trained in the Mental Capacity Act (2005) and no mental capacity assessments had been undertaken even though we were told there were people who lacked mental capacity to make some decisions.

We found that the home had suitable procedures in place to protect people against the risks associated with medicines.

Is the service caring?

People who lived in the home said the staff were caring and they felt well looked after. One said “Nothing is too much trouble.” Relatives also told us it was a caring home, one said people were “Very well cared for”, another said they were “Fine on caring.”

Staff spoke about people in a caring and respectful manner. They knew people well and treated them as individuals. One staff member told us the home was “More relaxed, time to sit and chat to clients.” Another said it was a “Homely home, we get to know people individually.” When asked if they would recommend the home to a loved one, the staff we spoke with told us they would.

Is the service effective?

The service is effective because people were involved in their care planning and their individual needs were recorded in their care plans. We saw examples of how people’s needs were met and this was confirmed to us by the people we spoke with.

Is the service responsive?

We saw the home responded to people’s individual needs and preferences. We saw that action was taken if people’s needs changed or their health deteriorated.

Is the service well led?

The registered manager was very open and committed to improving the service. However, there were several areas which required improvement and these had not been picked up through the provider’s quality monitoring systems. Staff spoke highly of the registered manager saying they were well supported and communication was good between staff and management.

On the day of our inspection there were eleven people who used the service. We spoke with six people, the manager and three members of staff.

People told us that they were happy in the home. They said staff were very kind and friendly. One person said “I feel safe and secure here”.

People told us that staff understood their needs and provided appropriate care and support. One person told us staff were “So friendly and could not be more helpful.” Another person said “Staff go the extra mile for you.”

We saw there were systems in place to protect people from the risk of infection. Staff told us that they had recently completed their infection control training refresher course.

We found that the issue identified at our last inspection in March 2013 had not been fully attended to. The provider had not relocated the medicines cupboard to a suitable location. However, the provider had introduced a monthly audit of medicines and new medicine charts. Additionally, the provider had ensured staff used new ordering and disposal forms for medicines.

There were systems in place to get the views of people who used the service as well as their relatives. The provider took notice of people’s comments and took action to make changes they were able to undertake.

The provider had systems in place to ensure good records were maintained to protect people from the risk of unsafe or inappropriate care and treatment. For example, we saw that the provided regularly update people’s care plans.

People told us that they enjoyed living at Appletree House. One person said "I like it here" and another told us "We are well looked after". A visitor to the home commented that it was "Very good" and "Staff let us know of any issues". Another visitor said it was "Very homely" and "Staff know everyone". We looked at feedback forms filled out by visiting professionals. These were all positive and included comments such as "Excellent", "Happy with the service" and "Staff appear well informed".

We observed that people were happy and comfortable during the day and were treated respectfully by staff. Staff appeared dedicated and were knowledgeable about all the people in the home. We saw that people were cared for with sensitivity and at a pace appropriate to them.

We found that medication was not stored in a suitable environment. The system for recording medication administration was confusing and there were sometimes errors in recording.

Staffing levels were sufficient to carry out all the necessary care tasks. However, we found that staffing levels did not allow much flexibility. One staff member told us "I often leave late" and that "Staff take people out voluntarily". Staff were supported in their roles trough training and supervision.

There were systems in place to get the views of people who used the service as well as their relatives. We found that the provider took notice of people's comments and took action to make changes where needed.

People told us that they enjoyed living at the home and that staff were patient, caring and kind. They told us they were never rushed and that there was enough staff on duty to support them when needed.

People told us the food was good and that they could choose and alternative if they did not want the food on offer at meal times. One person told us they preferred not to eat at the dining table and that the home accommodated this. People and their relatives told us they enjoyed the entertainment and activities on offer at the home.

We spoke with three people’s relatives who spoke highly of the home. Thy told us that visitors are always welcomed and that their relatives were happy and well cared for.

Staff members we spoke to told us that they were happy working in the home, that the team worked well together and that they had received the training they needed to meet individual’s care needs.

We inspected Appletree House residential care home on 30 and 31 July 2015. Appletree House is a residential care home that provides accommodation and support for up to fifteen people. The people living there are older people with a range of physical, mental health needs and some people living with the early stages of dementia. On the day of our inspection there were thirteen people living at the home. Appletree House is a detached house spread over three floors. People’s bedrooms were situated on the ground and first floor. The house is set within a garden.

The service had 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.

We previously inspected the service in September 2014 where the provider was not meeting the requirements of the law in regard to gaining people’s consent, assessment of capacity and training for staff in this area; person centred care where lunch was task focused and care plans did not correspond to the care provided: limited audits of practice in place and the need for refurbishment identified. At this inspection, we found that improvements had been made and that these issues had been resolved.

Consent was sought from people with regard to the care that was delivered. Staff understood about people’s capacity to consent to care and had received training in this area. The registered manager was aware of DoLS (Deprivation of liberty safeguards) and how to identify someone who may need this.

People who lived at Appletree House were safe as they were cared for by staff that knew them well and were aware of the risks associated with their care needs. There were sufficient numbers of staff in place to keep people safe and staff were recruited in line with safe recruitment practices. Medicines were ordered, administered, recorded and disposed of safely. Staff had received training in safeguarding adults.

People could choose what they wanted to eat from a daily menu or request an alternative if wanted. They were encouraged and supported to eat and drink enough to maintain a balanced diet. We observed that lunch time was calm and relaxed and people received their main course and pudding in a timely manner.

Staff were appropriately trained holding a National Vocational Qualification (NVQ) in Health and Social Care and had received all essential training. New Staff were carrying out a new recommended training called The Care Certificate which provides a benchmark for training in adult social care.

People could choose when they wanted to get up and go to bed and were cared for by kind and compassionate staff. People told us how well the staff knew them. One person told us “I’m very happy here in capital letters. I can find no fault”. Another person said “The good thing is the way they help you”. People’s individuality was respected and choices were given regarding how their care was delivered.

The provider did not have over sight of the quality of care being given or formal supervision arrangements in place for the registered manager. We have made a recommendation regarding this. The registered manager had created a culture that placed the person at the centre of the care that they received. Staff values reflected this and there was a cohesive approach to providing care and support. Professionals we spoke with told us that the staff contacted them in a timely way and worked in partnership to deliver care and support.