This inspection took place on 11 December 2018 and was unannounced. At the previous inspection in October 2017 we had found continued breaches of regulations regarding staffing and governance. The provider had failed to address these breaches, and additional breaches of regulations relating to safe care and treatment, and person-centred care were identified during the inspection. The provider had failed to implement the improvement plan they sent to us after the last inspection.

Apthorp Care Centre 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. Apthop care centre accommodates up to 108 people in ten flats each of which have separate adapted facilities. At the time of our inspection two of these flats had been decommissioned and 73 people were living in the home, many of whom were living with dementia.

There was no 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. The manager had started working in the service in late October 2018.

The provider had failed to sustain and embed previous improvements made in the quality and safety of the service. Although their systems had identified the failings we found in personalisation, risk assessments, medicines management, record keeping and the safety of premises they had failed to take effective action to address these concerns. The provider’s improvement plan was not driving improvements. The systems for involving people, relatives and staff in developing the service were not working effectively. While staff were optimistic about the potential for the new manager to make improvements, people and relatives were unclear about the management structure in the home.

There were not enough staff deployed to meet people’s needs. People told us they had to wait to receive care, and we saw people’s dignity was compromised as there were not enough staff available to support them in a timely manner. Bathrooms were dirty and this exposed people to the risk of harm due to poor infection control practice. Risks to people were not always identified, and risk assessments were not always followed. Medicines were not managed in a safe way.

People’s needs had not been assessed in line with best practice and resulting care plans lacked detail. The impact of people’s health conditions on their care preferences was not recorded and people’s dietary preferences were not always respected. The service had applied to the local authority to deprive people of their liberty under the Mental Capacity Act (2005) but we saw staff put in place additional restrictions on people’s liberty. Some areas of the home were not environmentally suitable for people living with dementia.

People’s dignity was not always upheld and the inspection team had to intervene on two occasions to ensure people’s dignity was restored. Care plans did not explore how people’s religious beliefs and cultural background affected their preferences for care. The service did not explore the impact of people’s sexual or gender identity on their experience of care services.

Records did not consistently demonstrate people had received care as planned or in line with their preferences. People had not been supported to explore their wishes for the end of their lives.

Staff recorded and escalated safeguarding concerns to ensure people were protected from abuse. People told us they were supported to attend healthcare appointments when they needed.

People told us staff were kind and we saw some positive, compassionate interactions between s

This inspection took place on 9, 10 and 11 October 2017 and was unannounced. During the last inspection on 1 February 2017 we found the service was in breach of four legal requirements and regulations associated with the Health and Social Care Act 2008. We found that people who used the service were not protected against the risks associated with their care and treatment. Medicines were not managed safely. There were not always adequate staffing levels at meal times. Staff were not receiving consistent support through regular supervision. Not all people were supported to maintain their personal dignity.

At a previous inspection in July 2016, we found the service to be inadequate overall. We placed Apthorp Care Centre into special measures and imposed a condition on the provider’s registration to submit monthly audit reports to the Care Quality Commission (CQC). Following the inspection in February 2017, although some improvement had been made, the service remained in special measures and the conditions on the provider’s registration remained in place.

This inspection was carried out within the six-month time frame to check if improvements to the quality of care had been implemented. At this comprehensive inspection we found the registered provider had taken action to achieve compliance with some of the regulations previously identified as non-compliant during the comprehensive inspection in February 2017. However, we found repeated breaches of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations.

Apthorp Care Centre is a purpose built residential care home that is registered to provide accommodation for up to 108 people who require personal care. The home is split into three floors that contain units called 'flats'. At the time of our inspection there were 75 older people living at the home, many of whom were living with dementia.

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.

At our last inspection we identified that staff were not effectively deployed around mealtimes. At this inspection we found that although there were sufficient staff on duty, at key times throughout the day such as mealtimes, we found that staff were not effectively deployed to ensure people received support with eating in a timely manner.

At our last inspection, we found that appropriate fluid monitoring records were not kept for people who were at risk of dehydration. At this inspection we identified repeated concerns in this area.

At this inspection, we found that although risk assessments were now identifying risks individual to people and staff were receiving appropriate guidance, some risks to people were, in practice, not actively mitigated against.

Improved systems and processes were in place to monitor quality of care. However, quality monitoring required further implementation and embedding.

Medicines were now safely stored and administered. Appropriate records were kept of medicine administrations and regular medicines audits took place.

Staff training, supervisions and appraisals were monitored and updated regularly. Systems had been implemented to ensure a better oversight of when staff training, supervisions and appraisals were due.

Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of the types of abuse to look out for and how to raise safeguarding concerns.

Care plans were person centred and reflected what was important to the person. Care plans provided appropriate guidance to enable staff to deliver person c

The Inspection took place on 1 February 2017 and was unannounced.

Apthorp Care Centre is part of The Fremantle Trust. It is a purpose built residential care home that is registered to provide accommodation for up to 108 persons who require personal care. It is divided into three floors that contain units called 'flats'. All bedrooms are single rooms with en-suite facilities. At the time of our inspection there were 75 people living at the service who were older people, who were living with dementia or were people who have learning disabilities or who have autistic spectrum disorder.

There was 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.

At the previous inspection on the 6 and 12 July 2016 we found Apthorp Care Centre to be inadequate overall with five breaches of the regulations. As such the service was put into special measures. This meant that the service was kept under review and would be inspected again within six months. There is an expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. As such we inspected within six months on 1 February 2017 to identify if the provider had made improvements to the service.

At our previous inspection in July 2016 we found that medicines were stored in an unsafe manner that resulted in medicines being disposed of and replaced. During our inspection in February 2017 we found there was now safe storage of medicines. However although we found no errors in the general medicines administration we found omissions in the controlled drug procedure that was not being followed appropriately by staff.

At inspection in July 2016 we found risk was not well managed by the service as some people had no risk assessments and risk assessments were not reviewed to take account of changing circumstances. During inspection in February 2017 we found most people had up to date, detailed risk assessments. However we found people did not have assessments to manage the risk of diabetes and one risk assessment review although reviewed had not taken account of a recent fall.

In addition we found in July 2016 that there was no falls matrix or a system that investigated falls, injury or bruising. In February 2017 there was a system in place that was being used to track and investigate falls injury and bruising however we found one example of bruising not being followed up with an incident report as the procedure stated. Therefore we saw the system was not yet embedded in staff practice.

At our inspection in July 2016 we found that health assessment such as Waterlow (skin integrity assessments) and Malnutrition Universal Screening Tool (MUST) were not completed and reviewed on a regular basis. During the inspection in February 2017 we found that these assessments were now in place and reviewed. However we saw that health monitoring forms were not completed on occasions for people. As such the service would not have the information recorded to ascertain if people were being well hydrated and had adequate food consumption. This had not been picked up by the service’s monitoring systems.

Staff told us they were now receiving good induction and training but we found staff still were not receiving supervision sessions on a regular basis as per the providers’ policy.

At our inspection in July 2016 people told us staff were kind, caring and respectful. During our inspection in February 2017 people and relatives still spoke highly of staff and we saw some sensitive and kind interactions between staff and people. We also noted the atmosphere was warm and friendly and there was lots of laughter and fun between staff and peo

This inspection took place on 6 July and 12 July 2016 and was unannounced.

Apthorp Care Centre is part of The Fremantle Trust. It is a three-storey purpose built residential care home that is registered to provide accommodation for up to 108 persons who require personal care. It is divided into ten units called ’flats’. All bedrooms are single rooms with en-suite facilities. At the time of our inspection there were 93 people living at the service who were older people, who were living with dementia or were people who have learning disabilities or who have autistic spectrum disorder.

There was not a registered manager in post as they had resigned from their post in June 2016. There was an acting manager and the provider was in the process of recruiting 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.

The previous inspection on 22 July 2015 the service had been found to be Good overall. However in the inspection prior to this in October 2014 the service was found to be Inadequate overall.

People told us they felt safe at the service however we found a number of concerns that put people were at risk of harm. People told us they received their medicines in a timely manner and that staff asked if they needed pain relief. We found no errors in people’s medicines administration records but medicines were not being stored in a safe manner in some of the units and we had to ask the service to take urgent action to make sure medicine was being stored safely.

We found that although most people had risk assessments, some risk assessments had not been updated after a change in circumstances, for instance when people had serious falls that had affected their mobility the falls risk assessments were not updated. Also one person did not have a robust risk assessment in place to protect them from other people who had behaviours that were difficult to manage. We found two people did not have risk assessments in their records in addition to lacking most of their care and support plans even though they had been living in the service since January and May 2016. This meant the service did not have systems in place to keep people safe.

Falls and injuries were not being adequately recorded and were not investigated in a robust manner and there was no falls matrix to identify if a person was falling for a specific reason or if there were trends in the service that was contributing to falls.

The provider undertook robust recruitment practices to ensure staff were safe to work with vulnerable adults.

We found that some staff had not received supervision for several years. In addition although some core training had taken place, training records were not well kept and it was not possible to identify what training staff had received or when they were due for refresher training. This meant that staff were not being supported to undertake their caring role.

Health assessments such as Malnutrition Universal Screening Tool (MUST) and the Waterlow Assessment (for good skin integrity) were not completed and reviewed on a regular basis. Therefore the service was not ensuring people’s nutritional needs were being met and did not consistently record people’s weight to ensure their nutritional intake was adequate.

We observed people being supported to eat tastefully prepared pureed meals in an appropriate manner however it was not consistently recorded why people required a pureed diet and one person’s records were not completed to show staff had supported them appropriately to eat.

Staff were able to tell us how they got people’s consent before offering care and support. The service had undertaken mental capacity assessments and made Deprivation

We carried out an unannounced comprehensive inspection of this service on 13, 15, 17 and 18 October 2014. At which we found several breaches of legal requirements The registered provider did not deploy staff appropriately and we found that there were not a sufficient number of staff available to meet people’s needs. Some medicines were not dispensed correctly and medicine administration charts were not always completed. Staff had not been appropriately supervised .We saw people did not always have an enjoyable experience at meal times, due to insufficient staffing and an uncaring attitude from some staff. Staff did not always understand the Mental Capacity Act 2005 including the Deprivation of Liberty Safeguards and how these affected the people they supported.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of Regulations 9, 10,13,17,18, 22 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this inspection on 2 and 3 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

Apthorp Care Centre provides care for people with learning difficulties, dementia and physical frailty. The home has 108 beds split into 10 units on the day we inspected there were 92 people living in the home.

The home has 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 and associated Regulations about how the service is run.

At our inspection on the 2 and 3 June 2015, we found that the provider had followed their plan and legal requirements had been met.

We found that action had been taken by the provider to improve in all the areas where breaches had been identified; we found that action had been taken by the provider to improve the way medicines were managed. Systems for the management of medicines were now safe. Protocols for the use of pain relieving medicines were in place, and medicines were stored securely and appropriately.

We found there were sufficient staff on duty in all flats to ensure people received a safe service. We spoke with the registered manager and regional manager who stated they felt that whilst staff numbers had not increased during the day time [night staff had however been increased from eight to nine waking staff] practices, morale, support and the organisation of staff had been improved. We noted rotas had been modified and that the provider had increased its management team to ensure staff numbers were highest at busiest times such as morning and lunchtimes. We also noted staff were now receiving formal supervision every two months and that the manager had commenced staff appraisals.

Appropriate checks were undertaken before people began work. Staff files contained a completed application form and supporting documents to demonstrate training and copies of photo identity, evidence of the person's right to work and a criminal record check .

The service had policies and procedures on safeguarding adults from abuse and on whistleblowing (confidential disclosure) and staff demonstrated a good understanding of these.

Staff told us they had completed training on the Mental Capacity Act 2005 (MCA ), its associated code of practice and the Deprivation of Liberty Safeguards (which provide a legal framework to protect people who need to be deprived of their liberty for their own safety). Staff spoken with had an understanding of the MCA  and the implications of this legislation

We found the provider had taken action to improve the effectiveness of the service. Members of staff spoken with told us they were provided with appropriate training and they were positive about their employment. Staff confirmed that they were provided with regular supervision and they were well supported by the management team.

Staff appeared motivated, and caring. Staff were observed interacting with people in a caring and friendly manner. They were also emotionally supportive and respectful of people’s dignity.

Activities provided entertainment and stimulation for people living in the home including those unable to leave their rooms.

The manager provided good leadership and people using the service, relatives and staff told us the manager had made a number of improvements since our last inspection.

We carried out an unannounced inspection on 10 March 2014 following compliance actions made against Apthorp Care Home on 19 November 2013 in respect of outcome 1, respecting and involving people; outcome 4, care and welfare of people and outcome 13, staffing.

During this follow-up inspection we spoke with ten people who used the service and nine members of staff.

We noted that a new manager had commenced employment at the Home in January 2014.

We observed that since our inspection on 19 November 2013, the provider had made various improvements which included introducing a new format of care and support plans, risk assessments and a new activities timetable.

During our follow-up inspection on 10 March 2014 we were concerned that there were not sufficient numbers of staff on duty during the night shift. We raised this with the provider and they informed us that they had immediately put an extra member of staff on duty during the night shift and provided us with evidence to confirm this.

During this inspection, people said they were treated with respect and dignity and they appeared well cared for. They had been provided with choices regarding meals provided and their likes and dislikes had been recorded.

We found the general decor of the home to be in poor condition with stains and paint chips on walls. The provider explained that funding for improvements had been approved. However, we found people's rooms clean and free of odours.

People were treated and spoken to with respect by staff and were encouraged to be independent around the home. People were well dressed and relatives of people who used the service told us they were very happy with the care provided. However, we found that people were not always involved in planning their care and treatment and were not always able to choose what they wanted to eat or drink.

We observed that staff used correct moving and handling techniques and treated people with care and respect at all times. However, we found that people did not have a sufficient number of activities to participate in and were left watching the television or sleeping for periods of time. We also found that people who had been assessed of being at risk of falls or pressure ulcers had no appropriate plan in place to suitably manage or reduce these risks. There were not always enough staff to fully meet people's needs and this meant that there were insufficient interactions or that people had to wait for their care and treatment.

Staff had received appropriate training and supervision to ensure that people were kept safe and the provider had systems in place to identify and manage risks in the home.

We spoke with people who use the service and their relatives. People said they felt safe and were treated with respect and dignity. Comments from people using the service and relatives ranged from “I’m happy and treated well,” to “brilliant I can’t fault it.” We spoke with three relatives who were visiting on the day of our inspection who told us that they were happy with the service and felt involved in the care and treatment of their relative.

On the day of our visit we saw people participating in community art sessions, organised as part of an external art project. People’s preferences in terms of likes and dislikes were respected and they felt involved.

There were no systems in place for assessing and monitoring the number of falls incidents involving people who use the service. Records held by the service show several instances of falls incidents during October 2012.

People who use the service confirmed that members of staff listened to what they wanted and did what they were asked. People who use the service gave examples of how they maintained their independence by helping to do small tasks in their units and by keeping a good level of mobility. They said that they were able to choose to spend time in their rooms if they wished or to join in the activities taking place. They commented

"Everything you say and tell them……they do".

"There's lots of entertainment here"

When we discussed whether staff talked to people using the service and explained what they wanted to do before providing care i.e. seeking consent they told us

"They do ask if they can do things".

Although people were often unaware of their care or support plan they said that they were satisfied with the care received and with the assistance given to enable people to maintain a healthy lifestyle. They told us that they were supported by members of staff in accessing health care facilities in the community. They commented

"Very good care".

"Marvellous healthcare".

"I went to Barnet Hospital (with a member of staff)".

The majority of people said that the menu offers alternatives and that the food was good. Portion sizes were generous and they said that they could choose whether to eat in the dining room or in their own room.

"You have a menu, you can choose from it, ideal".

”At lunch time it’s a cooked meal. Alternatives are available. It's a varied menu".

People told us that they felt safe living in the home and safe with the people supporting them. Names were given of who they would speak to if they were worried about anything or if they were upset and these included the names of members of staff working on their unit and the manager. Comments included

"I feel very safe. If I am worried I talk to the boss".

"I get on well with all staff here. It's safe here. Safe as two houses".

People living in the home said that the home was kept clean and they were satisfied with the overall standard of hygiene, which was a consistent feature of the home. Praise was given when talking about the domestics and the laundry service.

"A cleaner comes in every day and once a month I have to leave the room as they do a thorough clean, moving the chairs around etc. Which is fine".

When morning medicines were being administered people were reassured throughout and were able to communicate the level of support they needed. One person said that when she was in pain care workers always bring the painkillers promptly. Another person said that they were happy in the home and were well looked after and they said that they preferred care workers to administer their medication.

People were pleased with their surroundings and appreciated having personal accommodation that included en suite facilities. They said that it was warm enough.

"The accommodation is perfect".

People said that members of staff were knowledgeable about their needs and there was a good rapport between members of staff and residents with some good natured banter. Although people agreed that the members of staff providing care were kind and helpful they did not agree that there were enough staff on duty to support them and examples were given of when there were shortfalls.

"Staff know what help I need. They are all very nice people here".

"There are enough staff on duty and at night someone goes around. They respond quickly".

"There are not enough carers here. There is only 1 carer (on the unit) but they change all the time and it could be someone that doesn't know me".

"When I was taken into hospital it was a job to get anyone to bring my clothes in. There was a shortage of staff".

"There was no-one to put up the decorations. A carer tried to put some up Christmas Eve".

People said that the manager visited the units and when speaking with her they were addressed by name. Doors to the manager's office and the duty office were often open and people using the service spoke with managers when they had matters to discuss. Overall people were satisfied with the quality of the service provided and said that they had not had cause to complain. They knew who they would speak to if they had any concerns and if they had raised concerns they confirmed that they were listened to and that problems had been dealt with.

"If I had a complaint I would speak to the person in charge but I've not had to make one".

“If I’ve something to say, they do sort it out. I do appreciate it. If there’s a problem, I talk to Jan (the Manager) about it.”

We inspected Apthorp Care Centre on 13, 15, 17 and 18 October 2014. This inspection was unannounced. The service met all of the regulations we inspected against at our last inspection on 10 March 2014.

Apthorp Care Centre provides care for people with learning difficulties, dementia and physical frailty. The home has 108 beds split into 10 units. On the day we inspected there were 83 people living at the home. The service has a registered manager. 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 and associated Regulations about how the service is run.

People felt safe living at the home. However, people and their relatives commented on staff not always being available to support their needs.

Some medicines were not dispensed correctly and medicine administration charts (MARs) were not always completed. We saw errors in recording on people’s MAR charts. Therefore, people may not have been receiving their medicines as prescribed.

Effective systems were in place to ensure the service was kept clean. People and their relatives commented on the high level of cleanliness.

Staff had not been appropriately supervised. Staff were up to date with mandatory training, however night staff did not have an understanding of whistle blowing. Both day and night staff did not always understand the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and how these affected the people they supported.

People were supported to eat and drink. The service had a chef who people were able to approach should they need to discuss their nutritional needs or request special dishes. Records showed that staff recorded people’s fluid intake should that be required to reduce the risk of people becoming dehydrated. We saw people did not always have an enjoyable experience at meal times, due to insufficient staffing and an uncaring attitude from some staff.

Professionals visited the home regularly and this was recorded in people’s care records. Staff we spoke with were aware of how they could contact professionals quickly to support people’s changing needs.

Staff sometimes treated people with dignity and respect. They were aware of people’s likes and dislikes and these were recorded in people’s care records.

Activities were available at the home and most people enjoyed these. However, some people‘s activity needs were not met and they commented they were lonely and bored.

The home had regular meetings with people, relatives and staff. We saw these meetings were recorded and minutes available for everyone to read. This allowed people and relatives to keep up to date with activities in the home and this was also a forum to support people should they wish to make a complaint.

The registered manager completed regular audits to review the quality of the service. However, these audits had not been effective in capturing issues that we found on the day of the inspection.

People and relatives were asked their view of the service several times a year and the provider ensured everyone received feedback.

The home had made links with the local community. Students from several schools came and visited the home. People commented positively on seeing young people and looked forward to these visits.

We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of this report.