This unannounced inspection took place on 16 January 2017. We last inspected Bethel House in January 2016. At that inspection we found that there were no breaches of regulation. At our previous inspection in January 2016 we found that the service had made significant improvements and been rated as required improvement overall. During this inspection we reviewed actions the provider had taken to continue to develop and improve the service. We found that improvements made had been maintained and that the service was being developed and improved.

Bethel House is situated on the outskirts of Whitehaven. It is an older property that has been extensively adapted and extended to provide accommodation for up to 62 people who are living with dementia or other mental health needs. One part of the building provides nursing care. The home provides accommodation in 60 single rooms and two shared rooms with ensuite facilities. There are communal lounges and dining areas and secure garden areas for people to use. There is car parking for visitors and staff. At the time of the inspection there were 57 people living in the home.

The service had a registered manager in post and they had been in post since April 2016. 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. The registered manager had notified the CQC of any incidents and events as required by regulation.

People who lived at Bethel House told us that they felt safe in the home and that there were staff available to help them when they needed this. They made positive comments about their home. They told us that care staff were available to help them when they needed assistance, respected their privacy and that staff “couldn’t be nicer”. People living and visiting the home spoke highly of the registered manager and told us they were happy with the care and treatment.

We saw that the staff on duty approached people in a friendly and respectful way and everyone we spoke with told us that they felt safe living there and were “happy” and “being well looked after” living at the home. People had a choice of meals and drinks and they told us the food was “good” and that they enjoyed their meals.

We looked at the way medicines were managed and handled in the home. We found that medicines were being safely stored and administered and records were being kept of the quantity of medicines kept in the home and those disposed of.

Training records indicated that staff had received training on safeguarding people from abuse. The staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse and were aware of the procedures for reporting bad practice or ‘whistle blowing ‘within the organisation. We saw that the registered manager had followed the service’s procedure promptly in regards to misconduct by a staff member.

They service had safe systems for the recruitment of staff to make sure the staff taken on were suited to working there. We saw that care staff had received induction training and on going training and development and had regular supervision and annual appraisal.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.

Staff had completed a programme of induction training and there was programme of on going training for all staff. Staff told us how they felt supported through supervision and training to fulfil their roles.

The level of staffing on the day of the inspection was sufficient to ensure that the current number of people living in the home had their needs met in a timely manner.

Bethel House is situated on the outskirts of Whitehaven. It is an older property that has been extensively adapted and extended to provide accommodation for up to 62

people who are living with dementia or other mental health needs. One part of the building provides nursing care. The home provides accommodation in single rooms with ensuite facilities. There are suitable shared facilities and secure garden areas.

At our last inspection on 18th and 19th August 2015 the home was in breach of Regulations 12, 14,15,10 of the Health and Social Care Act because medicines, nutrition, the environment, dignity and care delivery were not being managed appropriately. We judged that these issues were related to a failure in 'Good governance' and the service was also in breach of Regulation 17. The overall rating for this provider was ‘Inadequate’. The service was placed in special measures.

The inspection of 14th and 15th of January 2016 was undertaken to ensure that significant improvements had been made. We had received a suitable action plan from the provider detailing the changes underway. The local authority and health care professionals had visited the service since the service was placed in special measures. We found evidence to show that all of the above breaches of regulations had been met. We have revised the overall rating to one of ‘Requires improvement'. To achieve the overall rating of 'Good' would require a longer term track record of consistent and sustained good practice in all areas.

At this visit we saw that the management of medicines had improved significantly with new measures in place to deal with the ordering, storage, administration of medicines. Staff had received suitable training and checks on their competence.

There had been problems recruiting nurses but we saw that there was a full complement of nursing, care and support staff in place. Recruitment had been done correctly with all new staff being suitably vetted.

The staff team were aware of their responsibilities in protecting people from harm and abuse.

The service had been rated as Inadequate in ‘Effective’ because nutrition was not well managed, staff development needed to be improved and there were problems with the environment.

At this inspection we observed that there had been investment in the environment with new furniture, décor and equipment in place. The provider had suitable plans in place for on-going improvements to the environment.

We also saw that nutritional planning had improved and that the advice of specialists had been taken. There were new arrangements around mealtimes and a new cook in charge of the kitchen.

Staff training and development had been reviewed and new training planned. Staff had received close supervision from the management team. We saw major changes in the delivery of care and the approach of the staff team.

We judged that the breaches had been met but we rated this outcome as ‘Requires improvement’ as we need to see sustainable improvement in these areas.

The manager and her deputy had worked closely with care staff to ensure that people in the home were given respectful and dignified care. We saw that some staff had left the service, others had reflected on their practice and some staff had been subject to some disciplinary actions. The approach we witnessed was very much improved. We judged that the service was no longer in breach of Regulation 10 and the domain ‘Caring’ was judged as good.

We saw that the staff team were much more focussed on people’s well-being. People were well dressed, comfortable and any distress or disorientation was dealt with in a sensitive way.

The team had reassessed the needs of everyone in the service. They had worked with the local authority and with health. A new care planning system was in place. We judged that the breach in relation to care planning and delivery had been met. We rated the ‘Responsive’ outcome as requires improvement as we need evidence of sustaine

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 caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

We had evidence to show that staff were very careful to keep vulnerable people as safe as possible. We saw that people with dementia were monitored and any problems that challenged the services and others were managed well.

We had evidence to show that staff reported any safeguarding issues appropriately and could manage any issues where people were at risk of abuse. Staff had received suitable training.

We did however find that there were some problems with the environment that might impact on people’s safety. The registered provider was dealing with this on the day of our visit to lessen the risk straight away.

Is the service effective?

We observed the care and attention given to individuals. We also read 25% of the care plans in the residential part of the home. We saw that detailed and effective care planning was in place. We saw good assessments of need, suitable plans for helping people to move and that appropriate arrangements were in place for people to receive suitable health care.

Is the service caring?

We observed the interactions between staff and people who lived in the service. We saw patient and kind interactions. People told us the staff were very caring. One person told us that the ‘end of life’ care was excellent. A health care professional confirmed that this was the case. They told us that “No one is left on their own at the end of life…I saw a young member of staff sitting with someone giving them the support they needed.”

Is the service responsive?

We observed people in the home being responded to in a timely fashion. We saw staff at all levels giving people attention when they asked for support. We saw care staff going directly to people who were distressed or who wanted help with their orientation. We observed the deputy manager arranging to meet with a person to give them time to discuss their anxieties.

We met with a number of visitors who said that the staff team did respond to their concerns. We also had evidence to show that the management team take complaints seriously.

We noted that some comments made through complaints and the quality monitoring systems had been taken on board. We had evidence that changes were made when people in the home or their representatives were dissatisfied.

Is the service well-led?

This service had an experienced registered manager with a nursing background. She had developed a quality monitoring system. We had evidence to show that she managed the care and nursing in the home very well. We also saw that she managed the staff team appropriately and followed employment legislation. She was suitably supported by her senior teams. The registered provider was in the home during our inspection and we had evidence to show that this company had suitably strategic plans in place to ensure the service would continue to operate effectively.

Not everyone who lived in the service could tell us verbally about their experiences. However many of the people in the home could tell us how things were for them on the day of our visit. We had lots of positive remarks about the staff, the food and the environment:

"I have a beautiful room and I enjoy all my meals here with everyone else."

We could also tell by the way that people responded to staff that they were happy with the way they were cared for. Everyone in the service had some form of dementia or other mental health problem. We judged that the staff managed both the mental and physical health needs of people in the service appropriately.

The home was clean and tidy on the day of our visit and there were good systems in place for maintaining a safe and clean environment.

We looked at medicines in the home and we found that staff were aware of their responsibilities, had suitable training and managed medication correctly. The home did not rely on sedative medicines and were keen to review medication so that people could be as well as possible.

The home was suitably staffed and we saw that rostering allowed for a good mix of staff with the right levels of skills and experience.

We looked at a wide range of records that backed up what we saw and what people told us. One person who lived in the home told us:

"They are always writing down notes...just to make sure everyone knows what is going on. I take a few myself as sometimes you need to do that to get yourself organised. It is the same for the staff!"

We learned that people in this service were supported to make suitable choices and staff helped people who found consenting to care and treatment problematic. We judged that good levels of care were provided to people with dementia.

A relative told us:

"I can say what I want to these staff...they listen and they do a good job...they give 100% care."

A person in the home told us:

"The staff work really hard...but still find time for me...I am happy living here and I get good care and attention."

Another said:

"These lasses are grand and we can have a laugh and a joke together...no complaints".

People in the service were protected from malnourishment but we want the provider to review the catering arrangements in the service.

Medication was being managed appropriately and the use of sedatives was at a minimum.

During our visit the home was clean and well cared for with suitable adaptations in place to support people with both mental health issues and physical disabilities. A fire safety matter was noted and referred to Cumbria Fire and Rescue Service.

New staff were recruited appropriately and checks made on their suitability for the work they were to do. Induction, training and supervision were in place.

People were supported to make complaints and suggestions. We saw that these were managed in a timely and appropriate way. No one had any complaints about the care and treatment provided on the day.

We spoke to a number of people who live in the service. Most people in the home have dementia but this did not prevent them from being able to comment on their experiences.

"I like the food...this dinner is really tasty. I am quite fat now...".

"My room is nice and I have good clothes and they wash the sheets and iron them...".

"I wasn't well a bit ago and thought it might be my time to die but I got good care and I think I will stay here for a bit longer. The atmosphere is warm here".

"I am friendly with them as they are friendly with me...I am quite old so couldn't manage on my own. My memory is bad but they remind me of what I need to do".

"The staff are all very good...some nicer than others but there are a lot of them. There is always someone to turn to...".

"We go out in our bus and go places...I like to go to the sea...St.Bees is nice when the weather is better".

We also spoke to some visitors who spoke on behalf of their relatives.

"We are very satisfied. One of us comes every day and we are always made welcome. We are kept well informed and we help make any decisions as [our relative] cant do this alone. Things are explained to us and we feel part of the care".

"We chose the home because we were impressed with the way the staff treat people and the general feel of the place. So far everything is fine and we know who to talk to if we are concerned".

This was an unannounced inspection that took place on the 18th and 19th of August 2015.

Bethel House is situated on the outskirts of Whitehaven. It is an older property that has been extensively adapted and extended to provide accommodation for up to 62 people who are living with dementia or other mental health needs. One part of the building provides nursing care. The home provides accommodation in single rooms with ensuite facilities. There are suitable shared facilities and secure garden areas.

Currently the home does not have 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 staff team were aware of their responsibilities in keeping people safe from potential harm, abuse or neglect. The home had suitable policies and procedures in place and staff had received training in this subject.

Suitable risk assessments and risk management plans were in place to keep people living with dementia as safe as possible. Accidents and incidents were recorded and reported appropriately.

The home had experienced problems related to recruitment and retention of nursing staff. The provider and senior staff had done their best to manage these problems. A new sickness policy was in place to reduce sickness absence. Disciplinary procedures were in place in the service.

Staffing levels were adequate because staff worked long hours and extra shifts to cover all the rosters. Staff from nursing agencies were brought into the home.

We looked at medicines management and we found that staff had not always signed that they had given medication. In one instance an insulin injection was not recorded properly. We judged this meant that the service was in breach of Regulation 12 of the health and Social Care Act. You can see what action we told the provider to take at the back of the full version of the report.

We found that the arrangements in place to give people the right levels of support in taking suitable nutrition and hydration needed to be improved on. We judged that the service was in breach of Regulation 14 because of these issues. You can see what action we told the provider to take at the back of the full version of the report.

We also saw that although some improvements had been made to the décor further work needed to be done. Some areas needed to be refurbished and some new furniture purchased. This meant that the service was in breach of regulation 15 because of the issues with the premises and equipment. You can see what action we told the provider to take at the back of the full version of the report.

We looked at staff development and made some recommendations about improving the ways staff were supervised, trained and developed.

The senior staff had a working knowledge of their responsibilities in relation to the Mental Capacity Act 2005 but would benefit from further training on this legislation.

People who lived in the service were given access to health care professionals. Local nurses and doctors said they were called out appropriately.

The staff team did not always talk about people in a dignified and respectful way. Some of the support given to people did not promote their dignity. We judged that the service was in breach of Regulation 10. You can see what action we told the provider to take at the back of the full version of the report.

End of life care was managed well with new training being offered to staff. We saw that suitable arrangements were in place in relation to resuscitation.

Every person had a care plan but some of these needed updating and some lacked detail. Care was not individualised despite the key worker system that was being operated.

We judged this meant that the service was in breach of Regulation 9 because we saw that care was not person centred. You can see what action we told the provider to take at the back of the full version of the report.

The home provided suitable activities and some people also went to the day centre that was attached to the home.

Complaints were managed in a timely and appropriate manner.

The service had a quality monitoring system, this was not being used to the best effect. Where issues had been identified these had not been resolved in a timely manner. The service was in breach of Regulation 17: Good governance. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.