This inspection visit took place on 08 February 2019 and was unannounced. At the last inspection completed in April 2016 we found the provider was meeting legal requirements. looked at. The service was rated as ‘good’. At this inspection we found improvements were needed and the rating of ‘Good’ had not been sustained. However, legal requirements were met.

Bethrey House 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. Bethrey House accommodates up to 19 older people. At the time of the inspection there were 16 people living at the service, many of whom were living with dementia.

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.

People were not supported in an environment that had been developed in line with best practice guidelines around dementia friendly environments. People’s rights were not always fully upheld by the effective use of the Mental Capacity Act 2005 (MCA). People did not have access to an appropriate range of leisure opportunities and activities. Governance and quality assurance systems were not consistently effective.

Staff understood how to protect people from abuse and harm such as accidents and injuries. Sufficient numbers of care staff were in post who had been recruited safely.

People received their medicines as prescribed. People were protected by effective infection control processes. People enjoyed the food and drink. People had regular support from a range of healthcare professionals and their day to day health was maintained.

People were supported by a staff team who were kind and caring. People were supported to make choices. Their privacy and dignity were respected and their independence promoted.

The care people received met their needs and preferences. People were involved in the development of their care plans and people’s changing needs were reviewed regularly.

People were happy with the management of the service. They felt they had a voice and could raise concerns when required. People were supported by care staff who felt motivated and well supported in their roles.

This inspection was unannounced and took place on 3 February 2016. At the last inspection in June 2014, we found the provider was meeting all of the requirements of the regulations we reviewed.

Bethrey House is registered to provide accommodation for up to 19 people who require personal care and support. On the day of the inspection there were 14 people living at the home. There was a registered manager in post. 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.

People told us they felt safe. People received care from staff that protected them from the risk of potential abuse. Staff were confident in reporting any concerns or suspected abuse. Risks to people were recorded and understood by staff. There were enough staff to meet people’s needs and provide them with effective care and support. People received their medicines as prescribed. Medicines were stored securely and there were clear audit trails for people’s medicines.

Staff received regular training and had the skills, knowledge and experience to meet people’s care and support needs. People’s consent was sought before care was provided and appropriate assessments had been carried out around people’s capacity to make certain decisions. People enjoyed the food provided and told us they received the food and drink they required. Staff were aware of people’s preferences and people with specific dietary requirements received appropriate food. People had access to appropriate healthcare according to their needs and staff responded without delay to changes in people’s health.

Staff knew people well and treated people with kindness. Staff had a good knowledge of people’s needs and preferences. People were involved in making decisions about their care and support.

Staff acted in a way that protected people privacy and dignity. People’s relatives were welcome to visit the home at a time of their choosing.

People’s care was tailored to their individual needs and choices. Staff had a good understanding of people’s preferences and life histories and provided them with support that was responsive to their needs. People felt able to express their views to the staff or the registered manager. There were systems in place to manage complaints.

People, relatives, professional visitors and staff felt the home was well managed. Staff felt they were listened to when they contributed ideas and that they were valued. The registered manager and senior staff carried out quality checks to ensure people received good quality care.

In this report the name Sharon Holland appears, who was not in post and not managing the regulatory activities at this location at the time of this inspection. Their name appears because they were still identified as the registered manager on our register at the time.

We carried out an inspection to help us answer five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who use the service, the staff supporting them and from looking at records. We spoke with three people, one visitor, three members of staff and the manager. We looked at three people's care records. There were 15 people staying at the service at the time of our inspection.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People we spoke with told us they felt safe living at the service. One person told us, “I do feel safe”. A visitor told us that they had never had any concerns.

Systems were in place to make sure that managers and staff learned from events such as accidents, incidents and complaints. This helped to reduce the risks to people.

No recent applications for Deprivation of Liberty Safeguards (DoLS) had been submitted by the service. DoLS is a legal framework that may need to be applied to people in care settings who lack capacity and may need to be deprived of their liberty in their own best interests to protect them from harm and/or injury. Staff showed good knowledge about how they should protect people’s rights.

Records showed that management addressed staff performance and training through the use of supervision meetings and appraisals and managed staff performance, when required. There were some gaps in training for staff, but the manager was taking steps to address these.

Is the service effective?

People’s health and care needs were regularly assessed and records reflected people’s individual needs.

People told us, and records reflected that staff ensured people received appointments with outside professionals to support their health and wellbeing. These included appointments for eye and foot care for people with diabetes.

People’s health was supported by being offered appropriate nutritional support. This included healthy foods and food supplements, where required.

One person told us that staff had recognised they needed emergency medical support even though they had not recognised that they were ill themselves. They told us that staff had reacted effectively and efficiently to ensure they received appropriate care.

People had the opportunity to take part in activities. We saw that the service arranged outside events for people, such as a canal trip and a trip to the theatre, which meant that people were kept stimulated by appropriate activities.

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Is the service caring?

We observed staff interacting with people and saw that these interactions were positive, patient and caring. People were complementary about the staff. One person told us that staff were, “Kind” and that they were “afforded every care”.

We saw that staff adapted their approach to suit the person. This included communicating in the most effective ways and delivering care in a way which bought comfort to people. A visitor told us that a person was tactile and enjoyed contact with people. We saw staff sitting with this person and holding their hand.

Is the service responsive?

People told us, and records confirmed that staff and the management team listened to their opinions about the service. We saw that the service sought people’s views in different ways. We saw that appropriate actions were taken to address any issues raised.

Although no recent complaints were recorded, people told us they would feel confident to speak with the manager if they did have a concern. People we spoke with told us they had never had cause to raise a complaint.

We saw that the manager undertook a number of audits to ensure the standard of the service and people’s safety and wellbeing. We saw that effective medication audits were carried out by staff and over seen by the manager.

Is the service well-led?

The previous registered manager had left the service. The new care manager was present during our inspection and showed us that there were taking steps to apply for registered manager status.

We saw that the care manager had implemented a number of improvements and had reacted to improvements required by the CQC and other agencies.

We saw evidence of the service cooperating with others, such as the district nurse service and G.P.s, to promote people’s wellbeing. This meant that staff took into consideration external professional advice in order to promote people’s health and wellbeing.

We used a number of different methods to help us understand the experiences of people who used the service. The people who used the service had complex needs which meant they were unable to tell us about their experiences.

We found that the management of medicines had improved since the last inspection and the service was now able to demonstrate that they were looking after and administering medicines safely. We found that the administration records were able to demonstrate that people were having their medicines administered as prescribed, by competent care staff.

At our previous inspection of 1 July 2013, the provider was non-compliant in all three outcomes we looked at. Since this inspection we have received concerns about the management of people’s prescribed medicines. Allegations were also raised about the lack of appropriate measures to prevent people developing pressure sores. During the inspection we spoke with three people who used the service, two visitors, three care staff, the manager and the cook.

We found that a needs assessment was carried out to establish people’s care and treatment needs but people could not be confident that their needs would be met. One visiting relative said, “I was involved in x initial needs assessment.”

People had a choice of meals but we found that recommendations made by a dietician had not been acted on. We found that people who required an ethnic meal did not have access to this. However, one person who used the service said, “The food here is lovely.”

The management of medicines remained unsafe and this meant that people did not always receive their prescribed treatment.

The provider had taken measures to arrange training for staff to ensure they had the appropriate skills and competence to carry out their role.

We found that the provider had taken action to implement a quality assurance monitoring system. However, we found that this system was not entirely robust to ensure people received that appropriate care and treatment.

We carried out an inspection on 12 April 2013 and found that the provider was non compliant in three out of six outcomes we looked at. This inspection was carried out to see what measures had been taken to improve the service provided to people.

On the day of the inspection there were 16 people in residence. We spoke with three people who used the service, a visiting relative, a care staff and the registered manager.

We found that the management of people’s medicines was unsafe and placed them at risk of not receiving their prescribed treatment.

We found that not all staff had received relevant training to ensure they had the appropriate skills to support people with their care and treatment needs. However, the people we spoke with were satisfied with the service they had received. One person who used the service said, "The staff are very kind."

The home’s quality assurance monitoring systems had improved but they were not entirely robust to ensure people were protected against the risks of inappropriate or unsafe care and treatment.

The home provided a service for older people due their health condition and frailty.

We found that people’s consent for care was obtained before this was provided.

We found that care plans did not provide staff with sufficient information to ensure people’s care and treatment needs were met. However, the care staff we spoke with demonstrated a good understanding about how to care for the individual. One person who used the service said, “I’m treated with care here.”

Discussions with two care staff confirmed they had a good understanding of their responsibility of protecting people from potential abuse. One person who used the service said, “I feel very safe here.”

The management of people’s medicines were unsafe and placed them at risk of not receiving their prescribed treatment.

We found that staff did not have access to relevant training and this placed people at risk of receiving inadequate care and support.

The home’s quality assurance monitoring systems were not robust to ensure people were protected against the risks of inappropriate or unsafe care and treatment.

A new manager was appointed in November 2011 and was registered with us in March 2012.

We found that care plans and risk assessments provided relevant information about people’s care needs and the support required.

People who use the service were encouraged to be involved in their care planning so they receive a service the way they like.

We observed staff attending to people’s needs in a caring manner and were available at all times to provide assistance when needed.

Staff spoken with demonstrated a good understanding of people’s care needs and how best to support them.

Care records were not always maintained to provide up to date information about the care given and this could compromise the level of support offered to people.

We found that a number of staff had not received essential training to ensure they have up to date skills and competence to deliver an effective service.

One person who uses the service said, “The staff are very kind and the food is very good.” “The staff do respect my privacy, they always knock my door before entering.”

Another person told us, “The staff look after me well and the food is very good.”