We inspected Coniston house on the 6 and 7 March 2018. We returned to the home on 8 March 2018 to provide feedback to the available staff and management at the home. As the home had significantly improved we invited staff at the service to hear the feedback and found a number of them showed interest in the findings from the inspection. The first day of the inspection was unannounced which means the home did not know we were coming to the home to inspect on that day.

The home has been in special measures since early 2016. Since that time there has been a new registered manager, new area manager and a number of new staff to the home. At the last inspection in July 2017 we found six breaches to the regulations. We were particularly concerned around how the home supported people who were falling and found appropriate timely action was not always taken to support these people. We issued a notice to ensure no further people were admitted to the home until the falls management at the home had improved.

Following the last inspection, we met with the provider to confirm an action plan to show what they would do and by when, to improve provision and meet the requirements of the regulations. The action plan showed us how the home intended to improve the ratings to the key questions of safe, effective, responsive and well led to at least good.

At this inspection we found the home had addressed the action plan. Enough improvement work had been completed by the home’s management team and staff, to show they had met all the previous identified breaches and were now safely managing falls. We found the home was now supporting people effectively to reduce the risks of further falls. This gave us confidence to allow the home to admit further people to the home in line with a developed readmissions plan.

Coniston house is a purpose built care home over two floors. Each floor has its own lounge and dining area. The lower floor houses the main kitchen and laundry facilities and the upper floor now has its own newly built satellite kitchen. This has greatly improved facilities to the top floor including access to drinks and snacks.

The home supports up to 43 people and at the time of the inspection there were 30 people living in the home. The low number was primarily due to the previous restriction on admissions. The home provides residential care and specifically focuses on providing residential support to people living with dementia.

Coniston house is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Coniston house does not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Coniston house is required to 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.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

At the last inspection in July 2017 we found the home was in breach of Regulation 12 in relation to how the home managed and supported people with falls. We also found them in breach of regulation 18 in that there were not enough suitably trained staff to meet people’s needs. We found these two breaches to have a high impact on the safety of people in the home and issued a notice to ensure no further people were admitted to the home. At this inspection we found the home had worked to greatly improve falls management and staff had increased to ensure people’s needs were suitably met. We have lifted the restriction on admissions an

We inspected this service on the 19, 20 June and 3 July 2017. The first and last day of the inspection was unannounced which meant the provider was not expecting us on the date of the inspection.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has a large communal lounge and separate dining room to the ground floor and a smaller shared lounge and dining room to the upper floor. The home can provide residential support for up to 42 people. At the time of the inspection there were 34 people living in the home. The kitchen and main dining area is on the ground floor of the building and both floors are accessible by a lift and stairs. The lack of an upstairs kitchen area is impacting on the quality of provision on this floor and we are assured this will be addressed as soon as possible.

The registered provider is RocheCare (UK) Ltd which also has two other care homes and a domiciliary care agency. RocheCare are currently building a purpose built home to support people living with dementia.

The provider had a registered manager who was registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection the service was rated as requires improvement overall and requires improvement for all key questions except safe which was rated as inadequate. At the last inspection we found the home in breach of five of the Health and Social Care Act (Regulated Activity) Regulations 2014. We asked the provider to send us action plans to assure us they were taking steps to meet the requirements of the regulations. At this inspection we found one of the regulation breaches had been met and the home were no longer in breach of Regulation 19 which is associated with the safe recruitment of staff. We found the home had also met the action plan for regulation 12 and we no longer had concerns with the safe management of medicines. However we found the home still in breach of Regulation 12 – Safe care and treatment, as we had serious concerns around the safe management of falls and were not assured risk assessment and risk management plans were completed as and when they were required. We also had new serious concerns around the staffing numbers and breached the home in this regulation. We took immediate action to assure ourselves people living in the home were kept safe.

When we returned to the home on the third day of the inspection, there were more staff on the rota and proactive action had been taken, to better support people at risk of falls.

At this inspection we identified two further breaches to the regulations than at the previous inspection. These were as identified above in relation to the staffing numbers and we also found people were not safeguarded from the risk of abuse. We found the home had not reported unwitnessed and unexplained injuries to the safeguarding team as required and we also found where people’s movement was restricted it had not been appropriately assessed. This was primarily around people’s access to their own bedroom and being supported on a separate floor to their sleeping accommodation. This had been a concern at a previous inspection and the home was required to understand and implement the principles of the Mental Capacity Act to ensure people were lawfully restricted.

We found the care records were not always consistent in detailing the needs of people in the home. Staff told us they did not always have time to update the records as were needed to support people in the home. Some people were not receiving the support they needed and the information was not available as to how best to support them. This included those people who no longer had a dedicated day and night routine. This aspect of their care

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on the 9 and10 August and was unannounced. This means the home did not know we were coming on the day we arrived to inspect.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has large communal areas on both floors and can provide residential support for up to 42 people. At the time of the inspection there were 35 people living in the home. The kitchen and main dining area is on the ground floor of the building and both floors are accessible by a lift and stairs.

The registered provider is RocheCare (UK) Ltd which also has two other care homes and a domiciliary care agency.

The provider had a registered manager who was registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection the service was rated inadequate overall and inadequate for three key questions, these were safe, effective and well led. Caring and responsive were rated as requires improvement. At the last inspection there were 10 breaches to the Regulations identified. Seven of these were given requirement notices and three were classed as a greater risk and the provider was issued with warning notices. The Regulations where warning notices were issued were Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment) and Regulation 17 (Good governance).

The manager in place at the last inspection was not registered with the Care Quality Commission and was removed from post during the inspection. At the time of the last inspection the provider was in the process of recruiting an area manager. As concerns were identified the provider and area manager were very proactive in identifying the actions they were to take to address the issues raised. The CQC raised a number of safeguarding alerts to ensure people were safe. We took assurances by the placement of the area manager and other competent managers in the home, that the risks to people in the home, would be managed going forward.

The provider began recruiting for a new manager as soon as the last one was removed and the manager currently in post has registered with the CQC. Since being in post the new manager has begun work on all of the areas identified as a concern. Some areas have been completed but others require more time to embed to enable us to identify if improvements are sustained. The introduction of a new electronic care planning system and a new electronic medication system have both shown improvements but also identified where more work is required.

At this inspection we have identified the home have met five of the 10 previously breached Regulations. Five of the Regulations remain in breach and a number of recommendations have been made to ensure improvements are sustained.

At the last inspection we issued a warning notice for Regulation 13, (Safeguarding). This has now been met. There are some concerns under Regulation 13 but these do not constitute a breach of regulation and two recommendations have been made. These are for the home to ensure all staff receive prompt training in safeguarding and the Mental Capacity Act and for the home to ensure everyone has a consistent message with regard to locking people’s bedroom doors.

We also issued a warning notice for Regulation 12, (Safe Care and Treatment). There are

We carried out an inspection of this service on the 17 and 19 of November 2015 and the 2 and 7 December 2015 and also on the 12 January 2016. We also attended the home to conclude aspects of the inspection and provide feedback to the managers and providers of the service on the 20 November and 4th December 2015. Comprehensive feedback was also provided at the end of each day of the inspection. The inspection was unannounced on each of the seven days but the provider was aware following the first day of the inspection we would be coming back to check immediate concerns had been addressed as we were told they would be. This means the service did not know the exact days we would be undertaking the inspection or indeed which was the final day until we told them on the 12 January 2016 that we would not return during this inspection process.

The length of this inspection is unusual and should not be expected again. As explained throughout this report and to the providers during the inspection; the length of this inspection was deemed appropriate due to the circumstances of the findings during the first two days of this inspection.

At the last inspection in February 2014 the provider was found non-compliant with the regulation around the safe handling and administration of medicines. An action plan was sent to the Care Quality Commission to say how the provider would meet this regulation and we took a specialist advisor who was a pharmacist with us on the 17th of November 2015 to ascertain if the action plan had been met. We found approximately half of the action plan had not been met including an increased and more structured format for audit and improvement. Over the course of the inspection the provider took steps to meet the action plan but there were ongoing concerns regarding the suitability of audit and improvement systems.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has large communal areas on both floors and can provide residential support for up to 42 people. At the start of the inspection there were 39 people living in the home. The kitchen and main dining area were on the ground floor of the building and both floors were accessible by a lift and stairs.

During the first half of our inspection process the home had a manager in post. However they were not registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. We found the manager in post at the start of our inspection had not fully understood their role in ensuring services met the regulations of the Health and social Care Act 2014. We found we were misled at the beginning of the inspection by the manager. This made our initial findings inaccurate and we were unable to use the evidence to support the home was meeting the regulations. This included being told information was available when it was not and actions had been undertaken and when we sought clarification and corroboration we found they had not been completed. The provider removed this person from post following feedback during the inspection and took immediate steps to ensure the service had suitable management cover until a full time manager could be appointed and register with the CQC.

During the first two days of the inspection we found a number of serious concerns. We saw there were not enough suitably qualified members of staff to meet the needs of people living in the home. We discussed this with the provider on day three of our inspection as only the manager was available prior to this point. We discovered the rota was not being covered when people called in sick and the homes dependency tool had not been used for some time to ascertain if there was enough staff. The provider immediately increase

This inspection took place on 10 February 2015 and was unannounced.

The last inspection of Coniston House took place on 19 March 2014. At that time we found inconsistencies in care planning and suitable arrangements were not in place to safeguard people against the risk of abuse. We deemed this to have a minor impact on people. We asked the provider to take action to make improvements in care planning and safeguarding procedures. We received an action plan, in which the provider said they would meet the relevant legal requirements by May 2014 . This action has been completed.

Coniston House is arranged over two floors, with each floor having bedrooms, bathrooms and a communal lounge and dining room. All bedrooms have en-suite facilities consisting of toilet and washbasin, with some also having a shower. There are gardens and a patio area with seating. The home is registered to accommodate 43 people. At the time of our inspection 39 people lived at the home.

The home is required to have 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 on19 March 2014 no registered manager was in place. In July 2014 a new manager was employed. This person’s application was accepted and a certificate issued on 24 December 2014.

People we spoke with all told us that they received their medication when they should. Staff administered medicines in a safe, kind and patient way. We saw that medicines were stored safely in medicine trolleys within a locked medicine storage room. However we had concerns over the access to this room. Some medication had gone missing. We also found gaps in some medicine administration records and the instructions for when people received ‘as required medicines’.

People we spoke with and their relatives told us that they felt safe and in a protected environment. Staff had received training in the protection of adults and policies and procedures in line with local guidelines were in place.

Robust systems were in place in terms of recruitment. A full range of background checks including references and Disclosure and Barring Service (DBS) checks had been completed. The DBS checks to see if there is any criminal or other reason why a person should not be employed to work with vulnerable people.

People who lived at the home and relatives we spoke with all told us they thought there were enough staff to meet people’s needs and keep them safe from harm. Staff rotas and our own observations confirmed this.

People we spoke with who lived at Coniston House told us they felt that staff knew them well and were able to access health and medical support as they needed it. Staff we spoke with were knowledgeable about the people they supported.

Staff had been supported to undertake a range of induction and basic training such as moving and handling, food hygiene and infection control. However staff we spoke with had not received training on the Mental Capacity Act 2005 (MCA) and the deprivation of Liberty Safeguards (DoLS). Whilst staff were witnessed to put the principles of the MCA into practice, their knowledge of what they were doing and why was limited.

Care plans we looked at showed people had been involved in planning their care and had given valid consent. Where people were unable to do so, we saw that their relatives had been involved in these discussions. We saw that all aspects of the recording and filing of DoLS applications and subsequent authorisations was good.

Staff we spoke with gave us mixed messages about staff supervision. We were unable to see any records that staff had received regular one to one supervision and appraisal during our time at the home. However we were provided with records which showed many people had received such support.

People who lived at Coniston House told us that they enjoyed the food in the home and that there was sufficient choice of nutritious food. We found the atmosphere in the dining room was calm and relaxed. Where people needed assistance this was done in a kind and unhurried manner.

People who lived at Coniston House and their relatives spoke well of the staff at Coniston House. Interaction between people who lived at the home and members of staff were seen by us to be respectful, kind and caring. People were treated with dignity and respect.

We found pre-admission assessments for people were of a good quality and consistent. Care plans we looked at contained details of personal information including people’s history and background. We found them to be personalised to each individual. Each care plan contained a range of risk assessments which explained the risk how staff should monitor and deal with each risk.

There was no restriction on visiting and contact with friends and relatives. We saw no organised activities during our inspection and the activities coordinator had recently left. However the home was actively recruiting someone to fill this post. We observed that staff had little knowledge on how to engage or interact with people who lived there to entertain them.

The home had policies and procedures in place to handle and deal with any complaints. There was information available to people on how to complain if necessary and people we spoke with knew how to make a complaint.

People who lived at Coniston House and their relatives were aware that there had been a number of changes in staff, both at management level and staff on the floor. They told us the new manager was approachable and supported the changes which had been made.

Staff we spoke with told us they felt happier and that there was now a better atmosphere. Staff told us they attended handover meetings at the start of every shift and regular staff meetings were held.

Regular audits and checks were carried out by the registered manager and other members of the management team for the home. We saw a system in place for the registered manager to monitor the response times when people used their call bells and a new medication audit tool had just been introduced.

We saw records of fire equipment, emergency lighting, water temperatures and the electrical system being checked. The home was also subject to internal inspections and audits by the family members of Rochcare (the parent organisation for the home), for instance the regional manager visited the home on a frequent basis.

We found that [the registered person had not protected people against the risk of people receiving their medication in a safe manner. This was in breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 (1)(g) 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 the report.

The manager was not on duty on the day of our inspection. We did make contact following our visit, in order to clarify certain aspects of our findings.

Care plans were in place and regular reviews were recorded. The majority of care plans we viewed were person centred and provided clear guidance for staff to follow. Personal profiles had been drawn up, giving good information regarding the individual’s history, abilities and preferences. We saw that when issues were identified care plans had been updated to reflect the changes.

However we found some inconsistencies regarding pre admission assessments, risk assessments, care planning and the support people received.

The relatives we spoke with provided positive feedback about the care provided at Coniston House. Comments included; “It is a lovely place. I have no complaints. The staff are very good.” And “Everything is going very well. I am extremely satisfied.”

There were short falls regarding staff training, written guidance and reporting practices regarding adult protection. Safeguarding arrangements need to be strengthened.

This inspection was carried out to follow up concerns we previously identified regarding; the care and welfare of people who use the service, the management of medication and the processes used to assess and monitor quality at the home.

During this inspection we found that the home had made the required improvements.

The manager monitored care plans and risk assessments to ensure these were regularly reviewed and updated. Regular reviews helped to ensure that changes were identified and responded to.

The relatives we spoke with were satisfied with the standard of care at the home. Comments included; “Everyone is very helpful.” And “The move here was handled well. We have no complaints.”

Medication management had improved. Some people were prescribed medication to be taken when required, such as for pain relief or constipation. There was now written guidance to advise staff when this should be given. This helped to promote consistency of use and ensured medication was given when needed.

The quality of the service was being monitored. Audits and checks highlighted areas for improvement and action was then taken to address any shortfalls.

At the time of our inspection a new manager had been in post for five weeks.

People told us their health needs were being met. One person living at the home told us, “When I was ill in bed they kept an eye on me. The staff kept popping in. They are very good.” The relatives we spoke with told us they were kept informed of important events.

There was a need to strengthen the care planning and review process. Although there was no evidence that people’s needs were not being met, the current arrangements did not ensure that full, thorough and regular reviews of people’s needs were carried out.

We found that medication practices needed to improve. People were not fully protected against the potential risks associated with medicines.

The induction and training of staff helped to ensure staff were equipped for their role. Staff meetings and individual staff supervision sessions provided good opportunities for staff to share their views. Staff told us “We can go to the manager or the deputy with anything.”

At the last inspection we identified some areas of non compliance and we saw that some improvements had been made. However there were still elements of the action plan outstanding. Improvements to the quality of the service had not been made in a timely manner.

A comprehensive complaints procedure was available. Records were kept of any complaints received and the action taken. Systems were in place to promote learning and service improvement from complaints.

The majority of relatives we spoke with were satisfied with the quality of care provided.

Due to their dementia symptoms some people living at the home were unable to give us their views about Coniston House. The majority of those we spoke with did indicate they were settled and happy at the home.

The relatives we spoke with were generally satisfied with the quality of the service. We were told that staff were polite and friendly and that relatives were kept up to date with any changes or health problems.

Staff told us they had good information about the needs of those they cared for and they received good support from the manager and senior staff.

We saw people were treated with respect and there was good information about each person’s past life, which helped the care staff to get to know them, their past skills and interests.

We found some inconsistencies regarding assessments, communication and responding to changes which could result in people’s needs not being fully met. Improvements could make meal times a more enjoyable social experience.

Medication arrangements needed to be improved and we saw some risks at the home that had not been identified or made safe. Quality monitoring was not effective.