This inspection took place on 14 and 15 August 2018 and was unannounced.

County Homes 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.

The home is registered to provide personal care and nursing care for up to 90 people, however the manager told us that the maximum number of people accommodated is now 82 because a number of rooms were registered for double occupancy but are no longer shared.

The home 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. The home had a registered manager who had been in post for several years.

The manager told us that all of the people accommodated were living with dementia and required nursing care. The home was divided three units known as Chester, Lancaster and York. Each of these had a unit manager. Each unit was further divided between ground and first floors, which meant that the maximum number of people living in each area was 14. Each area had its own lounge and dining room. Three areas accommodated men only and two accommodated women only.

At our last inspection of County Homes in July 2017, we found a breach of Regulation 9 of the Health and Social Care Act: Person-centred care, because care plans did not always provide sufficient details to enable staff to meet people's needs safely, and planned care was not always evidenced as provided. During this inspection we found that improvements had been made to the care plans and there was no longer a breach of regulations.

Relatives we spoke with told us that they felt their family members were safe in the home and that they had no concerns regarding their care. They told us the staff were kind and caring and protected the dignity and privacy of people living in the home. Visiting relatives were made welcome and were encouraged to be involved in the care and support of their loved one.

Staff were recruited safely. Staff were supported in their role through an induction, supervisions and an annual appraisal. Training was provided to ensure staff had the knowledge and skills to meet people’s needs.

People’s medicines were managed safely.

Applications to deprive people of their liberty had been made appropriately. Records showed that consent was sought in line with the principles of the Mental Capacity Act 2005.

Feedback regarding meals was mainly positive, however there were some room for improvement. Staff were knowledgeable about people’s individual nutritional needs and preferences.

A range of social activities was provided to keep people stimulated and occupied.

The manager and the area director completed regular quality monitoring audits which identified any areas needing improvement. Action plans were agreed and implemented by the manager and the staff team.

This inspection took place on 19 and 20 July 2017 and was unannounced.

County Homes is a large care home set in its own grounds in the Woodchurch area of Birkenhead. The home is registered to provide personal care and nursing care for up to 90 people living with dementia, across three units within the home. Each unit is separated between the ground and first floor. Chester unit comprises of 14 beds for both male sand females on the ground floor and 14 male only beds on the first floor. Lancaster unit comprises of 14 male only beds on the ground floor and 13 female only beds on the first floor. York unit has 14 male only beds on the first floor and 13 female only beds on the first floor.

During the inspection, there were 71 people living in the home.

At the last inspection in November 2016, we identified breaches of Regulation regarding safe care and treatment, staffing, the governance of the service and person centred care. We issued warning notices to the provider in relation to safe care and treatment and the governance of the service. The provider submitted CQC with a plan of action which identified the actions they would take to address the breaches of regulation. During this inspection we looked to see whether improvements had been made.

In November 2016 we found that risk to people was not always assessed accurately. During this inspection we found that staff had completed risk assessments to assess and monitor people’s health and safety. These assessments were reviewed regularly and appropriate measures put in place based on the outcomes. PEEPs were in place for people, which were detailed and provided information on how to support people to evacuate the home. We found that improvements had been made in how risk was assessed and mitigated and the provider was no longer in breach of regulation regarding this.

At the inspection in November 2016 we found that the building was not always safely maintained. During this inspection we saw that internal and external arrangements were in place for checking the environment to help ensure it was safe. During the inspection we observed that three fire doors did not close adequately within their frames. The registered manager arranged for them to be repaired immediately. We found that improvements had been made and the provider was no longer in breach of this part of the regulation.

At the last inspection we observed that people received unsafe care and support, such as when mobilising and eating. During this inspection we observed safe care being provided at all times throughout the inspection.

In November 2016 we found that there were not sufficient numbers of staff on duty to meet people’s needs in a safe and timely way. During this inspection we found that improvements had been made and staff and relatives we spoke with told us there were enough staff on duty each day to meet people’s needs. We found that improvements had been made with regards to staffing levels and the provider was no longer in breach of regulation regarding this.

At the last inspection we found that systems in place to monitor the quality of the service were ineffective. During this inspection we found that audits were completed which identified actions required to improve the service. However it was not always clearly recorded as to whether the actions had been completed, though those we checked had been addressed.

In November 2016 we found that activities were not provided for all people living in the home and people’s hobbies and interests were not considered within activity provision. During this inspection we found that improvements had been made and activities were provided both in groups and on a one to one basis, based on people’s hobbies and interests. The provider was no longer in breach of regulation regarding this.

Care plans provided person centred information regarding the care and support people received and people’s preferences and life experiences were reflected throughout their

This was an unannounced inspection carried out on 1, 2 and 4 November 2016. County Homes is a large care home set in its own grounds in Woodchurch, Wirral. The home is registered to provide personal care and nursing care for up to 90 people. The home primarily caters for adults who live with dementia.

The home accommodates six individual units over two floors. Some units are mixed, other units are male or female units only. Each person in the unit has their own bedroom and some of the bedrooms have en-suite facilities. A passenger lift enables access to all floors for people with mobility problems. In each unit there is a communal lounge and dining room for people to use. There is also a pleasant garden for people to enjoy and a small car park.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’

During this visit, we identified concerns with the safety and quality of the service. We found breaches in relation to Regulations 9, 12, 18 and 17 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 this report.

We looked at the care files belonging to seven people. We found some people’s needs and risks were not properly assessed and some management plans did not give staff sufficient guidance on how to meet people’s needs and keep them safe.

Some of the people who lived at the home displayed challenging behaviours. We found that people’s support in relation to this was inadequate. Staff lacked sufficient information on the potential causes of the people’s distress and how to support people to communicate their needs in a more constructive way. The support provided was not person centred and in some instances not an appropriate way to meet people’s needs. Dementia care overall was poor and staff had limited guidance on to communicate with and provide emotional support to people who lived with dementia.

Some of the moving and handling techniques used by staff at the home to support people’s mobility was unsafe. People’s nutritional needs were assessed with advice sought from the dietician when required. People had enough to eat and drink but some people who required assistance to eat their meals were not supported in a safe way. This placed people at risk of harm. People we spoke with were generally pleased with the quality and choice of food that they had at the home.

Some of the people we spoke with said there was not enough to do. We saw that some activities were available upstairs in the home’s activity room but no thought had been given to those people who due to their dementia were unable to participate in these activities. We saw some people had no access to any meaningful or suitable activities and spent most of the day sat in a chair or wandering around the unit. This did not promote their emotional well-being or quality of life. People’s care files contained information about people’s previous hobbies and interests but there was no evidence that this information had been used to plan activities designed to occupy and interest people.

Of the seven people’s files we looked at, six had personal emergency evacuation plans (PEEPs)in place that contained personal information about their needs in an emergency situation. One person did not have a PEEP in place and the PEEPs we looked at did not contain adequate information about people’s support needs. This information was also displayed in the entrance area of the home which did not respect people’s confidentiality.

People’s capacity was assessed in accordance with the Mental Capacity Act but capacity a

We spoke to four people who lived at the home and five relatives. People said they were well looked after and that staff always sought their consent prior to care being provided. People’s comments included “They ask if it’s alright by explaining what they want to do or want you to do” and “Staff explain what they are going to do and if I don’t agree I say so”.

We reviewed five care records. We saw people's needs were assessed and regularly reviewed. Care records contained information about a person's needs and promoted the person's independence where possible. We saw that where people had limited mental capacity, care plans detailed how to communicate with people so they were able to be involved in decisions about their day to day care.

We found the building provided a safe and suitable environment for people to live in but noted some parts of the home needed redecoration and refurbishment. We were told there were plans in place to ensure improvements were made to the home.

We reviewed six staff files. We saw there were recruitment and selection practices in place that ensured appropriate checks on the suitability and competency of staff were undertaken prior to employment. We also saw evidence that staff were appropriately supported and trained to care for people.

Staff we spoke with were knowledgeable about people's needs and spoke fondly about the people they cared for. We saw they treated people kindly and supported them at their own pace.

We spoke with people who lived at the home and relatives who were visiting them and they were all happy with the service provided. One person told us “Its very good here, I am kept clean and my bed is comfortable.” Another person said “I’ve no complaints about anybody.” A visitor said “The carers are all lovely.” We also looked at some letters that had been sent to the home. Comments included “The care and attention [my relative] receives from the staff seems excellent and we are grateful that in her last years she feels happy and cared for.” and “We are extremely grateful for all the professional and caring support you gave to [our relative]. It is heart-warming to know that there are such people in the world.”

At the time we visited, nobody living at the home was very ill or being looked after in bed. The staff team had completed the ‘Six Steps’ training programme for care homes to deliver the best end of life care and this was incorporated into the care plan for each person. People living at the home had a choice of several local GP surgeries. We spoke with a GP who told us that he visited County Homes twice a week and carried out regular reviews of all his patients. He described his relationship with the home as ‘great teamwork’ which ensured that people’s needs, and changes to their needs, were recognised and met.