This inspection took place on 13 and 14 March 2018 and was unannounced. Crawshaw Hall Medical Centre and Nursing Home is a ‘care home’ that provides accommodation for up to 50 people, some living with dementia. At the time of this inspection 47 people were using the service.

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.

At our last inspection on 9 January 2017 the service was rated ‘Requires Improvement’ overall. We found a breach of the regulations relating to the safe management of medicines and rated the key question ‘Safe’ as ‘Requires Improvement’. We asked the provider to make improvements in this area and they kept CQC informed of the changes that had been made.

At this inspection we found the provider had taken action to monitor and manage risks surrounding medicines. People received their medicines as prescribed by health care professionals. The home was no longer in breach of the regulations.

At the time of the inspection the home had a manager in post who was going through the process of registration with the Care Quality Commission (CQC). They subsequently became registered on 22 March 2018. The previous registered manager had stepped down to become the deputy manager and clinical lead at the home in July 2017. A registered manager is a person who has registered with the 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.

All of the staff we spoke with said they enjoyed working at the home. They said they received good support from the manager, provider and nursing staff. They felt their contributions in meetings were recognised and management staff listened to what they had to say.

People told us they felt safe living at the home. Training records confirmed that staff had received training on safeguarding and there was a whistle-blowing procedure available and staff said they would use it if they needed to. There was a good staff presence at the home and staff were attentive to people’s needs.

Action was taken to assess any risks to people and risk assessments and care plans included information for staff about action to be taken to minimise the chance of accidents occurring.

Staff had the knowledge and skills required to meet people’s needs. The manager and staff had a good understanding of the Mental Capacity Act 2005 and acted according to this legislation.

People told us they enjoyed the meals provided to them and they could choose what they wanted to eat. People were supported to maintain good health and they had access to healthcare professionals when they needed them.

People had been consulted about their care and support needs. These needs were assessed before they moved into the home. Care plans and risk assessments included detailed information and guidance for staff about how people’s needs should be met.

People’s privacy and dignity was respected. There were activities for people to partake in if they wished to do so but improvements were required around this and we have made a recommendation about this in the ‘Responsive’ section of the main body of this report.

The home had a complaint’s procedure in place and people said they were confident their complaints would be listened to and acted on.

The provider recognised the importance of monitoring the quality of the service. They sought the views of people using the service, their relatives and friends through residents’ and relatives’ meetings and satisfaction surveys. The manager and senior staff worked with professional bodies to make improvements at the home.

The inspection took place on 9 January 2017 and was unannounced.

Crawshaw Hall medical centre and nursing home is registered to provide care for up to 50 people. The home is registered with the Commission to provide nursing or personal care for older people as well as treatment of disease disorder and injury, for people living with a dementia, mental health, older people, people with a physical disability, and younger adults. The home is divided into two separate units; one is described as the dementia unit and the other as the medical unit. At the time of our inspection there were 42 people in receipt of care. All but two of the bedrooms were of single occupancy and all had access to either washing facilities or an ensuite room. There was a large garden with seating available for people to use; weather permitting.

The registration requirements for the home required a registered manager in post. The service had a registered manager in post on the day of our inspection. 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.

At the last inspection on 15 and 17 August 2016, we identified 10 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance, records, person centred care, dignity and respect, nutrition, fit and proper persons employed, staffing, infection control, medicines, premises and equipment. We also identified one breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 in relation to failure to submit statutory notifications to the Commission. We asked the provider to take action to make improvements and to send us an action plan. The provider complied with our request. During this inspection we found significant improvements had been made.

During this inspection we identified a breach in relation to the safe management of medicines.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Whilst improvements had been made in the safe administration and handling of medicines since our last inspection, we saw some further improvements were required.

Policies and procedures in relation to the safe handling of medicines had been updated since our last inspection. However there was no guidance in place to support staff on monitoring ambient room temperatures where medicines were stored.

People and relatives told us they felt safe in the home. Staff had access to updated policies and procedures to guide staff on the process for reporting any allegations of abuse.

Staff recruitment processes were in place and people were cared for by appropriately trained staff. The provider had recently purchased training from a new company and a planned programme of training was in place. Since our last inspection we saw regular supervisions and appraisals had taken place.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. There were completed application forms in place where it had been identified that people lacked capacity. The registered manager told us they were waiting for authorisation from the relevant authority.

People were treated with dignity and respect. Staff were observed speaking quietly to people when they discussed their care needs. People who us

We undertook a comprehensive inspection on 15 and 17 August 2016. The first day of the inspection was unannounced which meant they did not know we were coming.

Crawshaw hall medical centre and nursing home is registered to provide care for up to 50 people. The home is registered with the Commission to provide nursing or personal care for older people as well as treatment of disease disorder and injury, for people living with a dementia, mental health, older people, people with a physical disability, and younger adults. The home is divided into two separate units one is described as the dementia unit and the other as the medical unit. At the time of our inspection there were 47 people in receipt of care from the provider.

The registration requirements for the provider stated the home should have a registered manager in place. There was a registered manager in post on the day of our inspection. 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 inspection we identified breaches of the of the Health and Social Care Act 2008 regulations 2014 relating to medications, premises and equipment, staffing, fit and proper persons employed, dignity and respect, good governance, records, person centred care, infection control, recruitment and the 2009 registrations regulations relating to notifications.

People we spoke with told us they felt safe in the home. Staff were able to discuss the appropriate procedures they would take if they suspected abuse. Systems to protect people from the risk of abuse were in place. We saw evidence of completed safeguarding investigations which had been carried out appropriately.

Medicines were not managed safely; we observed the trolley was left unsupervised during the medication round and was not secured to the wall when not in use. We saw that staff did not check medicines had been taken when administered to people.

There was some evidence of risk assessments in place however we saw that these had not been up dated for three months. One record stated competency checks for medicines administration had been undertaken, however when we checked this with the provider these had not been completed.

The provider told us the relevant documentation was in place to protect people from unlawful restrictions. However we saw that the provider had failed to inform the Commission of three approved Deprivation of Liberty Safeguard applications.

People living in the home were offered choices of meals. We saw menus on display with meals choices on offer on the day of the inspection in one of the units. Some staff were seen engaging in a meaningful and positive dining experience with people who used the service however other people’s dining experience was observed as being inadequate.

There was evidence of staff training being provided. However we identified some concerns relating to the delivery of care by one staff member who had not received recent training or competency checks to confirm they had the knowledge to undertake this activity.

People we spoke with told us staff asked permission before undertaking any care delivery and we observed staff knocking on people’s door and waiting to be invited in. Care files had some evidence of consent being obtained from people who used the service or their relative, however not all records we examined recorded this.

People we spoke with told us they were happy with the care they received at the home. We saw some evidence of appropriate and timely support for people who used the service.

We observed some concerns relating to the dignity and respect afforded to people. Staff were seen failing to engage positively with people whilst supporting them with drinks and meals

We previously visited the service on 28th May 2014 and identified a breach of regulation 18 consent to care and treatment as well as regulation 14 meeting nutritional needs. We asked the provider to send us an action plan to tell us how they would ensure the breach was met. We revisited the service on 31st March 2015 to follow up on these breaches. The inspection was carried out by an adult social care inspector. During our inspection we spoke with four care staff and the registered manager. We spoke with people who use the service and undertook observations in public areas of the home. We looked at care records for six people who use the service as well as records relating to people's daily care.

Is the service safe?

Staff, people who live at the home and visitors told us they felt there was enough staff on duty at any time. This enabled people to be assisted with the food and drink in an appropriate time. All staff felt they received sufficient relevant training and felt competent to do their job. A member of staff told us "Yes there are enough staff here."

Is the service effective?

People's needs were being met at the home. We found people's needs were assessed in a timely manner and care files included information about people's diagnosed health conditions as well as their preferences. People's nutrition was monitored and there was liaison with other services.

Is the service caring?

We observed staff were kind, encouraging and spoke to people who used the service in a friendly manner. People appeared to be treated with dignity and the staff could tell us how they ensured peoples dignity was maintained. During mealtimes people were assisted in a calm manner and had their meal explained to them.One member of staff told us "I always knock on people's door." One person who lived at the home told us "The staff here are friendly and welcoming."

Is the service responsive?

People's needs had been assessed before they moved to the home. People's records identified personal preferences and choices and the support that needed to be provided. People had consented to the care that they received. The staff worked with GPs, dieticians and district nurses to ensure the appropriate care was being given to people.

.

Is the service well-led?

Staff felt listened to and supported by the registered manager. Staff had access to and were supported to undertake relevant training. There were systems in place to monitor the quality of the service.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

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 safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This a summary of what we found:

Is the service safe?

The manager told us there were two Deprivation of Liberties Safeguards (DoLS) in place at the home. We saw up to date documentation relating to DoLS in place and had been signed and dated appropriately in one file. However documentation relating to DoLS in the second file we looked at was out of date. There was no record of action for review seen.

There was evidence of care planning in place for two of the four care files we looked at. However we saw out of date care planning in one file in relation to DoLS and no care plan in relation to the second DoLS. This meant staff did not have access to upto date information in relation to the specific care need of people living in the home.

We saw risk assessments were in place and had been updated in the care files we looked at.

We looked at the duty rota and saw appropriate numbers of staff were in place to care for people living in the home. We were told the home very rarely used agency staff to cover sickness or holidays. This meant people living in the home received care from a regular and knowledgeable staff team.

Is the service effective?

We were shown an activity folder. There were details of people likes and dislikes and preferred activities in this. We saw evidence of activities taking place. A relative told us there had been a garden party the previous week, which people had enjoyed.

We looked at two training files in the home. We saw evidence that some training had taken place for example, person centred care, dignity in care and pressure ulcers. However not all staff had undertaken all training in the last year. An example seen was, only three staff members had completed training in dignity in care. The manager told us they would rectify this as soon as able.

There were copies of thank you cards on display in the link corridor to both units. An example comment was, ‘On behalf of (Named person) family I would just like to thank you for the caring and professional way you looked after (Name person)’.

Is the service caring?

We undertook a short observation framework for inspection during the lunch time period in one of the lounges. We observed staff engaged in little meaningful conversation with the people they were assisting. People who used the service were not informed of meal choices of drinks they were offered.

We looked around the home and in both units. The bedroom we looked at had been personalised with personal items and mementos.

We spoke with people living in the home who told us, “I feel safe and cared for. They (staff) take us out and they do things. I feel involved in decisions about my care”, “I am very happy here. If I ring my buzzer the staff come”, “I am happy with my care the staff are fine” and, “I am well cared for and happy”.

Is the service responsive?

We saw evidence of team meetings were taking place and staff we spoke with told us they attended the meetings and were able to voice their views.

There was evidence of resident and relative meetings taking place. Relatives we spoke with confirmed they were able to attend these and minutes. They were also sent copies of minutes to their home. This meant they were kept informed about the operation of the service.

Is the service well led?

There are two registered managers at the location, one based in the medical centre the other based in the nursing home. We spoke with the operations director on the day of our inspection. We were told he takes an active part in the running of the home and is visible in the home.

We asked for feedback about the managers and operations director from members of staff and people who live at the home. We were told, “(Named operations director and manager) are easy to approach with any concerns”, “(Named operation director) is brilliant” and, “(Named operation director) and the manager are very supportive, they are their all the time”.

We saw evidence of staff meetings taking place, with notes and topics discussed. This meant people living in the home were cared for by and updated and informed staff team

We asked about how they monitored the quality of service provision. We were shown evidence of audits taking place on, care plans, falls and medications. Action plans had been developed to address any shortfalls. We saw the audits had been completed recently and there was evidence of previous audits taking place.

We asked about staff supervision. We were shown a supervision file for the staff working in the medical centre. We saw evidence that supervision had taken place recently and there were notes on topics that had been covered. We noted however supervision prior to this had not been undertaken for some time for example one person’s file noted that the last supervision prior to April 2014 was October 2013. This is important to ensure staff have the opportunity to discuss their experiences of working in the home and identify any future training needs.

People told us they were treated with respect and were happy with the care and attention they received at Crawshaw Hall. One person said, “Everybody’s very nice, they look after us very well.” One visitor said, “The staff are very caring and kind, I couldn’t praise them enough.”

We found that members of staff had a good understanding of safeguarding procedures and told us they would report any concerns immediately.

We noted that all members of staff received the training they needed in order to provide safe and effective care for people using the service.

We saw that systems were in place to monitor the quality of the service provided. There was evidence to demonstrate that people were regularly consulted about the care and facilities provided at the home.