This inspection took place on 13 and 14 December 2018 and both days were unannounced.

Greenfields Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Greenfields Care Home is registered to provide accommodation and personal care for people living with dementia, older adults who may have physical disability, and mental health care needs. It is situated in St. Helens in Merseyside. Accommodation is provided on two levels, with a lift to both floors and wheelchair access to all parts of the home. The home can accommodate up to 30 people. At the time of this inspection, there were 28 people who lived in the home.

The service had 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.

We previously inspected this service in May 2016. After this inspection we received concerns regarding the provisions of activities in the home. We carried out a focused inspection in May 2017 and looked at the questions, Is the service responsive? and Is the service well led? The concerns were not substantiated. The registered provider was compliant with all regulations at that time and the service was rated overall ‘good’.

During this inspection in December 2018 we found shortfalls in relation to the management of risks associated to receiving care. This was because people at risks of falls and unintentional weight loss had not always received adequate support following falls or excessive weight loss. Accident and incidents had not been analysed to identify patterns and ensure lessons were learned. Assessments had not been undertaken before equipment such as bedrails and bed levers were used. There were shortfalls in the safe management of medicines and staff recruitment procedures were not robust to protect people.

Consent was not always sought where it was necessary to monitor people’s movement in their bedrooms. There were significant shortfalls in staff training supervision and appraisals. Quality assurance systems were not effective in identifying shortfalls or areas where the service was not meeting regulations and failure to drive improvements. In addition, there was a failure to inform CQC of significant events or incidents in the home. The provider had not always shared information about injuries with people’s relatives and information provided to CQC through the Provider Information Return (PIR) was not accurate. We had concerns about the provider’s ability to meet their duty of candour.

These shortfalls were six breaches of Regulations 11,12,17,18 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was a breach of regulation 18 of the Care Quality Commission Registrations Regulations. We made a recommendation in relation to medicines management. You can see what action we told the registered provider to take at the back of the full version of the report.

Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements withi

We carried out a comprehensive inspection of this service on 19 and 20 May 2017, the first day was unannounced. The service was found to be good across all domains safe, effective, caring, responsive and well-led with an overall rating of Good.

After the inspection in May 2017 the Care Quality Commission (CQC) received a number of anonymous complaints that highlighted specific areas of concern at the service that related to activities, people's involvement in their care plans and leadership.

This report only covers our findings in relation to the responsive and well-led domains that reflect on the areas of concern raised. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Greenfields Care Home' on our website at www.cqc.org.uk.

Greenfields Care Home provides accommodation for up to 28 people who require support with their personal care. The home mainly provides support for older people and people living with dementia. There were 28 people living at the home at the time of our inspection.

There was a registered manager in post within the service and has been registered with the CQC since November 2013. 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 and associated Regulations about how the service is run.

At our focused inspection on 9 June 2017, we were unable to substantiate the information received within the anonymous complaints.

People and their relatives were aware of the complaints process and told us they would feel confident to raise any concerns or complaints they had. The complaints policy and procedure had been followed appropriately for the complaints reviewed.

People's needs were assessed prior to them moving in to the service. Comprehensive care plans and risk assessments were developed and were regularly reviewed. Care plans were specific to the individual and gave staff clear guidance for the way a person wanted to be supported.

Records documented daily tasks undertaken to support people and highlighted key information including any changes to a person. Monitoring charts were in place for the management of pressure area care, nutrition and hydration when required.

Activities were encouraged at the service and a daily programme was available for people to participate in. People's spiritual needs were met through local clergy visiting the service regularly.

The quality monitoring systems in place ensured the standards were monitored and highlighted areas for development and improvement. Audits were undertaken in the areas of health and safety, environment, infection control and medication management.

There was a positive culture within the service that reflected the registered providers vision and values.

The inspection took place on the 10 and 11 May 2016 and was unannounced.

The service is located in St. Helens in Merseyside, and provides residential care for older people. The service is registered to accommodate up to 28 people and at the time of the inspection there were 27 people living at the service.

There was a registered manager in post within the service. 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 protected from the risk of abuse. Staff had completed safeguarding training and were aware of how to report any concerns that they may have. The registered manager held an up-to- date copy of the local authority’s safeguarding policy, and also had a whistleblowing policy in place.

There were sufficient numbers of staff in place to meet the needs of people using the service. People commented that staff were quick to respond to call bells, and rotas indicated that staffing numbers were consistent. Recruitment processes were robust, which ensured that staff were suitable to work with vulnerable people.

Checks had been completed on the environment to make sure it was safe. This included a gas and electrical safety check, as well as checks and servicing of the lift and other electrical equipment to ensure it was safe for use.

People were supported to take their medication as prescribed. There was an electronic system in place to support staff with dispensing medication, which helped reduce the possibility of errors occurring, and also prevented over and understocking of medication. People’s medicines were stored appropriately in a secure room, to prevent unauthorised access.

Staff had completed training in the Mental Capacity Act 2005 (MCA), and were aware of their roles and responsibilities in relation to this. The registered manager had referred those people who required deprivation of liberty safeguards (DoLS), to the local authority as appropriate, in line with the MCA. This meant that people’s rights and liberties were being protected.

Staff had been supported to undertake training in a number of areas, which included; infection control, moving and handling and first aid. Some staff were in the process of achieving additional nationally recognised vocational qualifications in health and social care. This ensured that staff knowledge was up-to-date and in line with best practice.

People’s comments on the food varied, however attempts had been made to improve the variety and choice available, which people commented positively on. People with special dietary requirements received meals that were appropriate to meet their needs, for example diabetic options. Kitchen staff said they were aware of those people who required a special diet. However, written records were not available for kitchen staff to refer to. We raised this with the registered manager who said that they would rectify this.

People were treated with dignity and respect. People and staff had developed a good rapport which was evident in their interactions with each other. Staff had a good knowledge of the people they supported and their individual needs. People and their relatives told us that staff were friendly and professional.

Staff had access to detailed and up-to-date information on people’s needs. Care records contained information about people’s physical and mental health needs, and were reviewed on a regular basis to ensure they remained up-to-date. This meant that staff had the information they required to provide people with the appropriate level of support.

People were aware of the complaints process and told us that they would feel confident in making a complaint if they had to. A copy of the complaints process was given to people when the

We considered our inspection findings to answer 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

Is the service safe?

We carried out a tour of the premises and saw that it was safe. We observed that up to date fire extinguishers and portable appliance checks had been carried out and were found to be suitable and safe to use. We saw people throughout or inspection being treated with dignity and respect by the staff on duty.

We saw members of staff positively interacting with people who lived in the home. Eight of the people, who lived in the home, told us they felt safe living at Greenfields Care Home. On the day of our inspection it was very hot and sunny with people sitting in the garden. We saw people wearing hats, sun cream being applied by care staff and cold drinks being provided.

In discussion and in observation, we saw that people were relaxed and at ease, with people telling us they were happy and treated with respect and dignity.

We found satisfactory safeguarding procedures in place, with staff having had up to date safeguarding training.

Staff recruitment records contained all the information required by the Health and Social Care Act 2008. This meant the provider could demonstrate that the staff employed to work for the service were suitable and had the skills and experience needed to support people living in Greenfields Care Home.

Is the service effective?

The people we spoke with in the home were complimentary about the service that had been provided. Some of the comments were, “I feel very safe here, if I didn’t I wouldn’t stay”, “It’s really good here, can’t fault it” and “The staff are fantastic, nothing is too much trouble”. We spoke with some visitors to the home, including relatives and a health professional. Some of the comments were, “I can go on holiday and know that my (X) is safe and really likes it here”, “I can now relax knowing that the staff treat (X) properly” and “The home has a relaxed atmosphere and a nice environment. The home runs smoothly”.

The staff we spoke with demonstrated that they had a clear understanding of people’s needs and how to meet them.

We found that people’s health and care needs had been assessed by the service before they went to live at Greenfields Care Home.

Is the service caring?

During our inspection we observed that staff were attentive, caring and enthusiastic about meeting the needs of people who received a service. People positively responded to members of staff, which showed that a good rapport existed between them. We saw people were treated with dignity and respect by the staff.

One relative said, “The personal care they give to (X) is excellent, I believe that all residents are looked after very well. I know (X) is treated lovingly by the staff”. Comments from some of the people living in the home were, “The staff are always there for you” and “They (staff) are all very nice and caring”.

Is the service responsive?

Greenfields Care Home had quality assurance monitoring processes in place. We saw that the provider sought the opinions and views of people who lived in the home and also sought the views of their relatives. There was written evidence that highlighted, when any issues had been identified, the service had responded and addressed them.

We saw documented evidence that resident and relatives meetings had taken place, with actions from meetings being implemented. Staff team meetings had also been taking place. Members of staff informed us they felt supported and things had improved since the present manager arrived and the team was now more together.

Is the service well-led?

Greenfields Care Home had a manager who was registered with the Care Quality Commission (CQC) to carry out their role. The service always informed us when there were significant incidents.

In discussion with some members of staff, they said that the atmosphere in the home had improved since the new manager had arrived and the staff team were much happier and working well together.

During our visit to Greenfields, we spoke with people living in the home, members of staff, relatives of people living in the home and a visiting health professional. Some of the comments from people living in the home included, "They (staff) are very good and kind to me”, “you get some really nice food here, something different every day” and “I like living here”.

Some of the comments from relatives and a health professional were, “I can’t fault it here. The staff are very good”, “We don’t have any complaints at all”, “I find the home fine, no problems” and the health visitor commented on how accommodating and friendly the staff team were and stated, “The staff are really good at contacting us straight away if they have any concerns”.

We saw different members of staff positively interacting with people in a sensitive, inclusive and unhurried manner. We observed a reminiscence activity. People who live in the home were taking part in a meaningful and stimulating way.

We saw that people were appropriately supported to move about the home as they wished.

People living in the home told us:

"Everything evolves around meals and going to bed", "It's alright, but not my cup of tea. Nothing going on at all, it drives you mad.” and “No activities take place".

We observed support workers doing a reminiscence activity. One person said, “This is done for your benefit (compliance inspector). I have been here for four weeks and this is the first time that I have seen any activity".

Other comments from people were, "The girls are alright",

"They do what they can",

“They (staff) get a bit fed up, mainly because of the shortage of staff",

“The cook didn't turn up and it's been a struggle for them. It's not fair on them";

"All you do is sit from morning till night. No exercise. Could do with something to get you on your feet” “We never go out” and “Don’t very often see the carers between meals".

Other, more positive comments included:

"I do get treated with respect”;

” I have just had a lovely meal. The food is good" and “it’s very nice here, can't really complain".

We spoke to people living in the home who told us that they were happy living in the service. Comments included "staff are really nice", "it feels like a home from home", "it’s the next best thing to home".

Our observations on the day of our visit showed meaningful and appropriate interactions between care workers and people living in the service. We saw that people were appropriately supported to move about the home as they wished.

People living in the service told us that they were confident that there care needs were meet. Comments included "they are happy to help", "nice caring staff, nothing is an issue, they are lovely, can't ask for better", "I feel happy, safe and well looked after living here. I wasn't sure at first as I did not want to leave my home but it was a really good decision and I'm so glad I did".

People living in the service told us that they liked the care workers and other staff working in the home. Comments included

"they make me laugh, always good fun"

"they make it worth living here"

"can not fault them" and

"they try hard, work hard and would do anything to help, easily the best".