About the service: Haydock Nursing and Residential Care Home is a nursing and residential care home that was providing personal and nursing care to 48 people aged 65 and over at the time of the inspection. Some people using the service were living with dementia.

People’s experience of using this service: The provider and registered manager had made significant improvements since our last inspection of 11 July 2018. These improvements require time to become embedded within normal routines and sustained to ensure continued development of the service.

During this inspection, we found two continuing breaches of the regulations in relation to safe recruitment and safe management of medicines. We have also made a recommendation in relation to the management of complaints.

People who used the service and their relatives told us they felt safe. Staff knew their responsibilities in relation to report any concerns of safeguarding and relevant policies and procedures were in place to guide them. Risks to people’s health and wellbeing had been assessed and were reviewed on a regular basis to keep people safe. Good infection control practices were observed throughout our inspection.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Relevant deprivation of liberty applications had been submitted to the assessing authority.

People told us they were supported by staff who were knowledgeable. We saw training for staff had improved since our last inspection. People told us they enjoyed the food and were supported to access a varied diet. Staff supported people to eat their meals when necessary.

We observed staff were kind and caring when interacting with people who used the service. People who used the service gave us positive feedback about the staff. Systems were in place to ensure people were able to communicate effectively. People were treated with respect and without discrimination.

Care plans had been reviewed and updated since our last inspection. The care plans we looked at contained good information about people’s individual needs and how to support them. People had access to activities both within the service and in the community.

We received positive feedback about the registered manager and the operation and oversight of the service. Audits and monitoring had improved although the new systems needed time to become embedded within normal routines. Team meetings were taking place that provided staff with updates about the home and its operation.

More information is in the full report.

Rating at last inspection: At the last inspection this service was rated requires improvement [published 25 January 2019]. Whilst the overall rating of this service has not changed at this inspection, the ratings in some domains has improved.

Why we inspected: We undertook this inspection based on the previous ratings of the service.

Enforcement: You can see what action we have told the provider to take at the end of the full report.

Follow up: We will plan a follow up inspection as per our inspection programme. We will continue to monitor the service and if we receive any concerning information we may bring the inspection forward.

This inspection took place on 11, 12 and 13 July 2018 and was unannounced.

Haydock Nursing and Residential Care Home is registered to provide accommodation for up to 50 people who need nursing and personal care. The home has two separate units, including a unit for people with dementia and is a modern, purpose built home located on a quiet road with views over the local countryside.

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

The service had a registered manager in place. 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.

We undertook a comprehensive inspection of Haydock Nursing and Residential Care Home on the 16 September 2015. The overall rating from this inspection was Good, with requires improvement in effective. This was due to two recommendations being made in relation to staff training and staff supervisions.

During this inspection we found no improvements had been made in relation to staff training or staff supervisions. We also found a number of concerns and highlighted five breaches of the regulations in relation to recruitment, risk assessments, medicines management, training and supervision of staff. We also made recommendations in relation to supporting people and the environment on the ‘dementia specialist unit’ and end of life care.

We also highlighted other concerns throughout our inspection which were addressed immediately.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals are concluded.

We found risks had been identified for people such as, weight loss, falls and pressure ulcers. However, there were no risk assessments in place to show how these risks were being managed and to direct staff. People who were at risk of choking did not have risk assessments in place. The registered manager had also not considered the risks present within the environment.

Medicines were not managed safely within the service. We found topical creams were not being stored safely, thickening powder was not being stored or used safely, rooms were medicines were being stored were exceeding the recommended temperatures and handwritten medicine administration records were not signed or had only been signed by one person.

Recruitment systems and processes within the service were not sufficiently robust. For example, we saw people subjected to conditions on their visas were working over the stipulated hours. People who other concerns had been raised about had not been risk assessed prior to commencing employment.

We identified concerns in relation to the premises and its safety. The nurse call system in one part of the building was not working correctly; immediate action was taken and we received confirmation shortly after our inspection it was fully functioning. Some hot water outlets were running higher than the recommended 43 degrees; this was dealt with during our inspection. Water samples were not being sent off as required to check for legionella; action was taken to address this during our inspection and we were told going forward this would be maintained. Substances which would be hazardous if ingested were found accessible in bathrooms and in a cupboard; these items were immediately removed. In a number of bedrooms, we found the bedding was poor, pillows and duvets were lumpy and some sheets were threadbare; the registered manager told us they would ensure these were replaced as th

We spoke with two people who used the service, two staff members, three relatives and the administrator during this inspection. We also looked at the quality assurance systems and records. This helped answer our 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.

Was the service safe?

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, safeguarding, whistleblowing and investigations. The registered manager audited any incidents and used the information to improve the service. Two people who used the service told us, "I have no concerns and you can talk to the manager or other staff if you do have" and "I have no concerns or worries. I cannot think of anything they do wrong".

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made and how to submit one.

We conducted a tour of the home and found it was clean, warm and free of any offensive odours. There were dedicated domestic staff to clean the home. A person had shared their experience with us and said the home sometimes smelled of urine. Two people who used the service told us, "The home is clean and tidy" and "The home is always clean and tidy. I have never known it to smell". Three relatives said, "It is always clean and tidy. No nasty smells which is important", "The home is very clean and tidy and no offensive odours" and "The dementia unit is clean and tidy. There are no offensive odours that I have noticed".

Was the service effective?

People's health and care needs were assessed with them if possible, and they were involved in writing their plans of care. We looked at three plans of care and found them to be individual to people's needs and kept up to date. Two people who used the service said, "The care I get is good and I do a lot of things on my own" and "The staff treat me very privately. They are real professionals and know how to care for me. They update me about my care. We have a laugh". Three relatives told us, "They look after her very well. We are very satisfied with her care. They are very careful to give her privacy", "I am happy with her care and have no complaints about care or her treatment" and "The care is very good".

Specialist dietary, mobility, skin care and community support needs had been identified in care plans where required. Specialist equipment was provided such as pressure relieving devices or mobility aids. People had access to healthcare professionals and specialists for treatment and advice.

The manager and other key staff audited the effectiveness of the systems they used. This included medication, the environment, infection control and plans of care. The information was used to improve the service.

Staff were trained in key topics such as health and safety, infection control, fire awareness, food hygiene, medication administration, first aid, mental capacity, deprivation of liberties and moving and handling. There were other training opportunities in dementia care. Staff were encouraged to take a nationally recognised qualification in health and social care. Two staff members told us, "We get a lot of training. I have done all the mandatory training and have just updated my safeguarding and infection control training again. We get regular supervision. You can discuss what you want or bring up your training needs" and "We are very well supported and get lots of training. I like the extra training like catheter care or how to peg feed".

The meals served at the home met people's expectations. Two people who used the service told us, "There are only one or two meals I do not like but they give me something else. They give you plenty. I see lots of people cannot eat it all" and "The food is very good". Three relatives said, "The food is very nice. I used to stay here when they gave her a meal and if I wanted they gave me a meal", "When I have been here the food has been good" and "The food is very good".

Was the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. There was a friendly atmosphere within the home and we observed that staff interacted and chatted to people

who used the service. Three relatives told us, "The staff are very good and know what they are doing", "The staff are very friendly. I have got to know a few of them. They are pleasant and polite to my aunt. They know how to look after her. They arrange everything she needs such as chiropody" and "The staff are very nice. I come here five times a week. They staff know what they are doing". Two people who used the service said, " Staff are wonderful to me" and "I am happy here. It has really surprised me how well I settled in".

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. People who used the service were encouraged to provide as much information about their past lives and what they liked or did not. This information gave staff the knowledge to treat people as individuals.

People lived in a comfortable environment and were able to personalise their rooms to make them feel more at home. People who used the service told us, "I like my room and as you can see I have made it my own" and "I have a nice room with a lovely view".

Was the service responsive?

People completed a range of activities in and outside the service regularly. Each person had their known hobbies and interests recorded. Activities were suitable for the people accommodated at the home. Two people who used the service told us, "I go shopping on my own twice a week and with family on other days. I go to church when I want. I go swimming twice a week. I like to use my computer and play my keyboard" and "They take me out but when I am inside I like to read. I also knit and crochet".

The registered manager held regular meetings with people who used the service and staff. Each day staff attended a 'handover' meeting to ensure they were up to date with people's needs. Staff were able to voice their opinions at meetings and supervision sessions.

Was the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. There was a system for providing information to other providers in an emergency.

Records we looked at were up to date and policies and procedures had been reviewed by the manager. The records were stored securely and readily available for inspection.

The service had good quality assurance systems. The registered manager undertook regular audits of the service. Records seen by us showed that identified shortfalls were addressed promptly and as a result the quality of the service was continually improving.

People who used the service told us, "I cannot fault it here. It takes a bit of getting used to. They are very nice people and I am happy. It's my home", "I am all right and I am happy here. There is nothing wrong with this home and I have nothing to complain about" and "I am only here while my daughters are on holiday. It is all right and I like it here but I prefer it at home". A visitor said, "I find the home great and have no qualms whatsoever about him being here. I have no complaints". People told us they were satisfied with their lives at this care home.

Plans of care contained sufficient up to date details for staff to give effective care. The home was warm, clean, free from offensive odours and suitably decorated in a homely style. People who used the service told us they were satisfied with their bedrooms.

There was a system for repairing any faults and keeping gas and electrical equipment in good working order. This helped protect the health and welfare of staff and people who used the service.

The records we looked at were stored safely and up to date. There were sufficient records to meet the needs of people who used the service and show that staff were well trained and safely recruited.

This service was inspected in January 2012 and did not meet five standards. They sent us an action plan to explain how they would make improvements. At this inspection they were able to demonstrate they had made the improvements and met the standards.

Several people told us that care was good. Plans of care contained sufficient detail for staff to follow good practice. The plans had been developed with people who used the service or their family members to take account of their wishes.

People who used the service said, "I am very happy here. It is an excellent home. Staff leave us to our privacy. They come quickly if you want them but they leave us to ourselves when we feel like it, which is how we wish to live" and "I am very well looked after. My mobility has improved and I go out to the shops, to church and swimming". People were satisfied with the care at this nursing home.

People told us they felt safe. There were robust systems to protect people from possible harm.

People who used the service said, "It is a home from home. I have all I need in my room. I have my computer and play music on my organ. I have the freedom to come and go" and "The family helped choose the home for us. They visit us regularly and the staff are good to our visitors. I am very satisfied with the bedroom and they let me eat here, which I prefer". People were satisfied with the facilities and equipment provided by Haydock Nursing and Residential Home.

The people that we spoke with during our visit told us that they were treated well by

staff and were encouraged to make choices and decisions about how they spent their

time and about how the home was run.

People who we spoke with told us they were happy with the care and support that they

received and told us they were consulted about their daily routines. They said, "I get the support that I need" and "I see my doctor when I need to". Comments from relatives included, "I am happy with the care", "I am kept up to date with any changes" and "My wife always looks immaculate, she is looked after really well". However we were concerned about the lack of detail in the care plans which could result in staff not understanding the care that people needed.

People told us they had access to different activities and entertainments. Comments

included, "There is nearly always something going on" and "Staff tell me what is on and I can choose whether to join in or not".

People told us they were happy with the meals. Comments included "The food is excellent", "The meals are always presented nicely", "We get plenty of choice and I always enjoy the meals" and "They make sure there is something to eat before bedtime as my wife gets hungry in the night".

People told us they were looked after properly and that staff treated them well. They

said they were often asked if they were comfortable and happy and would be able to

raise any concerns with staff or management.

People's opinions about the environment varied. One person told us, "It is always lovely and clean you can't fault it" whilst others said, "Some areas are a bit tired looking" and "There is a smell despite all the cleaning". We found all areas of the home to be clean but the dementia unit had a stale odour.

People told us there were enough staff. People said, "They always come when you press the buzzer no matter what time of day or night" and "There is always someone around".

Prior to our visit we were notified of some concerns. We shared the information with social services and have referred to the concerns in our report.

The service is registered to provide personal care for 50 older people who require nursing or personal care. On the day of the inspection 45 people resided within the home.

We last inspected this service in August 2014 when the service met all the standards we inspected. This inspection was brought forward due to a complaint that staff on night duty were trainees and not sufficiently well trained to meet the needs of people who used the service.

The service had 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service had needed to change their training organisation and the delay in the provision of some training, such as food safety and the Mental Capacity Act (2005) or Deprivation of Liberties Safeguards (DoL’S) meant some staff may not have the knowledge to safely meet the needs of people who used the service. The service had located a new training provider and we saw that training sessions were planned to fill in any gaps in staff knowledge. We had confidence that the provider would ensure the training was completed. We have recommended staff complete all the necessary training to fully meet the needs of people who use the service.

Supervision had recently been completed for all staff. However, some staff had not received formal supervision for at least a year between sessions. This meant staff may not have been given the opportunity to raise any training or personal issues or have their performance scrutinised by management. We have recommended formal supervision is conducted regularly to ensure staff can air their views and have a chance to discuss their performance.

We looked at staff files and the training matrix. We found staff were robustly recruited and were employed in sufficient numbers to meet people’s needs.

There were systems in place to prevent the spread of infection. Staff were trained in infection control and provided with the necessary equipment and hand washing facilities to help protect their health and welfare.

People told us the food served at the home was good and they were offered choices about what they ate. We saw there was a good supply and choice of food.

We found the ordering, storage, administration and disposal of medication was safe.

The registered manager had completed training albeit several years ago (2009) around the Mental Capacity Act and Deprivation of Liberties and was aware of the requirements to protect people’s rights and liberty in the least restrictive way. Nine applications had been made using the correct procedures and personnel and were awaiting local authority staff to process the applications.

Electrical and gas equipment was serviced and maintained. There was a system for repairing faults or replacing equipment.

There were individual risk assessments to keep people safe and evidence that the service contacted healthcare specialists for advice or equipment when required.

People had an emergency evacuation plan and there was a business continuity plan to keep people safe in an emergency.

We toured the building and found the home to be warm, clean and fresh smelling. Furniture and equipment was suitable to the needs of people who used the service and there was a homely atmosphere.

Plans of care were individual to each person and had been regularly reviewed to keep staff up to date with any changes to people’s needs. People’s choices and preferred routines had been documented for staff to provide individual care.

People who used the service were able to join in activities if they wished and we observed people going out with their visitors. There were two people employed to provide suitable activities.

We observed that staff were caring and protected people’s privacy and dignity when they gave personal care. Staff were observed to have a good rapport with people.

Policies and procedures were updated and management audits helped managers check on the quality of the service.

People who used the service were able to voice their opinions and tell staff what they wanted in meetings and by completing surveys. People who used the service were also able to raise any concerns if they wished.

We saw the manager analysed incidents, accidents and compliments to improve the service or minimise risks.