Heath Cottage is a large detached property and provides care for up to 28 people. There were 22 living at the home at the time of our inspection

There was a registered manager at the service. The registered manager had been in post since May 2016. 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 unannounced inspection took place on 12 December 2016. At the last comprehensive inspection which was carried out 04 September 2015 the service was rated as requires improvement. We found the there was one breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was in relation to safe care and treatment. We found the provider had not protected people against the risk associated with the safe management of medication.

We carried out a focused inspection 12 January 2016 to check that the breach of relation to medicines had been met. At this inspection we found that medicines were still not being safely managed. The Care Quality Commission (CQC) issued a warning notice with conditions to be met by 25 March 2016.

At the inspection on 12 December 2016 we found that medicines were now being managed safely and the warning notice had been met. Medicines were stored appropriately. Controlled drugs (CD) were stored and handled appropriately. Procedures were in place for the safe disposal of medicines. Medicines were administered in accordance with the prescriber’s instructions. Records were completed accurately. Medicines management was audited on a regular basis and appropriate action taken when issues were identified. Staff had received training in the administration of medicines.

People told us they felt safe and secure at the home. The service’s recruitment procedures were robust and helped ensure people employed at the service were suitable to work with vulnerable people.

Staff were knowledgeable about people’s likes, dislikes, preferences and care needs. They approached people using a calm, friendly manner which people responded to positively.

Staff we spoke with told us how they encouraged and supported people to make decisions for themselves, which ensured people were able to live the life they chose.

The service was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) applications were made appropriately. Consent was sought for all interventions and there was no use of restraint at the home.

Risk assessments and detailed care plans were in place. This helped staff to deliver the care and support people needed.

People were offered appropriate food and fluids to maintain their nutrition and hydration. Those who required prompting or support to eat were assisted by patient and attentive staff which ensured that people’s nutritional needs were met.

A wide range of activities were available which people’s family and friends were invited to. People were encouraged to pursue their own hobbies and interest.

There were sufficient staff on duty to meet people’s needs. If people were upset or unwell and more staff were required, this was provided straight away to support people.

Complaints and concerns were dealt with appropriately and people were aware of how to make a complaint or raise a concern.

This unannounced Focused Inspection was undertaken on the 12 January 2016.

Heath Cottage is a large detached property and provides care and accommodation for up to 28 people. The home does not provide services to people who require nursing care. There is a car park to the side of the building and ramped access to the rear of the property.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

As part of this focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the reports from our last comprehensive inspections, by selecting the 'all reports' link for Heath Cottage on our website at www.cqc.org.uk.

We undertook an unannounced comprehensive inspection on the 09 December 2014. During that visit we found that the registered person had not protected people against the risk of associated with the safe management of medication. We undertook a further comprehensive inspection of the service on 04 September 2015. At that inspection we found that the service was still failing to protect people against the risk associated with the safe management of medication.

During our inspection conducted on the 12 January 2016, we checked the medicines and records for eight people. We found that all the records of people we looked at had photographs and their allergies recorded on their medicines records, which reduced the risk of medicines being given to the wrong person or to someone with an allergy and was in line with current guidance.

The MARS (Medicines Administration Record Sheets) had been printed by the community pharmacy, with the exception of a few handwritten MARS. The handwritten MARS had been checked and countersigned by two members of staff to check and confirm the accuracy of them. We found that one person was taking a pain killer to be taken ‘when required’ with variable doses (one or two tablets), the MAR chart had the number of tablets administered recorded to make it clear what the person had taken.

Controlled drugs (prescription medicines that are controlled under the Misuse of Drugs legislation) were being stored as per legislation, which was an improvement in comparison to when we visited in September 2015. The fridge had also been replaced and temperatures were recorded daily.

We found some medicines were not always given as prescribed by the doctor. Three people were taking medicines that should have been taken before breakfast, however these were given as part of their morning medicines rather than being separate. One person was taking a medicine to thin their blood with a variable dose, we found that on one day a dose was given that was higher than what the doctor had prescribed. This meant that this person’s blood level may have been too high.

We checked the quantity levels recorded by the home for medicines belonging to four people. The quantities recorded for medicines belonging to two people were different to what was in the home; this meant that these medicines could not be fully accounted for.

A person who was self-medicating when we visited previously did not have a lockable drawer or cupboard for their medicines and their room was unlocked. The home had since fitted a lockable medicine locker, however the service user’s room was still unlocked and the medicine cupboard had not been locked when we visited. This is contrary to current national guidance and the home was not following their own medicines policy.

This is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the registered person had not protected people against the risk of associated with the safe managemen

This was an unannounced inspection carried out on the 04 September 2015.

Heath Cottage is a large detached property and provides care and accommodation for up to 28 people. There were 19 people staying at the home at the time of our visit.

At the time of our visit, the manager was in the process of registering with the Care Quality Commission as the 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.

At our last inspection on the 09 December 2014, we found that the registered person had not protected people from the risks associated with the safe administration of medication. This was in breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

As part of this inspection, we checked to see what improvements had been made. We found that medicines were not always given as prescribed by the doctor. One person was prescribed pain control that should have been administered every twelve hours to help relieve pain during the whole day. We found the time interval between each dose was only seven hours rather than twelve.

We checked the quantity levels recorded by the home for medicines belonging to three people. The quantities recorded for medicines belonging to two people were different to the stock at the home, which meant that these medicines could not be fully accounted for.

Controlled drugs, which are prescription medicines that are controlled under the Misuse of Drugs legislation, were not stored as per legislation. Other medicines were generally stored safely.

A person who was self-medicating did not have a lockable drawer or cupboard for their medicines and their room was unlocked when we visited. This was contrary to current national guidance and their current policy.

We found current fridge temperatures were recorded, but most of the results since July 2015 had been outside the recommended fridge temperatures for storage of medicines. The inside of the fridge was wet, which could increase the risk of contamination.

Medicines audits had been completed, but no action had taken place where concerns had been identified. For example, the audit had not identified the non-compliant controlled drugs cupboard and the lack of records of stock checks. Fridge temperatures had been recorded, but no action had been taken about temperatures outside the recommended range.

We found that the registered person had not protected people against the risk of associated with the safe management of medication. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

People who lived at the home told us that on the whole they did feel safe living at Heath Cottage.

During the inspection we checked to see how people who lived at the home were protected against abuse. We found the home had suitable safeguarding procedures in place, which were designed to protect vulnerable people from abuse and the risk of abuse.

We looked at a sample of seven care files to understand how the service managed risk. We found the service undertook a range of risk assessments to ensure people remained safe.

On the whole during our visit, we found there were sufficient numbers of staff on duty during the day to support people who used the service. However, we saw several instances of staff members talking in group in corridors leaving people unattended in lounges. People we spoke with told us that at times they did not think that there was enough staff on duty to deal with their needs or their loved ones needs.

We found that staff received regular supervision and training to enable them to carry out their duties effectively.

We found that before any care and support was provided, the service had obtained written consent from the person or their representative, which we verified by looking at care plans. During our inspection, we observed staff seeking consent from people before undertaking any tasks. This included when supporting people eating, mobilising or when attending the toilet.

During our last inspection in December 2014, we found the environment at Heath Cottage had not been adequately adapted to meet the needs of people who were living with dementia. At that time we made a recommendation for the service to explore relevant guidance on how to make environments used by people with dementia more ‘dementia friendly’. As part of this visit, we looked to see what improvements had been made by the service. We found that the environment at Heath Cottage had largely remained unchanged since our last visit.

We have made a further a recommendation for the service to explore relevant guidance on more ‘dementia friendly’ environments.

People’s views on the quality and enjoyment of the food were mixed. We saw evidence that nutritional and hydration risk assessment had been undertaken by the service, which detailed any risks and level of support required.

People who lived at the home told us they were well cared for by the staff.

Throughout the day we observed many lost opportunities by staff to engage with people who used the service. We observed residents sitting for long periods of time without being spoken to by staff.

People we spoke with said that they were happy that staff knew what care they needed. One person told us the home had been very responsive in ensuring they had a shower each day. However, some people told us that staff did not always have time to sit and chat to them about what was important to them or how they wished to be cared for.

We looked at a sample of seven care files of people who used the service. Care plans were comprehensive, person centred and of a good standard.

During our inspection, we checked to see how people were supported with interests and social activities. We saw that people were involved in group activities like cake making and other games that took place during our visit.

Relatives we spoke with told us that they knew who the manager was and felt they could approach them with any problem they had. Staff told us the manager was approachable and supportive.

During our last inspection we identified concerns regarding the effectiveness of quality assurance auditing undertaken by the service. This was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance. During this inspection, we found the provider was now meeting the requirements of regulations, however some audits such as medication were not effective in addressing concerns.

We found that the service had recently implemented a comprehensive system of auditing and governance to ensure different aspects of the service were meeting the required standards. These were undertaken by both the manager and ‘head office.’

This unannounced inspection was carried out on the 09 December 2014.

Heath Cottage is a large detached property and provided care and accommodation for up to 28 people. There were 22 people staying at the home at the time of our visit.

There was a registered manager in place, however they had been absent through a prolonged period of ill health. Temporary coverage had been provided by another registered manager from a sister home of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines effectively. We found that not all medication administration records we looked at had been signed by staff.

We were informed that only trained senior carers administered medication at the home who worked between the hours of 8am and 8pm. From reviewing records, we established that a number of people who lived at the home required the use of PRN medication, this is medication given as and when required such as Paracetamol to relieve pain. This meant no member of staff was able to administer any PRN medication during the night-time if it was required.

When we checked the medicines trolley with a member of staff, we found two medicines stored within the trolley required cold storage once opened. With one of those medicines, we found it had been opened and administered since the 28 November, but it had not been stored in line with the manufacturer’s instructions. Another medicine we found within the trolley, manufactures instructions clearly stated that the medication once opened should be thrown away after 28 days. The medicine had been opened on the 26 October 2014 and was still in use by staff contrary to the manufacturer’s instructions.

When we checked the medication fridge temperatures, we found no current records existed and the last record we found was dated 9 January 2014.

We found that the registered person had not protected people against the risk of associated with the safe management of medication. This was in breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment

We found the service did not have effective systems in place to monitor the quality of services provided. We spoke to the covering manager about the effectiveness of auditing, who agreed the current audit tools used were not effective in raising standards in quality of care. For example, we noticed that in one building audit undertaken in June 2014, a kitchen unit door required repair. We found that improvement work had still not been undertaken.

The service was unable to demonstrate how they regularly sought the views of people who used the service and took regard of any complaints, comments and views made. The last residents meeting conducted at the home was dated 20 November 2013, where minutes had been recorded. We were told that annual questionnaires were sent out to people who used the service, relatives and health professionals, though none had been sent out recently. We saw no evidence of any completed questionnaires.

The covering manager told us, concerns raised by people who used the service or their families or staff were dealt with directly by the manager and the people concerned. The covering manager confirmed that such matters were not documented.

We found that the registered person did not have effective systems for monitoring the quality of service provision. This was in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance.

We undertook a tour of the building to ensure it was clean, tidy and fit for purpose. Generally, we found that the home was clean and tidy and observed domestic staff undertaking various cleaning tasks during the inspection.

We spoke to staff and people who used the service and asked them whether they had concerns about staffing levels. We received a mixed response from people who used the service regarding suitable staffing levels. We also looked at staff rotas and on the whole found there were sufficient numbers of trained staff on duty to provide care and support for the current numbers of people staying at the home.

We saw evidence of involvement with other health care professionals within peoples care plans. These included GPs, chiropodists and opticians where necessary.

We found the environment had not been adequately adapted to meet the needs of people who were living with dementia. We have made a recommendation about environments used by people with dementia.

We observed staff were very cheerful and treated people kindly and as individuals, calling them by their names. People told us that they felt that they were treated respectfully and as individuals.

During our inspection, we observed people were treated with dignity and respect. For example, where people were asleep in their chair, they were not disturbed and were only offered something to eat or drink once they had woken up.

We saw staff allowed people to be as independent as possible when providing care. For instance, encouraging and prompting people to eat their own food at lunch time before intervening.

On the whole, care plans provided clear guidance for staff on how to provide care for people. However, It was unclear to us whether people were consulted about their continuing support needs.

From our observations and discussion with people who used the service, activities to stimulate people mentally and physical were limited. There was an activities board on display in the hallway but this was clearly out of date. We have made a recommendation about the service ensuring people have opportunities to take part in activities.

The registered manager was currently absent through a prolonged period of sickness. The covering manager who was a registered manager at a sister home divided their time between two homes. This meant the manager was not always available to provide guidance to staff when they needed it and monitor what was going on at the home.

From our observations during the inspection and speaking to staff and the covering manager, it was apparent the current management arrangements were not effective in providing a service that was able to demonstrate good leadership.

Staff told us they felt they could contribute to the running of the home and were listened to by the covering manager if any concerns were raised.

Heath Cottage is registered to provide personal care and accommodation for a maximum of 28 people. At the time of our visit there were 19 people who were resident at the home. We spoke to six people who used the service, five visiting relatives and friends and four members of staff.

At the time of our inspection the registered manager was on long term sickness and temporary management arrangements were in place until the registered manager was able to return to work.

Our inspection was co-ordinated and carried out by an inspector, who addressed 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. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. Safeguarding procedures were in place and staff were able to demonstrate they understood how to safeguard the people they supported.

We found systems were in place which made sure managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. We found though most staff had received training, the staff we spoke to had limited knowledge of the legislation. The service were able to demonstrate that refresher training had been scheduled for all staff.

The service was safe, clean and hygienic. Equipment was maintained and serviced regularly therefore not putting people at unnecessary risk.

Management set the staff rotas, they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. We found on the day of our inspection there were sufficient numbers of staff available to meet the needs of the 19 people who used the service. This ensured that people’s needs were always met.

Recruitment practice was safe. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

It was not clear to us that people’s health and care needs were assessed with them, and that they were involved in writing their plans of care.

Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Visitors confirmed that they were able to see people in private and that visiting times were flexible. One visitor told us “My impression is it is a very comfortable place, staff are very friendly. We can visit at any time and are always made to feel welcome.”

Is the service caring?

People were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. People commented “Everything is taken care of, they are dedicated and kind and I’m very satisfied.” “No complaints, they do their job and work so hard.”

People who used the service and their relatives completed a satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People’s preferences, interests, and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People completed a range of activities in and outside the service.

People knew how to make a complaint if they were unhappy. The complaints procedure was displayed within the home.

Is 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.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. They felt supported by both management and the provider.

We spoke with five people who lived at the home and the relatives of three people who used the service. People we spoke with were quite happy with the service they received, however some concerns were raised about the general management of the home and the day to day care and welfare of the people who used the service. We saw other health and social care professionals were involved in peoples care.

We found nutritional risk assessments were in place for each person. Where concerns had been identified there was increased monitoring in place. We had some concerns about the dining experience and the evening meals. The provider told us these areas would be looked into.

We found action had been taken to address concerns relating to monitoring the quality of the service we identified in June 2013 however we did not have confidence in the robustness of the providers quality assurance and monitoring systems.

We saw that some notifications had not been submitted to the Care Quality Commission as required.

During this inspection we spoke with eleven people who lived at the home, two visitors, three members of staff and the registered manager. As part of this inspection process we contacted Salford Local Authority who monitor the care of the people who had been placed at Heath Cottage. They told us that they did not currently have any concerns in relation to this service.

People we spoke with told us that they were happy and had no complaints. Some of the comments we received were:” Everyone is lovely here, the care is first class.” "I am quite happy with things generally and I have made friends".

We spoke with two visitors to the home both of whom were positive about the care their relative received. We were told that the care was good and the staff were “great”. One person said:"The staff are kind and caring, they communicate well with us”.

At the last inspection we had some concerns about the records relating to the care, treatment and support of people who used the service. During this inspection we saw some improvement in the care plans.

Staff told us that training was good at Heath Cottage. There was a programme of staff supervision and appraisal.

The evidence from our observations during this visit and comments from people we spoke with, particularly in relation to the dining experience and a lack of stimulation for people we spoke with, led us to have some concerns in the robustness of the providers quality assurance and monitoring systems in place.

We spoke with four people who lived at the home, staff on duty and the manager. One person told us:"The staff are great, they are kind and they look after me well." The other said, "I have no complaints about the care, my needs are met. I would just love to get out more. I would like to do more and I enjoy company. Sometimes I sit here and I want to chat, they do but other times they seem to think I am asleep, I’m just bored.” We saw there was an activities programme in place and there were plans to develop this further.

We found that people experienced care and support that met their needs. During our inspection we observed care to be delivered in a respectful and patient manner. For one person we observed they were not being supported to have their right to dignity fully respected. From our observations, we saw some evidence of good practice in relation to the support staff provided when transferring people from chair to wheelchair.

We found some shortfalls in the record keeping but the manager assured us they were in the process of reviewing all the care plans to make these more person centred.

As part of this review process we contacted Salford Local Authority who monitor the care of the people who had been placed at Heath Cottage. They told us that they did not currently have any concerns in relation to this service.

We visited Heath Cottage to assess whether the service had made improvements in relation to some concerns we identifiedduring the last inspection in December 2011.

People told us they felt involved in the care and treatment they received and they were treated with respect and dignity. Three people we spoke with told us the staff were “friendly, always nice and were helpful.” One person told us; "I am treated with respect by the staff here” and “I have what I need here, the girls are smashing.”

We spoke with three visitors to the home who told us they felt they did not have any reasons currently to make any complaints about the care their relatives were receiving. One person told us: “The staff are friendly and helpful, they do a fine job, in fact if I did have any worries I do believe I can share the concerns with management.” Relatives believed their relatives were generally well cared for and had their needs met quite well overall.

People living at Heath Cottage told us that the staff treated them with respect, encouraged them to make some choices in their daily lives and maintained their dignity. People told us they felt safe and were well looked after at Heath Cottage. Comments from people included;

They respect my choice for privacy, if I want to stay in my room I can."

" I am helped to decide what I want to wear each day, I feel generally happy at Heath Cottage".

"I believe the staff here can care for me properly."