This inspection took place on 2 and 3 November 2017 and was unannounced.

Hugh Myddelton House is a care home providing nursing care. 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.

Hugh Myddelton House is registered to provide nursing care and accommodation for a maximum of 48 adults, some of whom live with dementia. At the time of our inspection, there were 46 people living in the home. The home covers three floors. On the ground floor there is capacity for 19 elderly frail people. On the first floor there is capacity for 19 people living with dementia and on the second floor there is capacity for ten younger people with disabilities.

During the last inspection on 29 and 30 September and 2 October 2016, we found the home was in breach of one regulation associated with the Health and Social Care Act 2008 in relation to staffing levels.

A registered manager was in post at the time of this 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.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question safe to at least good. We found that improvements had been made to staffing levels and deployment of staff to ensure people’s care needs were met. Our observations and feedback received from staff, people and relatives was that staffing levels had improved. On both days of the inspection, we observed there to be adequate numbers of staff to ensure people’s care needs was met in an unhurried manner. However, at times we observed communal areas to be left unattended whilst staff attended to people in their bedrooms. Some staff and relatives commented that it would be good if staff had more time available to spend with people on a one to one basis.

Detailed current risk assessments were in place for most people using the service which were updated on a regular basis and as changes occurred. However, we found one instance of a person’s risk assessment not being reassessed following a number of incidents of behaviour that challenged.

Accidents and incidents such as falls were recorded and analysed. However, we found an instance of where an incident had been reviewed and signed off by the registered manager, despite inconsistencies over how the incident had been managed at the time.

There were systems in place to ensure medicines were handled and stored securely and administered to people safely and appropriately.

Most people told us they enjoyed the food provided and that they were offered choices of what they wanted to eat. People were supported to eat and drink in a timely manner, where appropriate. Additional staff were deployed effectively at mealtimes to ensure people received their meals in a timely manner.

People received a nutritious diet and enough to eat and drink to meet their individual needs and timely action was taken by staff when they were concerned about people's health. Referrals had been made to other healthcare professionals to ensure people's health was maintained.

Staff training, supervisions and appraisals were monitored and updated regularly. Systems had been implemented to ensure oversight of when staff training, supervisions and appraisals were due.

People were positive about the service and the staff who supported them. People told us they liked the staff that supported them and that they were treated with dignity and kindness.

People told us they felt safe living at Hugh Myddelton House. Staff understood the importance of safeguarding and

This inspection took place on 29 and 30 September and 2 October 2016 and was unannounced. Our inspection was brought forward because we had received concerns relating to staffing levels and the high number of safeguarding alerts raised with the local authority by health and social care professionals.

During the last inspection on 10 May 2016, we found the home was in breach of two legal requirements and regulations associated with the Health and Social Care Act 2008. We found that people who used the service were not always protected with the risks associated with their care and there were deficiencies in relation to the monitoring of people’s hydration and nutrition.

Hugh Myddelton House is registered to provide nursing care and accommodation for a maximum of 48 adults, some of whom live with dementia. At the time of our inspection, there were 46 people living in the home. The home covers three floors. On the ground floor there is capacity for 19 elderly frail people. On the first floor there is capacity for 19 people living with dementia and on the second floor there is capacity for ten younger people with disabilities.

A general manager commenced employment at the home at the end of June 2016. The general manager has applied for registration with the Care Quality Commission. 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. A deputy manager had also been recruited since we last inspected the service.

There were insufficient numbers of staff on duty at all times to meet people’s needs. Whilst staffing levels had been determined using a recognised tool, we identified errors had been made in using the tool. We received consistent feedback from people, relatives and staff that staff levels were a cause for concern. From our observations, care often appeared to be task focused and, on a number of occasions, people were either left in bed or wheelchairs for extended periods of time. There was an activities programme in place, although many people remained in their bedrooms and were not always supported to access communal areas or engage in activities as staff were engaged with care tasks. Staffing levels also did not reflect the rotas in place at the time of the inspection.

Medicines were being managed safely.

People, relatives and staff spoke positively of the current management team. Quality assurance processes were in place to monitor the quality of care delivered. However, learning from incidents of home acquired pressure ulcers was not evident and the service did not follow pressure ulcer prevention best practice.

People told us they felt safe. Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. All staff had completed training in safeguarding adults and demonstrated an understanding of types of abuse to look out for and how to raise safeguarding concerns.

Detailed current risk assessments were in place for all people using the service. Risk assessments explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person.

Appropriate checks had been made to ensure the premises was safe.

We saw evidence of a comprehensive staff induction and on-going training programme. Staff had regular supervisions and annual appraisals; however the general manager told us they were behind with annual appraisals. Staff were safely recruited with necessary pre-employment checks carried out.

People were given choices during meal times and their needs and preferences were taken into account. Nutritional assessments were in place for most people, which included the type of food people liked and disliked. Peop

This focused inspection took place on 10 May 2016 and was unannounced. We undertook this inspection because we had received some concerns about staffing levels and how this impacted on people who use the service. This report only covers our findings in relation to staffing levels within the home within the safe section, how staffing levels impacted on mealtimes and the monitoring of people’s food and fluid intake under the effective question and the management of complaints in respect of staffing levels under the responsive section. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Hugh Myddelton House on our website at www.cqc.org.uk

Hugh Myddelton House provides care and accommodation for a maximum of forty-eight people. At the time of our inspection, there were 46 people living in the home.

The home covers three floors. On the ground floor there is capacity for 19 elderly frail people. On the first floor there is capacity for 19 people living with dementia and on the second floor there is capacity for ten younger people with disabilities.

A registered manager was not in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. An operations manager was managing the home on an interim basis with the assistance of the regional director until a newly appointed manager commenced employment.

One assessment had not been updated to reflect a person’s current needs. On one occasion a risk assessment had not been completed for a person using the service.

We found that fluid intake for people at risk of dehydration was not always monitored. Guidance was not available for staff in relation to a persons minimum required fluid intake and the actions to be taken when people's fluid intake was low.

People told us they felt safe living at the home. Most people told us that there were sufficient numbers of staff to meet their care needs. Two people told us that they felt that there was insufficient staff during the night and they did not receive assistance from staff when they used their call bells. The service was unable to provide records of call bell response times at night due to a technical problem with the call bell monitoring system. Overall, people spoke positively about staff and how hard they worked.

Relatives and staff told us that staffing levels had been a concern previously when the number of carers had been reduced on the first floor following the completion of a needs assessment by the provider. The staffing levels had since been increased and staff and relatives told us that generally staffing levels were adequate.

Medicines were managed safely and effectively.

We saw caring and friendly interactions between staff and people who used the service. People spoke positively about staff. Staff worked together and assisted colleagues in other areas of the home to ensure that people’s care needs were met and people received medicines and meals on time.

Mealtimes on the ground floor and second floor were relaxed and people received their meals on time. We saw on the first floor, where more people required assistance to eat, some people did not receive their meals in a timely manner despite staff being deployed from other areas of the home to assist with serving food. However, in the dining room we observed staff assisting people to eat in a patient and caring manner.

Complaints were recorded and investigated with a response sent to the complainant and actions had been taken and improvements had been made.

We identified two breaches of regulations relating to risk management and nutrition and hydration. You can see what action we told the provider to take at the back of the ful

This inspection took place on 18 May 2015 and was unannounced. Hugh Myddelton House provides care and accommodation for a maximum of forty-eight people. At the time of our inspection, there were forty-two people living in the home.

At our inspection on 2 and 6 May 2014 the service did not meet Regulations 9, 13 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Our inspection on 21 August 2014 found that regulation 13 had been met. At our inspection on 18 May 2015 we found that regulations 9 and 23 had been met.

There was a registered manager in post at the time 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.

People who used the service told us they felt safe in the home and around staff. Relatives and care professionals we spoke with said that they felt people were safe in the home. There were systems and processes in place to help protect people from the risk of harm. These included thorough staff recruitment, staff training and systems for protecting people against risks of abuse.

We saw staff spent time with people and provided assistance to people who needed it. There was mixed feedback from relatives about whether there were sufficient staff on duty to meet the needs of people. We discussed this with the registered manager and area manager and they showed us their staffing assessment tool which indicated that staffing levels were more than adequate.

Medicines were managed and administered safely and staff received appropriate training.

We found the premises were clean and tidy. There was a record of essential inspections and maintenance carried out. The service had an Infection control policy and measures were in place for infection control.

Food looked appetising and the head chef was aware of any special diets people required either as a result of a medical need or a cultural preference. People and relatives spoke positively about the food at the home.

People received personalised care that was responsive to their needs. Care plans were person-centred, detailed and specific to each person and their needs. People’s health and social care needs had been appropriately assessed. Identified risks associated with people’s care had been assessed and plans were in place to minimise the potential risks to people.

Staff had the knowledge and skills they needed to perform their roles. We saw that the majority of staff had received supervisions and had an opportunity to discuss any queries or concerns with the registered manager. Staff spoke positively about their experiences working at the home and the registered manager.

The majority of staff had received training in the Mental Capacity Act 2005 and were able to demonstrate a good understanding of how to obtain consent from people. They understood they needed to respect people’s choice and decisions if they had the capacity to do so.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS ensure that an individual being deprived of their liberty is monitored and the reasons why they are being restricted is regularly reviewed to make sure it is still in the person’s best interests. We saw evidence that the home had applied for DoLS where necessary.

The home had residents’ meetings where people were encouraged to express their views about the service and make suggestions about the running of the home. People could participate in a range of activities they liked and these included music therapy, reminiscence and games.

Positive caring relationships had developed between people who used the service and staff and people were treated with kindness and compassion. People were being treated with respect and dignity and staff provided prompt assistance but also encouraged people to build and retain their independent living skills. People told us they liked the staff who supported them and staff listened to them and respected their choices and decisions.

People using the service, their relatives and friends were positive about the registered manager and management of the home. The service had an open and transparent culture where people were encouraged to have their say and staff were supported to improve their practice. We found the home had a clear management structure in place with a team of care staff, the registered manager and area manager. There was a system in place to monitor and improve the quality of the service which included feedback from people who used the service, staff meetings and a programme of audits and checks.

We carried out an unannounced comprehensive inspection of this service on 2 and 6 May 2014. Several breaches of legal requirements were found. As a result we undertook a focused inspection on 21 August 2014 to follow up on whether action had been taken to deal with the most significant breach.

You can read a summary of our findings from both inspections below.

Comprehensive Inspection of 2 and 6 May 2014

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

Hugh Myddleton House provides accommodation for up to 48 people who require nursing, personal care and support. At the time of our inspection 46 people were using the service.

People who used the service and their relatives were happy with the service received. Staff treated people kindly and with compassion. Staff were aware of people’s likes, interests and preferences. However, we were not able to find evidence that staff understood people’s care and support needs in all cases. The relatives we spoke with told us staff kept them informed of people’s progress and any changes in their healthcare needs.

Ten people who used the service told us that they felt safe. Staff were knowledgeable in recognising signs of potential abuse and concerns were appropriately reported. We found the service to be meeting the requirements of the Deprivation of Liberty Safeguards.

Risk assessments and care plans were in place, however, we found that many of them lacked detail and there were some inaccuracies in the information recorded in people’s care records. This meant we could not be assured that care was always tailored to people’s individual needs and that preventative measures were put in place to protect people’s welfare and safety.

The home did not meet requirements around the storage, safe administration and appropriate recording of medicines. This put people who used the service at risk of not receiving medicines safely.

People who used the service were offered a range of activities to suit their needs. They told us they enjoyed some of the activities offered, and told us that they were able to decide if they wanted to take part in activities or not.

The manager had been in post for six weeks and staff told us that, so far, they felt supported by her. Staff did not receive regular supervisions and appraisals which meant that staff were not being supported to deliver care safely and appropriately. The manager had not submitted an application to the Care Quality Commission to become the service’s registered manager; however we were told that she had started the process.

There were three breaches of health and social care regulations. You can see what action we told the provider to take at the back of the full version of the report. We considered the issues related to medicines management were serious enough to take enforcement action.

Focused inspection of 21 August 2014

One inspector and a pharmacist inspector carried out this unannounced inspection. The purpose of this inspection was to see whether the service had made improvements since our inspection on 2 and 6 May 2014, following enforcement action we had taken against the service. During our inspection on 2 and 6 May 2014, we were concerned that the service had failed to protect service users against the risks associated with the unsafe use and management of medicines, by means of the making of appropriate arrangements for obtaining, recording, handling, safe keeping, dispensing, safe administration and disposal of medicines.

During our inspection on 21 August 2014, we found that the service had taken appropriate action to ensure that the concerns raised at our inspection were addressed.

We will undertake another unannounced inspection to check on all other outstanding legal breaches identified for this service.

We carried out an unannounced inspection to check whether the provider had dealt with the compliance actions arising from our last inspection of 19 April 2013. At that time appropriate steps were not being taken to ensure that at all times there were sufficient numbers of suitably qualified, skilled and experienced persons employed. Additionally accurate records were not being maintained of each person, there were gaps in the records for managing the service and records were not stored securely.

At this inspection we found that matters had been dealt with. The provider was taking appropriate steps to ensure that there were sufficient numbers of suitably qualified, skilled and experienced persons employed to safeguard the health, safety and welfare of people. The provider had reviewed people’s records and had produced an action plan to improve record keeping. Records were retained and stored securely in accordance with the Data Protection Act 1998.

We saw that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. The registered manager who has been in post for less than a year was praised by relatives, staff and visiting professionals.

We saw records that showed the provider had carried out regular audits to monitor infection control and had carried out improvements where actions had been identified. One person told us “cleanliness is excellent.”

Records showed that equipment was regularly maintained and serviced and there were regular tests and audits. People told us that the equipment was suitable for their needs and was kept clean.

One relative told us that, “there have been serious issues but staffing has improved in the last six months.” However appropriate steps were not being taken to ensure that at all times there were sufficient numbers of staff to provide the service.

An accurate record was not being maintained of each person to protect them from the risks of unsafe or inappropriate care or treatment. There were gaps in the records for the management of the service. Records were retained for no longer than is necessary but were not stored securely in accordance with the Data Protection Act 1998.

The people we contacted were happy with the service. Staff said things are “an awful lot better” and “staff are much happier”.

A person told us that they choose if they wished to participate in any activity.

People confirmed that staff were kind and approachable. Staff provided them with the care and support they needed in the way that they wanted.

People had a choice of meals. Comments from people about the food included “It’s very nice” “It’s excellent.”

We were unable to speak with most people living at the home about their medicines because of their medical conditions. In order to assess whether the provider had complied with the warning notice, we reviewed medicines records and supplies to check whether all medicines were now available for everyone at the service and whether these medicines were now being used correctly and as prescribed.

We found that people were generally happy with the quality and choice of meals provided. For instance, people told us, “I had breakfast, lots of toast, and staff did ask what I would like”. However, two people commented that the food was ‘’bad’’ and they had to eat whatever staff bring. They felt that some of the food for that day’s lunch was hard to chew.

At our last review of the service in March 2012, we had major concerns with the way the service was managing medicines for people, which may have placed people at risk.

We took enforcement action by issuing a warning notice to the provider, Barchester Healthcare Homes Limited, requiring urgent improvements to their management of medicines by 23rd April 2012.We saw that although recording had improved appropriate arrangements were still not in place for the obtaining and using of medicines.

We found that there were enough qualified, skilled and experienced staff to meet people's needs.

Records protected people from the risks of unsafe or inappropriate care and treatment.

We asked people who use the service about staff. People generally reported no concerns with current staffing levels and the capability of staff.

We spoke with people living at the service and their relatives.

A number of people said that they had to wait a long time before the call bell was answered especially at night.

On the 29th of March 2012 a pharmacist carried out an inspection of medications. A sample of medicines and medication charts were reviewed from each of the three floors, together with discussions with the nurses in charge on each floor, as the manager was not at the service on the day of the inspection. In view of the major concerns identified in this outcome area the Care Quality Commission served a warning notice on the registered provider on 11th April 2012.

We looked at the rota and observed staff on shift we identified that the service had not taken steps to ensure that people that use the service were supported by sufficient numbers of qualified staff. The rota did not reflect the actual numbers of staff and named staff working in the home. In view of the major concerns identified in this outcome area we are considering enforcement action.

Records viewed showed that actions needed to maintain and promote people’s health and welfare were not always recorded which could result in their care needs not being met. A compliance action had been made at the previous inspection on the 24th of January 2012. In view of the major concerns identified in this outcome area we are considering enforcement action.

Audits seen on file did not show that the specific actions identified had been acted upon. The quality assurance system was not effective.

Generally People confirmed their privacy was respected. We asked people if the staff knocked on their bedroom door before entering and we were informed they did.

When we asked people about their care we were told “staff were kind and caring they do a good job and know what they are doing.

We asked people whether they were satisfied with the meals service in the home. People told us “meals are fine, there is enough to eat.”

We asked people about their medication a person said, “I don’t know the names of them but know what they are for.” However recording of medication indicated that medication procedures were not being followed effectively as there were gaps in the medication Administration Records.

Generally equipment was working well. However, systems were not fully effective with regard to identifying equipment that was not in working order.

People had personalised their rooms by using their own furnishings.

Prior to the inspections concerns had been raised with regard to staffing levels in the home. On the day of the inspection there was no evidence to suggest that people were not being assisted in a timely manner. However, dependency levels of people appeared high.

People spoken with were aware of how to make a complaint. We were informed that meetings had taken place with those people that had made complaints and these meetings were ongoing.

People who use the service told us staff respected their choices and decisions about their care.

A relative expressed concerns regarding a lack of provision of fluid which the person who used the service required to promote their wellbeing.

The majority of people said that the food had improved since the recruitment of the new chef. They also said that portion sizes were good. A relative said the tea and coffee facilities had improved since the new manager came into post.

We were told “there is plenty of grub”. Another person said “the food is quite nice”. “The food is hot enough.

People appreciated having personal accommodation that included en suite facilities. People had made their rooms more personal by installing small items of furniture, ornaments and pictures. Within the building the overall décor, and furniture were in good condition.

Although people agreed that members of staff providing care were kind and helpful they did not agree that there were enough staff on duty to support people that use the service and examples were given of were there where shortfalls.

On the day of the visit we saw one member of staff working on the dementia care unit with eight people that use the service. Staff confirmed that staff are taken from other units to cover shortages. When asked how often this happens staff answered often as recently as two days prior to our visit. “They don’t replace staff, they make do with what they have”.

We were told, “There are some really good staff but they have such a lot to do” and “They don’t have the time.” Other relatives told us “They look after our relative very well, he feels safe here”.

Relatives told us that they had raised issues of concern with the management that they felt had not been fully responded to. This was discussed with the manager who thought the concerns had been resolved and had not logged them as complaints as a consequence of this.

Hugh Myddleton House provides accommodation for up to 48 people who require nursing, personal care and support. At the time of our inspection 46 people were using the service. 

People who used the service and their relatives were happy with the service received. Staff treated people kindly and with compassion. Staff were aware of people’s likes, interests and preferences. However, we were not able to find evidence that staff understood people’s care and support needs in all cases. The relatives we spoke with told us staff kept them informed of people’s progress and any changes in their health care needs.

Ten people who used the service told us that they felt safe. Staff were knowledgeable in recognising signs of potential abuse and concerns were appropriately reported. We found the service to be meeting the requirements of the Deprivation of Liberty Safeguards.

Risk assessments and care plans were in place, however, we found that many of them lacked detail and there were some inaccuracies in the information recorded in people’s care records. This meant we could not be assured that care was always tailored to people’s individual needs and that preventative measures were put in place to protect people’s welfare and safety.

The home did not meet requirements around the storage, safe administration and appropriate recording of medicines. This put people who used the service at risk of not receiving medicines safely.

People who used the service were offered a range of activities to suit their needs. They told us they enjoyed some of the activities offered, and told us that they were able to decide if they wanted to take part in activities or not.

The manager had been in post for six weeks and staff told us that, so far, they felt supported by her. Staff did not receive regular supervisions and appraisals which meant that staff were not being supported to deliver care safely and appropriately. The manager had not submitted an application to the Care Quality Commission to become the service’s registered manager; however we were told that she had started the process.

There were three breaches of health and social care regulations. You can see what action we told the provider to take at the back of the full version of the report. We considered the issues related to medicines management were serious enough to take enforcement action.