This inspection took place on 14 February 2017. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting.

The service was last inspected in September 2015 and at that time required improvement in the safe domain due to concerns around the administration of medicines and in the caring domain due to negative feedback about a small minority of staff. A further inspection took place in June 2016 by a Care Quality Commission (CQC) pharmacy inspector. At the June 2016 inspection we found that further improvements needed to be made around medicines to be taken when required, being missing for some medicines, incomplete records for topical medicines, medicines not having a carried forward figure, (mainly dietary supplements) and although a stock balance record was in place, where counts were out this was not always notified to the registered manager so that they could investigate.

Following our last inspection the registered provider sent us information, in the form of an action plan, which detailed the action they would take to make improvements at the home.

At this inspection we found that medicines were now administered safely. Medicines to be taken when required guidance was now in place and a daily count system of all medicines was taking place. However due to this count there was a potential risk of dropping bottled medicines. We recommended theservice obtain a tablet counter from the pharmacy to prevent this potential risk. The concerns raised about a minority of staff had been investigated and these staff members no longer worked at Leeming Garth.

Leeming Garth provides general nursing and residential care for up to 55 people. The home is situated in the village of Leeming Bar with easy access to the A1 motorway. It is spread over two floors, with lift access to each floor. There are parking and garden areas. At the time of inspection the service was no longer providing general nursing care.

There was a registered manager in place who had been registered with the Care Quality Commission since 2015. 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.

Risks to people arising from their health and support needs or the premises were assessed, and plans were in place to minimise them. Risk assessments were regularly reviewed to ensure they met people’s current needs. A number of checks were carried out around the service to ensure that the premises and equipment were safe to use.

On the day of inspection there were enough staff to meet people's needs. However, existing staff and relatives were concerned there were not usually enough staff. We discussed this with the registered manager who explained due to two staff members being on maternity leave it was difficult getting their shifts covered. Both staff members were returning in March 2017 which would ease the workload. They were also in the process of recruiting another member of staff. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. Staff were given effective supervision and a yearly appraisal.

Staff understood safeguarding issues, and felt confident to raise any concerns they had in order to keep people safe.

Staff received training to ensure that they could appropriately support people, and the service used the Care Certificate as the framework for its training. Staff had received Mental Capacity Act (MCA) (2005) and the Deprivation of Liberty Safeguards (DoLS) training and clearly understood the requirements of the Act. This meant they were working within the law to support people who may have lacked capacity to make their own decisions. T

We carried out an unannounced comprehensive inspection of this service on 30 September 2015. A breach of legal requirements was found and we required that the provider make improvements to ensure the safe management of medicines. The service was given an overall rating of requires improvement. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the safe management of medicines.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at: www.cqc.org.uk

We carried out this focused inspection on 18 May 2016. This was an unannounced inspection visit and was completed by a specialist pharmacist inspector.

Leeming Garth provides residential and nursing care for up to 55 people, with the service user bands older people, physical disability and younger adults. The registered provider is HC-One Limited. The home is situated in a rural location on the outskirts of the village of Leeming Bar and consists of an old listed building with modern extensions. The accommodation is arranged over two floors with lift access. There are private car parking facilities, gardens and grounds.

The service had a registered manager who was on duty during 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.

We observed medication being administered to people safely. Safe storage arrangements for medicines were also in place.

Improvements had been made to ensure that medicines were administered in a timely way, with medicine rounds being completed to allow safe time periods between medicine administration.

Systems for the management of end of life medicines and oxygen had also been improved, in response to safeguarding investigation findings.

Arrangements were in place for recording the administration of oral medicines, but some improvements were needed in the records relating to medicine stock, medicines prescribed 'as required' or with a choice of doses, and for topical medicines.

We looked at how medicines were monitored and checked by management to make sure they were being handled properly and that systems were safe. We found that the provider had completed a monthly medication audit which identified similar issues to those we found relating to recording. Staff also completed daily checks of medicine records. However, these checks had not always been effective. For example, because staff had not always notified the registered manager when discrepancies had been identified.

We found a breach of regulation, relating to records and governance. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 30 September 2015 and was unannounced. This meant that the registered provider and registered manager did not know we would be visiting.

Leeming Garth provides residential and nursing care for up to 55 people. The home is situated in a rural location on the outskirts of the village of Leeming Bar. The home consists of an old listed building with modern extensions. The accommodation is arranged over two floors with lift access. There are private car parking facilities, gardens and grounds.

The service had a registered manager who was on duty during 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.

Staff we spoke with knew how to administer medicines safely and the records we saw showed that medicines were being administered and checked regularly. However, the morning medication round was not completed until 11.40 hours. This meant that there was the potential risk that people would not get their medicines at the correct and safe time intervals, especially when agency staff [who are less familiar with the service and needs of individuals] were on duty. We had also received some information of concern about medicines both before and shortly after our inspection, which was being looked into by the local authority. We have required that the provider makes improvements to ensure the safe management of medicines.

People using the service, and their relatives, told us they felt safe at Leeming Garth. Staff knew how to report any concerns about people’s welfare and had confidence in the registered manager taking action. People had individual risk assessments in place which helped ensure staff were aware of the risks relevant to people’s care.

Staff were recruited safely, but the service did not have enough staff employed to provide the nursing hours needed. The registered manager was actively trying to recruit staff and used agency staff to cover any short falls. We found that staff were busy and that there were some difficulties completing the necessary tasks in a timely fashion. We have recommended that the registered provider reviews staff levels and deployment to ensure that enough staff are available at peak periods.

The service had emergency contingency plans in place, including personal evacuation plans for people who used the service. Equipment was checked and serviced appropriately, to ensure it was maintained in safe working order.

Staff were provided with access to relevant training and support. The registered manager monitored staff performance through supervision and appraisal systems.

The service was following the principles of the Mental Capacity Act 2005. At the time of the inspection one person was subject to a DoLS authorisation. The registered manager understood the Deprivation of Liberty safeguards (DoLS) and had made appropriate applications, most of which were pending action by the local authority.

People told us that the food was good, with plenty of snacks and drinks available between meals. People’s dietary needs were assessed and monitored, and we saw staff providing the support people needed with eating and drinking.

People told us that they were cared for by staff and usually treated with dignity and respect. We observed kind and caring interactions between staff and people who used the service throughout our visit. However, we received negative feedback relating to a small minority of staff who did not always treat people who used the service, relatives or other staff with respect. This was raised with the registered manager at the time of our inspection, who was aware of the issues and able to tell us what action they were taking.

People had their needs assessed and had care plans which were individual to them. The care and nursing staff we saw and spoke with knew people well and were able to describe people’s needs. We also observed the care described in people’s care plans being delivered in practice.

Information about the complaints process was displayed in the reception area. The manager was open to complaints and comments about the service. People we spoke with told us that they would feel able to raise any issues or concerns. However, resident and relatives meetings were not taking place regularly.

People had access to activities and events, but some people living at the home did not want to take part in these. A new activities coordinator had recently been recruited and a person who used the service was going to help them develop what was on offer.

The service was well-led. Everyone we spoke with told us that the registered manager was approachable and had made positive improvements since starting work at the home. There were regular checks and audits taking place. Senior staff from the registered provider’s organisation also visited the service to monitor performance.

At this inspection we identified a breach of Regulation 12 (1) & (2) (g) of the Health and Social Care Act (Regulated Activities) Regulations 2014, because the registered person did not ensure the safe management of medicines. You can see what action we told the provider to take at the back of the full version of the report.

Our inspection team was made up of one inspector. During the inspection we asked five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

On the day of the inspection we talked with people who lived in the home and spent time in the communal areas of the building observing the interactions with staff and people who lived in the service. Some people who lived in the service had dementia type illnesses and found it difficult to discuss their experience of care. We talked with four people about their experience of care and we spoke with five relatives and friends. We talked with six staff and the Quality Manager who had responsibility for quality assurance at homes managed by the provider. We looked at records. Below is a summary of what we found. 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 and people we spoke with told us that they felt safe. Staff had received training in safeguarding and understood how to safeguard the people they supported. Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents.

People were cared for in a service that was safe, clean and hygienic. Risk assessments were in place in individual support plans in relation to activities of daily living. Staffing on the day of the inspection were agreed as appropriate for the levels of dependency in the home. Staff we spoke with told us that they believed there were not always enough staff on duty and they were concerned that they sometimes had to rush people who lived in the service when providing care. We saw that there had been staff recently recruited but there were still some vacant posts. The quality manager told us that staffing levels were reviewed and adjusted to address any changing needs.

Is the service effective?

People we spoke with told us that they were happy with the care they received. From our observation and from speaking with staff that they understood people's care and support needs and they knew them well. Staff had received training to meet the needs of the people living in the home. People's health and care needs were assessed with them and where it was possible for them to do so, people were involved in developing their plans of care. Relatives we spoke with were able to describe specific benefits to the health and wellbeing of their relatives and the impact that this had had on their daily life. One relative told us. "I can't praise this place enough, they treat people with respect 100%."

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were supported to be as independent as possible.

Is the service responsive?

People were involved in a range of activities inside and outside the service. The home supported people to take part in activities within the local community which included visiting local places of interest. People knew how to make a complaint if they were unhappy and two people we spoke with told us that they felt that they could talk with any of the staff if they had a concern or were worried about anything.

Is the service well-led?

The service worked well with other agencies and services to ensure that people received their care in a joined up way. The service had a quality assurance system which included planned audits. Records seen by us showed that complaints were investigated appropriately. People who lived in the service, staff and relatives were asked for their views. People who used the service were invited to complete an annual survey. This had recently been circulated and so we were not able to see the outcome of this. Where shortfalls or concerns were raised, these were addressed. People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes. Any identified shortfalls were addressed promptly and as a result the service was constantly improving. Staff told us that they felt they could talk with the manager if they had concerns.

In August 2013 we carried out an inspection in response to concerns identified to us. We judged, at that time, that improvements were needed to ensure that people's care and treatment was planned and delivered in line with their individual care plan. Following this, the provider wrote to us and told us what they were going to do to address the issues identified. During our follow up inspection in October 2013 we found that improvements had been made.

At our last inspection we identified that peoples’ weights were not being monitored appropriately. At this inspection we saw improved systems were in place to manage and monitor peoples’ weights. We also identified at our last inspection that people were not always being repositioned and checked in bed at the required time as indicated in their care records. We found in the majority of cases at this inspection that improvements had been made and people were now being checked and repositioned appropriately. During our inspection we observed a calm environment with call bells being responded to in a timely way. People living at the home were clean, well dressed and appeared relaxed in their surroundings with positive interactions observed between people living at the home and staff.

We visited this service at 05:50am as we received concerns that people were being got up early in the morning due to staffing issues.

The majority of people we spoke with were positive about the care they received. We saw that people were clean and appeared well cared for and were supported by staff in a person centred and dignified way. We also found that health care professionals were contacted as people's needs changed and regular visits were made by health professionals. We spoke with a visiting professional on the day of our visit. They told us that they had been called in promptly to visit two people who staff were concerned about. This helped to ensure that advice was being sought to help maintain people's health and wellbeing. Despite this, we found that not all people's care and treatment was planned and delivered in line with their individual care plan. We have asked the provider to address these issues.

The provider should note that whilst there was no evidence that Leeming Garth was not meeting the regulation relating to staffing; there needs to be a review of the deployment of staff during the morning period to ensure that a coherent and systematic arrangement is in place for ensuring that people’s needs are met in line with their care plan. There needs to be clear leadership and direction in place for staff to follow. We have discussed these issues with the provider and will continue to monitor this area of compliance.

We spoke with seven people living at the home, six relatives of people and also attended a resident’s and relative’s meeting during the inspection. We spoke with six of the home’s care staff and the home’s manager.

People said they were generally well looked after, with comments including “Oh yes, I’m very happy and get looked after very well”, “The food is nice and I have a choice” and “My relative is happy here and I don’t worry about them.” Care plans reflected people's needs and had been reviewed regularly. People were given special diets where needed and people were monitored for weight loss.

However, negative feedback regarding dissatisfaction with staffing levels was received from the people we spoke with. Comments included “I’m concerned that a lot of the experienced staff have left”, “People keep ringing in sick and nobody will cover because everybody’s tired” and “You just rush all the time.” However, there was also less negative feedback, including “The basics of care are there”, “It’s busy but I don’t see any lack of care” and “I have to wait sometimes to go to the toilet or when we’re taken to the dining room, but it’s generally ok.”

The home manager said they were currently recruiting and awaiting start dates for new staff. Following feedback the home supplied information to show they had increased staffing levels in the mornings on a permanent basis. The home had systems in place to monitor the quality of the service.

During this visit we spoke to nine people who use the service and four people’s relatives. We also spent time observing the care and support provided. All the residents and visitors we spoke to said how kind and pleasant the staff were. We saw people being treated kindly and with respect by staff. Comments made by people who use the service included “they help me, they're lovely, very kind.” Comments made to us by relatives included “my relative is always clean and tidy, and we can ask for and get anything.” Care plans reflected people’s needs and had been reviewed regularly.

People told us that they liked the food. Special dietary requirements were being catered for and people were monitored for weight loss. People’s comments included “I’ve had a lovely meal, the food was good.” However, we found that fluid and food intake monitoring could be improved.

People who use the service and staff told us that staff were very busy and that sometimes people had to wait for their needs to be met. Our observations supported this and we saw occasions when staff were not available when people needed them. Comments made to us included “the staff are really, really busy, and look miserable” and “we are struggling, I’m worried that care is suffering because we rush all the time.”

Staff knew how to report any concerns they had and systems were in place to monitor the quality of the service. This included seeking the views of people who used the service.

People told us they were happy with the staff at Leeming Garth and the care that they provided. They said they felt that staff were able to meet their needs.

People told us that they were happy at Leeming Garth. One person said "It's alright here." They also said that their views and preferences are sought and these are taken into consideration.

People said they were satisfied with the care they were receiving. They also said that if they wanted anything, they would just ask the staff who would sort this out for them.

People told us that they were happy with the staff at Leeming Garth and the care that they provided. We also spoke with relatives who were visiting and they gave positive feedback on the staff. One person told us "They do their best."

People commented that they knew how to raise issues, should they have any. They also said that the manager is happy to see people at any time and operates an open door policy. Everyone that we spoke with said they didn't have any complaints or concerns.