A focused inspection took place at Mewsbrook House on 2 and 3 August 2018 and was unannounced. The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This was following information shared with the Care Quality Commission (CQC) by an anonymous whistle-blower and the local authority. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Before the inspection we had information that the registered manager had failed to always notify the Care Quality Commission (CQC) of incidents in relation to allegations of abuse. A provider must inform the CQC of any incidents in relation to abuse or allegations of abuse. A notification is information about important events which the provider is required to tell us about by law. This was discussed with the registered manager during the inspection.

Mewsbrook House is registered to provide care and accommodation, including nursing care, for up to 50 people and there were 48 people living at the home when we inspected. The service was providing care for a wide range of care needs including older persons, dementia, mental health, substance misuse and physical disabilities.

All bedrooms were single. Communal areas consisted of several lounge and dining areas, which had all been merged to create one large communal area. There was a garden, which people used.

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

Recruitment practices did not always ensure the suitability of staff. Risks to people were not always assessed when recruitment decisions were made. Risks to people were not always assessed and recorded. Where risk assessments were not available the registered manager resolved this during the inspection. People were protected against avoidable harm and abuse however risks were not always assessed and safeguarding processes were not always followed.

Infection control processes kept people safe from infection however offensive odours were present in some areas of the home on both days we visited. There were systems for monitoring the quality of care and support including auditing systems but not all issues were identified or acted on.

Staff worked closely with community health professionals and therapists to maximise people's well-being and worked well in partnership with other agencies.

Good systems were in place for reporting accidents and incidents internally and the service was responsive to people's individual needs. Medicines were managed and stored safely by staff.

People had positive and caring relationships with the staff who supported them. Some people and their relatives were provided opportunities to give their views about the care they received. People and relatives said they knew what to do if they were not satisfied with the service. The registered manager demonstrated a 'hands-on' approach and knew people well. Complaints were logged and records showed that complaints were responded to. Sufficient numbers of nursing and care staff were deployed to meet people’s needs.

The last inspection was carried out in February 2017. The overall rating given was good.

We found breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

The inspection took place on 13 and 17 February 2017 and was unannounced.

Mewsbrook House is registered to provide care and accommodation, including nursing care, for up to 50 people and there were 49 people living at the home when we inspected. The service was providing care for a wide range of care needs including older persons, dementia, mental health, substance misuse and physical disabilities.

All bedrooms were single. Five bedrooms did not have an en-suite facility, 17 had an en-suite bathroom and 28 an en-suite toilet. Communal areas consisted of several lounge and dining areas, which had all been merged to create one large communal area. There was a garden, which people used.

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

At the last inspection on 26, 30 November and 14 December 2015, we identified three breaches of Regulations associated with the management of medicines, the premises and environment were not adequately maintained or decorated. Standards of hygiene were not sufficiently maintained and the care records were not securely stored when not in use. We also recommended the provider introduce a system so people and visitors could identify staff working in the home. Following the last inspection, the provider wrote to us to confirm that they had addressed these issues. At this visit, we found that the actions had been completed and the provider has now met all the legal requirements.

At the last inspection, we identified that medicines were not safely managed. This was a continued breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely. Therefore, this regulation was now met.

At the last inspection, we observed the premises were not always clean or properly maintained. This was in breach of Regulation 15 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found noticeable improvements had been made to the home environment which had been service user led. The home was clean and tidy throughout, routinely maintained and monitored by the registered manager; therefore, this regulation was now met.

At the last inspection, we noted care records were not securely stored when not in use in order to ensure people’s personal information was kept confidential. The provider had not ensured care records were securely stored, which meant people’s confidential records cold be accessed by other people and visitors. This was in breach of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we observed that cupboards containing confidential information were lockable. We also observed signs on each cupboard reminding staff to keep the cupboards locked when not in use. Therefore, this regulation was now met.

At the last inspection, we found improvements were needed in regards to some of the care plans and risk assessments, which required reviewing to include people’s needs and preferences. At this inspection, we found care plans represented people's needs and preferences to enable staff to fully understand people's needs and wishes.

Systems were in place to identify risks and protect people from harm. Risk assessments were in place and reviewed monthly. Where someone was identified as being at risk, actions were identified on how to reduce the risk and referrals were made to health professionals as required.

Staff worked closely with comm

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time of this inspection. The provider has advised CQC of the changes and the register will be amended accordingly.

At the time of our inspection 42 people lived at the home. We spoke with four relatives and four people to seek their views of the home. It was not always possible to establish some people’s views due to the nature of their conditions. To help us understand the experience of people who could not talk with us we spent time observing interactions between staff and people who lived in the home. We reviewed the care records of four people. We also spoke with four staff, the registered manager and the provider.

The inspection team was made up of a single inspector. We set out to 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.

Is the service safe?

People were treated kindly and with dignity and respect by staff. Staff were clear they would report concerns to the manager and these would be acted on. There was a system in place for recording of incidents and accidents and staff could describe to us how this information was used to improve the service for people.

Care plans had been developed for people based on an assessment of needs, however these did not always reflect the person’s current needs and there was not always evidence of forward planning for people to ensure their individual needs were met.

Records held for people at the time of our visit were not always up to date and did not reflect their current needs. Some records could not be found at the time of our inspection visit and therefore staff could not locate these promptly. Daily records were inconsistent in their completion and did not always reflect the action staff had taken to meet people’s needs. The lack of up to date care plans and inconsistencies in recording of daily records meant people may be at risk of receiving care and support that was unsafe or inappropriate to their needs. We have asked the provider to tell us what action they will be taking to ensure they meet the requirements set by law in relation to care planning and delivery and records.

CQC monitors the operation of the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS) which applies to care homes. Management we spoke with had a good understanding of DoLS and their responsibility in this.

Some areas of the home were not clean at the time of our inspection and we observed some practices which would increase the risk of spread of infection. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to infection control.

Is the service effective?

Before people received care they were asked for their consent. Staff supported people to make day to day decisions. Staff were observed to respect the decisions people made. Where people lacked capacity to make decisions the provider was not able to demonstrate they had applied the Mental Capacity Act 2005 in full. Capacity assessments were not undertaken for specific decisions that needed to be made. No evidence of best interests’ decisions could be found. We have asked the provider to tell us what action they will be taking to ensure they meet the requirements set by law in relation to consent to care and treatment.

Is the service caring?

The staff we spoke with knew people well. Our observations demonstrated staff had a good understanding of people’s needs and the support they required. We saw staff were kind in their approaches when supporting people. All of the relatives we spoke with expressed their satisfaction with the service provided. All four told us they felt their relative was safe and well looked after. They told us the staff were kind, caring and knowledgeable of people’s needs.

Is the service responsive?

People's health and care needs were assessed and care plans were developed to enable staff to support people in the way they not only chose but also needed. Where there were risks associated with people's care and treatment, these had been assessed and actions to reduce these risks had been identified. This meant people received care which was planned and delivered in a way that was intended to ensure people's safety and welfare. Care plans were reviewed monthly and basic information about the persons current support needs was documented, however this did not always trigger a review of the content of the planned care.

Is the service well led?

The service had a number of systems in place to monitor and assess the quality of service. All of the staff and people who used the service said they felt supported and listened to. Staff told us they were confident issues of concern would be acted upon.

We saw there were systems in place to monitor and assess the quality of the service including questionnaires, meetings with people who lived at the home and regular staff meetings. We saw learning from accidents and incidents took place and staff were able to tell us how leaning from these was shared. The manager showed us the system they would be introducing in the month following our visit to audit care plans to ensure these were accurate and up to date.

We spoke with 10 people living in the home and five relatives. We also spoke with six members of staff, the manager and a social work professional.

One person spoken with told us "All the staff treat me with dignity." A relative told us that "It was good on the whole" and that their family member was always well groomed. Another relative told us "I am very pleased with all they have done. The staff are very friendly and they know [family member] very well. "

A relative told us that they had received information about the care and support on offer in the home prior to admission. However another person and their relative told us that they had not received any information as the move had been an unexpected one from another home. They were however satisfied with the care in the home, saying that there had been an improvement in life in general at the home in recent weeks since there had been a change in the management.

We found that there were appropriate arrangements in place to ensure that people were safeguarded from abuse. The social work professional spoken with told us that the home worked with them to ensure safeguarding concerns were fully investigated.

We found that there were not correct measures in place for the prevention and control of infection. There was not an infection control and prevention lead.

We saw that medicines were handled safely in the home.

We saw that staff were appropriately trained and supported.

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

We spoke with 12 people living in the home, two visiting relatives, a visiting general practitioner and five members of staff. We also spoke with a social work professional and a member of the community mental health team on the telephone. We toured the premises and observed the lunchtime meal.

One person spoken with told us "Staff call me by my Christian name as this is my preference and this I think is a mark of respect”

A relative told us ‘The family received information about the care and support that their family member would be given before using the service and the home has fulfilled this promise”

We saw that there was a nutritious meal on offer which people told us they enjoyed.

We found that there were appropriate arrangements in place to ensure that people were safeguarded from abuse.

We found some deficiencies in the management of medication and the training programme was not up to date.

People had a limited ability to express their views on life in the service, But those spoken to stated they were happy in the Ormsby Centre.

We spoke to one relative visiting on the day and he was very happy with the care offered.

We spoke to some relatives on the telephone and they expressed satisfaction with the care in The Ormsby Centre. The family of a person now deceased were very satisfied with the care given by the service in the persons last days.

We spoke to some health and social care professionals and their comments are included in the body of the report and were in the main positive but with one criticism on communication

We spoke to people living in the home and they told us they were happy in the home and that staff help them. One person told us that she enjoys outings and that she enjoys shopping for clothes. Other people who had been out on a trip said they had enjoyed it. Another person told us that he enjoyed the garden. People told us that they enjoyed the food.

The inspection took place on 26 and 30 November 2015 and was unannounced. A further visit was made to the service on 14 December 2015 following receipt of information of concern.

The home provides care and accommodation, including nursing care, for up to 50 people and there were 37 people living at the home when we inspected. The age range of people was from 52 to 94 years. The service was providing care for a wide range of care needs including older persons, dementia, mental health, substance misuse and physical disabilities. At the time of the inspection the service provided care to people who had complex needs including people who had suffered a stroke and people with different types of dementia. The service also accommodated people as part of a staged rehabilitation from hospital called ‘Step down.’

All bedrooms were single. Five bedrooms did not have an en-suite facility, 17 had an en-suite bathroom and 28 an en-suite toilet. Communal areas consisted of several lounge and dining areas which had all been merged to create one large communal area. There was a garden which people used.

This inspection was carried out to check on the provider’s progress in meeting the requirements made as a result of the inspection on 16 and 17 June 2015, which resulted in the service being rated Inadequate and being placed into Special Measures. The previous inspection report identified some serious concerns, in relation to:

• How risks to people, such as falls were managed as well as the safe management of medicines.
• The provider was not following the Mental Capacity Act 2005 and its associated Code of Practice, where people lacked capacity to consent to their care and treatment.
• People were not always supported to eat adequate food at meal times.
• Staffing. Staff had not received appropriate support, professional development and training to perform their role.
• People were not always treated with respect and dignity. Arrangements were not made to ensure people’s privacy was always upheld.
• People’s care needs were not adequately assessed and care was not always arranged to meet those needs.
• The provider did not have adequate systems to assess, monitor and improve the service.

The provider and manager took action to address the concerns we found at the last inspection and submitted action plans of how they were addressing the areas in need of improvement. At this inspection we found the provider had taken action to address these breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we identified that further improvements were needed regarding the safe handling and management of medicines, the cleanliness and maintenance of the environment, and safe storage of confidential records.

Whilst records of medicines administered by nurses were kept, records of creams and ointments used by care workers frequently lacked details of the product or where it had been applied. Information to support the administration of medicines was variable. For example, allergy information was consistently documented but guidance for staff on when “as required” medicines was not always available.

The service did not have 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was an acting manager who had been in post since February 2015 and had applied to register with the Care Quality Commission.

There were policies and procedures regarding the safeguarding of people. Staff had a good awareness of procedures for dealing with any suspected abuse. People and their relatives told us they felt safe at the service and said staff treated them well.

Care records showed any risks to people were assessed and there was guidance of how those risks should be managed to prevent any risk of harm. There were systems in place to review any accidents or incidents to people to prevent the likelihood of any reoccurrence.

The manager used a needs dependency tool to assess the required staffing levels to meet people’s needs. Relatives considered there were enough staff to meet people’s needs. Sufficient numbers of nursing and care staff were deployed to meet people’s needs.

Staff received training in a variety of subjects and the provider told us 80% had a national qualification in care such as a National Vocational Qualification (NVQ). Since the last inspection additional training has been provided for staff in areas such as caring for those people with a mental disorder and those living with dementia. Newly appointed staff received an induction to prepare them for work and staff received regular supervision.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The acting manager had made referrals for a DoLS authorisation where people did not have capacity to consent to their care and treatment and where their liberty was restricted for their own safety. A DoLS authorisation is made by the local authority where people do not have capacity to consent to their care and treatment and have their liberty restricted for their own safety. Assessments of people’s capacity to consent to decisions were assessed. Not all staff had a clear understanding of the MCA and DoLS and staff identified this was an area they needed additional training in.

People were supported to eat and drink. Specialist diets were catered for such as diabetic diets and soft foods. The advice of specialist services such as the Speech and Language Therapist were sought so people could be supported to eat and drink.

People were supported to access health care services including from the occupational therapist and physiotherapist, GP and other specialists. A visiting GP told us people’s health care needs were met and appropriate referrals were made when medical assessment or treatment was needed.

Staff were observed to treat people with kindness and respect. There was a rapport between staff and people who shared jokes and chatted together. People were consulted about their care.

Each person’s needs were assessed and care plans were individualised to reflect people’s needs, preferences and routines. Staff were observed to follow guidance included in care plans when supporting people. Procedures for monitoring care needs were included in care plans and charts of daily care interventions completed.

The complaints procedure was displayed and people said they knew what to do if they were not satisfied with the service. Complaints were logged and records showed the provider looked into complaints and responded to complainants.

It was evident the manager and provider had invested their time and resources into improving the service following the previous inspection. Systems for assessing, monitoring and reviewing the quality and safety of the service had been expanded. These included seeking the views of people, their relatives and professionals as well as reviewing incidents and accidents at the service. Staff reported that the manager and provider had involved staff in discussions and decision making regarding improvements the service needed to make.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 including one which was a continued breach from our inspection on 16 and 17 June 2015. You can see what action we told the provider to take at the back of the full version of this report.