At the inspection of 17, 18 19 and 23 May 2017 we found breaches of Regulations 9, 12, 13 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider wrote telling us the actions they were taking to make improvements. At this inspection we found Regulations 12, 13 and 18 were met and Regulation 9 partially met.

This inspection took place on the 25 and 26 April 2018 and the first day was unannounced. The registered manager was aware of the subsequent visit.

Athelstan House is a care home providing nursing and residential care for up to 80 people. At the time of the inspection there were 53 people living at the home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is arranged over two floors with Primrose and Lavender on the ground floor and Foxglove and Heather on the first floor. In Lavender people were receiving nursing care and residential care was mainly delivered to people in Foxglove and Heather. Re-admissions into Primrose the empty unit will be over a period of time.

A registered manager was 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.

Safeguarding processes were in place and ensured people at the service were safeguarded from abuse. Staff had a good understanding on of the types of abuse and the actions needed where there were concerns of abuse. People generally said they felt safe.

Risk assessments were in place but not regularly monitored to assess the effectiveness of the action plan.The staff we spoke with were knowledgeable about people’s individual risks and the actions needed to minimise the risks. Individual risks to people included falls, risk of malnutrition, choking and mobility impairments.

Quality Assurance systems were in place but areas identified at the inspection were not reflected in the audits. There was inconsistent action for some people identified at risk of malnutrition and for one person that had sustained an injury. Weight monitoring charts were not in place for one person that was at high risk of malnutrition. Staff had not reported extensive bruising for one person. The registered manager took prompt action when we identified this and reported the incident to appropriate authorities. Appropriate reporting action had been taken in the upstairs units. .

The robust medicine systems in the residential units ensured safe systems of medicines. However, the same situations were not found in the nursing units. Medicine audits had identified gaps in when required medicines (PRN) but the timeframe for meeting the action was not met.

Gaps in the administration of medicines were not reported and we observed unsafe medicine administration by a registered nurse. The registered nurses comments indicated their awareness of gaps in the recording of medicines administered. checks were not taking place. Where audits had identified shortfalls these had not been actioned.

Medicine profiles included a photograph of the person and essential information such as known allergies and how the person preferred to take their medicines.

Care plans upstairs in the residential units had elements of person centred care and were reflective of people’s current needs overall. In the nursing units we found inconsistencies. For one person at high risk to weight loss the care plan stated that staff should support them to be weighed once every two weeks but this had not happened since April 2018. Mental capacity assessments were not always in place and records needed to be clearer.

The safety

OSJCT Athelstan House provides nursing and residential care for up to 80 people. In addition to long term care, the home offers short stays to people who require support with rehabilitation or a period of respite care.

This inspection took place on the 17, 18 19 and 23 May 2017. The first day of the inspection was unannounced and the manager was aware of subsequent visits.

A registered manager was not in post. There had been several changes in managers in a 12-month period. Staff said there had been five managers. These changes did not enable the staff to clear guidance and leadership. 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 said the staff and the security of the building made them feel safe. Some of the staff we spoke with said people were not safe. These staff said they were not delivering adequate levels of care at all times. Staff said they did not felt confident to raise concerns to the provider, as they felt their concerns were not taken seriously. During the inspection, 11 staff came forward to raise concerns about the service.

People were at risk because information and record keeping was inconsistent. Staff said identified risks were assessed and action was taken to minimise the risk. We saw that risk assessments lacked detail and action plans were not followed. Where people had capacity to make decisions and were refusing textured diets, risk assessments were not developed and agreements were not reached on the foods to be eaten. Where people’s fluid and food intake was monitored the charts were not analysed or totalled at the end of each day. This left people at higher risk of dehydration. People were not supported to move position according to the risk assessment which meant they were at higher risk of developing pressure ulcers.

People expressed concerns about insufficient staffing levels and lack of effective management in the deployment of staff. They said at certain times of the day, they had long waits before help arrived. Documents provided on staffing levels indicated that in 12 months, 31 staff had left the service which included registered nurses, seniors and carers, housekeeping and catering staff. The staff raised concerns about the deployment of staff.

During our visit we noted the call bells ringing. Staff told us their hand held devises were not working effectively and they were not always aware of people summoning them for attention.

Staff expressed concerns about training. Staff said training was often cancelled and there were times when they were not able to attend as there were insufficient staff on duty to maintain staffing levels.

One to one meetings were not taking place and staff felt there was a lack of opportunities for personal development. Staff told us one to one meetings with their line manager and appraisals were not taking place. Registered nurses were not supported to maintain their registration. They said a re-validation programme was not available for them to maintain their registration.

The care plans we looked at were inconsistent and were not updated following the reviews. We found care plans were task led and had little information about people’s preferences on how people liked their care to be delivered.

Relatives were aware of the complaints procedure but were concerned that little happened when they raised a concern.

While a member of staff said their units ran smoothly and a unit lead was available for support and guidance, other staff told us there was conflict between staff and there was little support from managers. The head of care agreed there was a lack of leadership on the nursing units and the RGN’s were being helped to delegate with the introd

This inspection was arranged in response to concerns raised by the Local Authority following a safeguarding alert made to them. A person who lived at Athelston House was admitted to hospital on 9 January 2014. On this date, it was discovered that they had not been administered their prescribed medicine for five days and had subsequently become unwell. A safeguarding early strategy meeting was held on 14 January 2014. The provider and the contracted pharmacy, which supplied medicines to the home, were both required to investigate the circumstances which led to this omission and to report back to a further meeting. At the time of our inspection this follow up meeting had not taken place and the investigation had not been concluded.

We visited Primrose Unit at Athelston House, which was where the subject of this error was cared for. They had returned to the home, following a short spell in hospital. We looked at this person's records, including daily records, multi disciplinary (MDT) notes and medication records. We looked at other documents, including the communications diary, the shift handover records and staff training records. We looked at the investigation carried out by the home, including statements from staff members. We also looked at the report from the pharmacy.

Our pharmacist inspector spoke with staff about medicines management, checked medicines records and observed a medication round. We found the arrangements in place for ordering medicines had not been followed and systems in place for checking medicines had not been followed consistently. A small number of medicines administration records had not been completed fully so in these cases it was not clear whether people had received their medicines as prescribed.

We spoke with the registered manager and the area operations manager. We were concerned that home's investigation of the error had not been sufficiently thorough and was incomplete. Although we were told that some processes had been amended in the light of the error, no feedback, guidance or further training had been provided to the staff involved and other staff employed in the home, to ensure that mistakes like this did not happen again.

People we spoke with told us that they had been asked to give their agreement before care and support was provided. We received positive comments about how their care needs were met. “I am very well looked after and I couldn’t ask for any better” and “I have lived here a long time now and the staff are like my family now. They really care for me”.

We found that on the whole the management of medicines was in line with good practice although we have suggested that the provider make additional improvements in order to audit medicines returned to the Pharmacy.

Athelstan House was designed around the needs of older people with physical disabilities and sensory impairment and was a suitable environment for the 80 people who lived there.

We looked at recruitment files to check that safe procedures were followed before staff were appointed to work in the home. Appropriate checks were undertaken.

People were made aware of the complaints system and a copy of the complaints policy was placed in an information folder in each room. A suggestion box was also sited at the main entrance.

All records we asked to look at were provided promptly. Care records provided a clear and accurate account of the care and support provided to each person, were kept up to date and were fit for purpose.

We previously visited this home in May 2012. Although feedback from people who lived at the home was positive, we saw insufficient documented evidence that people were receiving the care and support that was prescribed in their care plans and that met their needs. We also had concerns that staff training, supervision and appraisal records were not up to date. The provider submitted an action plan which detailed the actions they had taken to achieve compliance in these areas. We made a return visit to check their progress with this.

We did not speak with people living in the home as part of this review. We spoke with the registered manager and to one member of staff.

We looked at care plans and records for people who received nursing care on Lavender Unit. Although we saw some inconsistent practice in relation to record keeping, records for the most part evidenced that people received the care and support they required.

We looked at staff records. The manager had put in place improved systems to ensure that all staff received regular supervision and appraisal. A training matrix was displayed but this showed a significant number of training gaps. When we highlighted this, the provider checked individual staff records and later provided us with information which demonstrated that most staff were up to date with training in essential subjects.

We spoke to a number of people who lived at the home. They told us they enjoyed living at Athelston House. They all spoke positively about the staff. One person said “They treat me with a great deal of respect”. Another person told us “In all the years I have lived here I have never encountered anything but kindness”. They said of one member of staff, “X has compassion in abundance”.

People told us that when they used their call bells to summon assistance, the staff usually responded quickly.

People told us they thought they were fortunate to live in a home which was comfortable and homely. One person said “this is my home; I have so many friends; there is always someone to talk to”. People said they liked their bedrooms which were spacious, airy and light and they thought that the home was clean. Most people told us that they enjoyed their meals and that there was always enough to eat and drink. They said they could always ask for an alternative if they did not like what was on the menu.

People enjoyed regular activities organised in the home and outings in the community.

People told us that they felt safe and well cared for at Athelston House. They said they felt able to raise any concerns with staff and confident that concerns would be acted upon.

People were generally happy with the service provided. One person told us that Athelstan House is “a very good service, they’ve been wonderful to me”. A person told us “I feel safe here” and another said that they “fully trust” the care workers.

People said that staff were helpful. One person told us “they come in and ask me if I need help often”. A person told us they appreciated the support given to them by the home, saying “they’ve been quite helpful getting special stuff I need so that I can move around when I want”. A person said that they were pleased that they could continue to look after their own medication, saying “I want to do this”.

People told us they liked the home environment. One person told us “my room is nice and they tidy it well”. Another person told us “what I really enjoy is the beautiful bath” and another they appreciated that the “toilets are always clean”.

However some people felt that certain areas could be improved. Not all people felt consulted about their care. One person told us “I don’t have a care plan”. We observed that some records were not completed in full or reviewed when they needed to be. Some people also felt that there was a lack of action when they raised issues. One person told us “I have talked to the person in charge but nothing happened”,

Athelstan House provides nursing and residential care for up to 80 people. In addition to long term care, the home offers short stays to people who require support with rehabilitation or a period of respite care. The staff provide care and treatment to people with nursing needs and to people living with dementia. We found breaches of regulations at the previous inspection which relate to medicine management Regulation 13 and quality assurance systems Regulation10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 come into force on 1 April 2015. They replace the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010These relate to previous regulations now correspond with Regulation  The provider sent an action plan telling us how they were going to achieve compliance with the regulations.

The inspection of Athelstan House was unannounced and took place on the 12 and 14 August 2015.

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

Quality assurance arrangements were effective and ensured people's safety and wellbeing. Internal audits were used to assess the quality of care people received. However, medicine audits had not identified that protocols for some people with prescribed when required medicines needed reviewing. This meant people may not be having their medicines when they needed them.

Management systems in place ensured there was a supporting culture. The service benefited from strong leadership. People told us the registered manager was visible and staff said the registered manager was skilled in conflict resolution and providing the resources needed to meet people needs. However, some staff said they did not always understand each other roles and when their suggestions were rejected they were not given the reasons behind these decisions. This meant some staff may not understand the decisions reached and commit to the agreements reached.

Safe systems of medicine management were in place. However, the protocols needed reviewing for some people prescribed with when medicines required medicines. This meant staff may not be administering when required medicines when needed by the person. A medication administration record (MAR) file was in place to support staff with the safe administration of medicines. Each person had a photograph in the MAR file which helped staff identify the person and included was important information about the person. MAR charts were signed by staff to evidence the medicines administered.

People’s needs were assessed before they moved into the home so that individual risk assessments and care plans could be developed. Care plans were developed to meet people’s needs in their preferred manner. They gave information and directions for staff to follow and meet people’s health and welfare needs. Care plans were updated when their needs changed.

Risk management systems ensured where there was potential harm to people action was taken to lower the risk. When people had support needs with moving, risk assessments were developed on safe systems of moving and handling. Procedures were in place for the reporting of incidents and accidents. These events were analysed by the registered manager to identify trends and patterns.

People's health was monitored. A record of visits from social and healthcare professionals described the nature of the visits and the actions that must be taken. Good working relationships were in place where people’s care was shared with other healthcare professionals such as Occupational Therapists and Physiotherapists.

People were able to pursue their interests, hobbies and religious beliefs. There was an activity programme in place and people had an opportunity to participate in group activities or on a one to one basis.

People’s views about the service were gathered through house meetings and internal questionnaires. People said their views were valued and their suggestions were acted upon. Staff respected people’s rights and promoted positive relationships with people. Staff delivered care in a way that helped people to maintain a good level of independence. They were encouraged to make choices and were enabled to do as much for themselves as possible.

People were enabled to make choices about their daily lives. Where people had a cognitive impairment their capacity to make decisions was assessed. Mental Capacity Act (MCA) 2005 assessments were developed for specific decisions and where people lacked capacity best interest decisions were made on their behalf by the appropriate decision maker. Members of staff were knowledgeable about the principles of the MCA.

Members of staff received an induction when they started work at the home. They attended training which helped them to develop the skills and knowledge needed to meet people’s changing needs. One to one meetings and appraisals supported staff to meet their roles and responsibilities.

The procedure for making complaints was on display which meant people were informed on how to raise concerns. Staff knew the procedure for making complaints. A record of their complaints was maintained which the manager investigated and action taken to resolve them.

Procedures and processes were in place to safeguard people from abuse. The staff were able to recognise the signs of abuse and were clear on the expectations placed on them to report suspected abuse. People said they felt safe at the home.

People’s needs were met by sufficient numbers of staff that had the appropriate skills and knowledge. Where agency staff was used to cover vacant hours the same staff was used to maintain consistency of care to people.