We inspected this service on 2 July 2018 and returned on 3 July 2018. On the first day of our inspection we arrived at the home during the afternoon, we stayed throughout the evening to get a better view of the service during the evening and when the staff changed to the night shift. The inspection was unannounced on 2 July 2018, and we told the registered manager that we would return on 3 July 2018.

Overslade House is a 'care home' operated by Barchester Healthcare Homes Limited, who are a large provider of care services. Overslade House is a purpose-built home which provides accommodation with personal and nursing care for up to 89 adults, including people living with dementia and physical disabilities. End of life care is provided at the home. 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.

Of the 89 beds, 15 are contracted by the local Clinical Commissioning Group (CCG) for people discharged from hospital and in need of personal and nursing care. Ten of these beds are offered on a ‘Discharge to Assess’ basis; for an initial six-week assessment period. The home is split into three units. At the time of our visit, there were 79 people living at the home.

A requirement of the services’ registration with us is that they 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 a registered manager in post at the time of our inspection visit.

We last inspected this service on 4 January 2018 to undertake a planned comprehensive inspection. We then returned on 16 February 2018 because we were made aware of a serious incident which had taken place in the home. At that inspection, we rated the safety of the service as Requires Improvement because there was an on-going external investigation into the serious incident that had occurred. We gave the service an overall rating of Good.

We undertook this inspection following further information of concern received. This inspection focused on two key areas; the safety and governance of the service. At the time of this inspection, the investigation into the serious incident remained on-going.

Overall, staff knew how to keep people safe because risks were assessed and actions implemented to mitigate risks of harm or injury. However, staff did not always recognise when people's behaviours or their own practice created risks that could compromise people's safety. This meant some risks were not assessed which could put people at risk of harm or injury.

People had their prescribed medicines available to them. Medicines were given to people by trained staff.

Staff understood their responsibilities to protect people from the risks of abuse. Staff had been trained in what constituted abuse and would raise concerns under the provider’s safeguarding policies. The provider checked staff’s suitability to deliver care and support during the recruitment process. Staff received training and, overall, used their skills, knowledge and experience to provide safe care to people.

People and their relatives had no complaints about the service. However, some people and relatives felt more staff were needed because at times staff took over five minutes to answer call bells.

Staff on shift met people’s individual needs, however, staff were very busy and rushed. This had been recognised by the provider who was recruiting to an additional nurse post for day shifts.

The registered manager and provider had systems in place to monitor the quality of the service people received. Increased spot checks had b

We inspected Overslade House on 04 January 2018 and then returned on16 February 2018. Both days were unannounced. We returned because we were made aware of a serious incident which took place after our first inspection day and currently remains under investigation. Overslade House is divided into three separate units over two floors, and provides personal and nursing care for up to 89 older people, including people living with dementia and physical disabilities. There were 80 people living at the home when we inspected the service.

A requirement of the service’s registration is that they 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 and the associated Regulations about how the service is run. There was a registered manager in post at the time of our inspection visit. We refer to the registered manager as the manager in the body of this report.

We last inspected this service in January 2016 when we rated Safe as ‘Requires Improvement’ because we found staffing numbers required improvement, with an overall rating of Good. At this inspection we found whilst improvements had been made to staffing levels, there is a lack of clarity about what happened with regard to the serious incident at the home, and we have therefore continued to rate Safe as Requires Improvement.

Since our previous inspection in January 2016 we have reviewed and refined our assessment framework, which was published in October 2017. Under the new framework certain key areas have moved, such as support for people when behaviour challenges, which has moved from Effective to Safe. Therefore, for this inspection, we have inspected all key questions under the new framework, and also reviewed the previous key questions to make sure all areas were inspected to validate the ratings.

We found risk management plans were established to ensure the environment and premises were managed safely, and environmental risks to people were minimised. In addition, we found people had individual risk assessments completed and staff were instructed on how to minimise risk to people’s health and wellbeing.

Most people told us there were enough staff at the home to provide them with safe care. We saw there were enough staff during our inspection visit to ensure people were cared for safely. However, three people told us they sometimes had to wait for assistance to go to the toilet, or for personal care, at busy times. The manager assured us staffing levels were worked out to ensure people received safe care. Although there were busy times of day, there were sufficient staff to meet people’s needs. Quality assurance procedures were in place to monitor staffing levels remained safe.

All necessary checks had been completed before new staff started work at the home to make sure, as far as was possible, they were safe to work with the people who lived there. People were supported by a staff team that knew them well, as the manager did not employ temporary staff.

Staff received training and had their practice observed to ensure they had the necessary skills to support people. Staff treated people with respect and dignity, and supported people to maintain their privacy and independence.

People had been consulted about their wishes at the end of their life. Plans showed people’s wishes about who they wanted to be with them, and the medical interventions they had agreed to. People and their relatives told us the care they received at this difficult time was excellent.

People received their medicines as prescribed to maintain their health and wellbeing. People were supported to access healthcare from a range of professionals inside and outside the home, and received support with their nutritional needs which assisted them to maintai

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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 7 and 8 January 2016. The first day of the inspection was unannounced. This inspection was conducted by one inspector, an expert by experience and a specialist advisor. An expert by experience is someone who has experience of caring for someone who uses this type of service. A specialist advisor is someone who has current and up to date practice in a specific area. The specialist advisor who supported us had experience and knowledge in nursing care.

We spoke with seven people who lived at the home and seven people’s visitors or relatives. We spoke with four nurses (one of which was the clinical/deputy manager), four care staff, two members of staff involved in preparing and serving food to people and two activities coordinators. We also spoke with the chef, the trainer, an administrator, the registered manager and the Regional Director.

We reviewed the information we held about the service. We looked at information received from statutory notifications the provider had sent to us and commissioners of the service. A statutory notification is information about important events which the provider is required to send to us by law. Commissioners are representatives from the local authority who provide support for people living at the home. We also spoke with two visiting health professionals during our inspection visit.

We also reviewed the information in the provider’s information return (PIR). This is a form we asked the provider to send to us before we visited. The PIR asked the provider to give some key information about the service, what the service does well and improvements they planned to make. We found the PIR reflected the service provided.

We looked at a range of records about people’s care including eight care files. We also looked at other records relating to people’s care such as medicine records and fluid charts that showed what drinks people had consumed. This was to assess whether the care people needed was being provided.

We reviewed records of the checks the manager and the provider made to assure themselves people received a quality service. We also looked at personnel files for three members of staff to check that safe recruitment procedures were in operation, and that staff received appropriate support to continue their professional development.

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 is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service. The inspection was unannounced.

Overslade House provides accommodation with nursing and personal care for up to 89 older people who may have dementia. Seventy-eight people were living at the home on the day of our inspection. The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found people’s health needs were assessed and care plans were written to minimise the identified risks. However, people’s emotional and psychological needs, which related to their dementia, were not planned for in the same detail as their health needs. Staff levels were decided according to people’s health needs, which did not always take into account people’s emotional and psychological dependencies related to their dementia.

During our inspection we saw there were not enough staff to ensure everyone’s needs were met in a timely manner. Relatives we spoke with confirmed that people regularly had to wait for assistance to eat. This was a breach of regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

The provider had a robust recruitment process. The registered manager checked staff were suitably qualified to work with people before they started working at the home. All the staff we spoke with told us they received regular training and supervision to enable them to deliver care and support effectively. Staff understood their responsibilities for protecting people from abuse and knew how to respond to any concerns appropriately.

The registered manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). For people who were assessed as not having capacity, records showed that their families were involved in discussions about who should make decisions in their relation’s best interests. The registered manager told us they checked with the local authority that the way they cared for people did not amount to a deprivation of their liberty. No one was under a DoLS at the time of our inspection.

People told us staff were good and knew them well. Records we reviewed showed staff were mentored and supervised by experienced staff. Staff told us they received training that helped them to understand and meet the needs of people who lived at the home. At the time of our inspection there was an ongoing programme for all staff from the Alzheimer’s Society’s training in dementia awareness.

People told us the food was good and they always had a choice. We saw records of menu planning meetings, which included information from people’s care profiles about their dietary requirements and preferences.

Relatives we spoke with were satisfied their relation had access to other health professionals, such as doctors, dentists and opticians, when they needed it. People and their relatives told us they were able to discuss their ongoing needs for care and support with the nurses. They told us they were invited to attend group meetings to discuss things of interest to them.

The service had a good reputation for delivering effective end of life and palliative care, but we found improvements were needed in recording people’s preferences for the care and treatment they would like in the future. The registered manager assured us they would check people’s understanding of advanced decisions they had already made at their regular care plan review meetings. They told us the provider planned to implement written end of life care plans for those people who would like them.

We observed staff were thoughtful and caring with people. We saw from people’s response to staff’s actions that staff knew people well and anticipated their needs. We saw that staff encouraged people to maintain their independence. Staff encouraged people to be involved in physical and community events according to their interests. Relatives told us they always felt welcome and were involved in decisions about their relation’s care. Meetings for people and their relatives were recorded and we could see how suggestions were acted on.

Everyone we spoke with told us they respected the registered manager. The registered manager made sure that people who lived at the home were confident to approach her about any aspect of the home or their personal care needs. Staff told us the registered manager was approachable and they respected her judgement and expertise.

We saw that the registered manager attended staff handover meetings so they kept up to date with changes in people’s care needs. Staff meetings were arranged to ensure all staff could attend at a suitable time of day. Staff were encouraged to champion, or take a lead role, in a specific aspect of care, which improved the quality of care and supported staff in their personal development.

We spoke with 15 people who lived at Overslade House about their experiences of the service. We also spoke with three relatives about their family member's experience. We observed the care that was given to people during our inspection. We spoke with a range of staff including the registered manager.

Relatives we spoke with told us that the care planning was discussed with them every six months. We saw that people or relatives were involved with the reviews of people's care.

We saw that staff listened to people about their care needs and their wishes. We saw people's independence was promoted within their care plans and on the day of our inspection.

We found that the care plans were person centred and reflected people’s individual needs. We saw the members of staff supported people as detailed within their care plans. We observed that staff were compassionate and caring when supporting people.

We found appropriate arrangements were being undertaken to manage the risks associated with the unsafe use and management of medicines.

We spoke with four staff members about what they thought abuse was and they showed they had a good awareness of the importance of keeping people safe. They understood their responsibilities for reporting any concerns regarding potential abuse.

We found that people using the service were involved with providing feedback on their experiences and systems were in place to monitor the quality of service being provided.

We reviewed the service's compliance with a number of essential standards in May 2012, as part of a planned inspection. This inspection was carried out to look at all the information we had received since we told the provider where they needed to improve.

We spoke with two people who used the service and two family members of people who lived at Overslade House. We also spoke with three staff members.

People we spoke with told us that they were on a softened diet as they were at risk of choking. They told us that their softened meals were well presented. People also told us that there were alternatives available should they require them.

Relatives we spoke with told us that staff monitored how much their family member would eat and encouraged them to eat more. Relatives also told us that the staff were very good at ensuring thickener where assessed as required was used for their family member's drink.

We saw care plans related to people's nutritional needs were reviewed every month. We also saw risk assessments were in place for people that were at risk of choking when eating and drinking. We saw that were people were at risk of choking; staff ensured thickener was used within the person’s drink.

We saw that people were supported during meal times and the right equipment was available for people to use. For example, we saw one care plan stated a person preferred to use a spoon and we saw them using a spoon for their meal.

We used a number of different methods to help us understand the experiences of people using the service, because people could not easily tell us about their experiences due to their health condition.

We therefore spoke with the relatives of five people and we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Family members spoken with told us that they were involved with their relative’s care and could visit anytime they wanted to. We saw that care plans had been reviewed with family members every six months. Family members who we spoke with told us that they had discussions with staff about people’s care and felt involved.

Most family members spoken with told us that people received the support that they needed and that the care was ‘very good on the whole’. One relative told us that where specialised equipment had been requested, there had been a delay in fulfilling the request.

We observed the lunch time meals and saw that some people did not always receive the support that they needed. An example of this was one person who did not have access to the correct equipment as stated within their care plan. Relatives spoken with told us that people had a choice of meals and the meals looked ‘nice’. One family member told us that food available was of a very good standard although on ‘odd’ occasions the food could be cold. We observed that people’s meals were sometimes served before any support was available which meant the meal could become cold.

We read a care plan about a person who could sometimes present challenging behaviour and could be a risk to other people. We saw that a referral had been made to a Deprivation of Liberty (DoLs) advisor for guidance about managing the risk posed to other people and the person’s behaviour.

We saw that people enjoyed the range of activities that were offered and that there were events scheduled throughout the year. Relatives told us they were invited to join in with activities and attended events that the service held.

Family members told us that people received the correct medication and at the right times. We observed the nurse who dispensed medication and saw that medication was given in a safe way.

Relatives found that the staff were friendly and were supportive with people’s needs.