The inspection took place on 29 November and 3 and 6 December 2018 and was unannounced. During our last comprehensive inspection, including dates in December 2017 and March 2018, we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safeguarding, staffing, complaints, good governance, nutrition, dignity and respect and safe care and treatment and we rated the service as “Requires improvement.”

Prestbury Care Home is a 'care 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.

Prestbury Care Home provides accommodation and nursing care for up to 75 people. At the time of our inspection there were 57 people living at the home.

At this inspection we found that improvements had been implemented. The provider was no longer in breach of several of the regulations. However, we identified a continued breach with regards to Regulation 18 (staffing) and identified a breach of Regulation 9 (person centred care). Although improvements had been made and the effective and caring domain had improved to “Good”, we found that the overall rating for the service remained “Requires improvement”.

There was a registered manager in place. 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 were mixed views about staffing levels. Observations, feedback and records indicated that at times insufficient staff were deployed to meet people’s needs in a timely way. The regional manager told us that this would be addressed. Several new staff had been recruited and recruitment of nursing staff was a priority.

Aspects of care were not provided in a person-centred way. Within the Gawswoth Unit we found that a routine was in place around personal care, which did not always meet people’s individual needs.

A new electronic recording system had been introduced. We found that charts were not always completed to demonstrate that people had received appropriate care such as positional changes and safety checks. Care plans contained some person-centred information, however these had not always been updated or amended to reflect changes where there were changes to care needs.

Overall medicines were managed safely. However, we found some minor shortfalls in medicines management relating to covert administration and inaccurate recording.

Checks were carried out during the recruitment process to ensure only suitable staff were employed.

Risks associated with people's care and support needs were assessed and guidance was in place to support staff to keep people safe, however further work was needed to improve aspects of risk management further.

Improvements had been made to ensure that safeguarding procedures were robustly followed and continued to be embedded. Staff understood their duty to protect people from harm and abuse.

The home was clean and well maintained. The home was decorated and furnished to a high standard and suitable for the people living there.

People were supported by staff who were suitably trained and supervised. The registered manager and staff were aware of their responsibilities and acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. (DoLS).

People's nutritional and healthcare needs had been assessed and were met. People were positive about the food on offer and staff supported people to have sufficient to eat and drink. People had access to healthcare professionals as required

Overall, staff were caring and treated people with dignity and respect. Wh

This inspection on 12, 13 December 2017 and 8 March 2018 was unannounced. There was a delay in returning to complete the inspection partly due to an outbreak of influenza within the home. On the last inspection which took place on 18, 20 21 April 2017, 26 May 13, 14, 21 and 22 June 2017 we found breaches of regulations 9, 10, 11, 12, 13, 14, 16, 17, 18, 19 of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014 and a breach of Regulation 18 of the Registration Regulations 2009. The service was placed in special measures rated inadequate.

On this inspection we found the provider had met the legal requirements of regulations 9, 11, 14 and 19. The provider remained in breach of regulations 10, 12, 13, 16, 17 and 18 of the Health and Social Care Act Regulations.

Following the last inspection, the provider sent us an action plan to show the Commission what they would do and by when to improve to at least good. The provider demonstrated they had met the positive conditions which were served by the Commission. We also met with the provider and discussed progress being made to meet the breaches found.

Prestbury Care Home is a 75 bedded care home. There were 53 people living in the home at the time of this inspection. 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. It has three units over three floors called Haddon, Gawsworth and Capesthorne which have separate adapted facilities. Gawsworth specialises in caring for people living with dementia. 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.

On the last inspection which commenced on 18 April 2017 we found the provider was in breach of regulation 9 Person Centred Care. This was due to care plans not providing enough detailed information about the person's preferences, likes of dislikes. Some risk assessments/care plans required to deliver person centred care were absent. On this inspection we found improvements had been made and the provider was no longer in breach of person centred care. Care plans were no longer absent and some person centred information such as a person’s place of birth, family member’s names, previous pets and places of interest were seen in the care plan.

On our last inspection which commenced on 18 April 2017 we found the provider had not mitigated risks when they became aware of them. We found some improvements on this inspection but continued to find risks which were not mitigated. For example, we found a trailing oxygen pipe on the floor and although there was a risk assessment for having oxygen in the home there were no risk assessments in place for the storage of oxygen in people's bedrooms. A new computerised system to manage recording of administration of prescribed medicines was being implemented in the care home at the time of our inspection. We found one person had not received their prescribed medicine on our inspection. The provider remained in breach of Regulation 12 Safe Care and Treatment.

Improvements were seen in safeguarding people as unexplained bruising was being recorded, reported and body mapped however, some complaints seen in the complaints file were safeguarding concerns which had not been dealt with appropriately. There was a repeated breach of Regulation 13 Safeguarding.

On the last inspection we found concerns in relation to people having appropriate foods to meet their needs and a breach of regulation 14 Nutrition and Hydration. We found improvements on this inspection an

We undertook a focused inspection on 18, 20 April 2017 and a comprehensive inspection on 26 May 2017, 13, 14, 21 and 22 June 2017 unannounced. At our previous inspection on 5 October 2016 the service was rated Good in all domains and overall.

Prestbury House Care Home is a modern purpose-built three story care home located in the centre of Macclesfield. Shops and amenities are within easy walking distance. The Home is registered to provide nursing care for up to 75 people divided into three separate units. Prestbury House Care Home is part of the Porthaven Care Homes Group. Sixty one people were living at the care home at the time of our inspection.

The service has 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. The registered manager was present during the inspection.

The service was not always safe with risks not always being identified to remove the risk or mitigate the risks for the person. There was no challenging behaviour care plan for 9 people with challenging behaviour and 3 behaviour care plans seen were not detailed enough.

Not all safeguarding concerns documented in the care records seen were being reported to the safeguarding authority and some staff were not competent to know when to report a safeguarding concern. Staff were aware of whistleblowing and were aware of what to do.

Staff recruitment systems were in place however, we raised concern staff were not always being assessed according to their probationary period. Staff who did not have a background in care were not always being supported to be competent in caring for people. Induction included staff reading the staff handbook and shadow shifts. We found the staff handbook did not include any information in safeguarding people.

Supervision sessions were inconsistent and appraisals were not always undertaken with staff. They were not being undertaken in line with the provider’s policy issued October 2015 which stated supervision should be undertaken at least once every two months and an annual appraisal. The provider was working towards an action plan to address this.

Staffing levels were not sufficient in meeting people’s care needs. People who required staff to be aware of their whereabouts at all times according to their care plan were not receiving this level of oversight from staff. Others were not receiving one to one assistance to ensure they had the optimum opportunity to eat and drink.

Medication management was not always safe with some people not receiving their prescribed creams and food supplements.

Recommendations by healthcare professionals were not always being followed by staff with weekly weights not always being recorded therefore, health monitoring was not always effective.

There was a structure in place for assessing people’s mental capacity and best interests meetings seen in the records. DoLS (Deprivation of liberty safeguard’s) authorisations were not always being renewed when expired. We found one person's DOLS authorisation had expired. Staff were unaware of what constituted restraint until we asked the provider to include training for staff.

People were not always being supported to have enough to eat and drink. We observed people being interrupted when being supported to eat, another person spilling their liquid down themselves due to not receiving the support they needed.

People told us if they needed to see a doctor this was arranged quickly. We found healthcare professionals were involved such as Dietician’s, Speech and Language Therapists and Chiropodists.

People told us staff were kind. We observed both positive and negative interactions. Staff did not always have the necessary training, skills and kn

The inspection was unannounced and took place on 5 October 2016

The service was last inspected in August 2014 and was found to be meeting the regulatory requirements which were inspected at that time.

Prestbury House Care Home opened in 2011 and is a modern purpose-built two story home located in the centre of Macclesfield. Shops and amenities are within easy walking distance. The Home is registered to provide residential accommodation for up to 75 people including those who need nursing care and is divided into three separate units each catering for different levels of need. Prestbury House Care Home is part of the Porthaven Care Homes Group. Sixty four people were being accommodated at the time of the inspection.

The service has 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.

The registered manager was present during the inspection and was able to provide all the necessary information and documentation we requested.

The people who lived at Prestbury House and their relatives told us that they were treated with respect and kindness by the staff. Comments included, “All the staff are kind and caring, even the agency staff are good with us” and “Wonderful place I have never looked back since I came here”. Everyone we spoke with told us they felt safe and secure within the building and with the care and support received. Risks to people’s safety and welfare had been assessed and information about how to support people to manage risks was recorded in their plan of care.

Medicines were administered safely to people by staff. We found in a small number of cases there was a lack of clarity around the recording of people’s medicines. This was brought to the manager’s attention during the inspection and appropriate actions taken.

Arrangements were in place to protect people from the risk of abuse. We spoke to staff about their understanding of safeguarding and they knew what to do if they suspected that someone was at risk of abuse or they saw signs of abuse. People who lived in the home and their relatives told us that they felt that staff provided safe and supportive care.

We looked at recruitment files for a selection of newly appointed and long term staff members to check that effective recruitment procedures had been completed. We found that appropriate checks had been made to ensure that they were suitable to work with vulnerable adults.

Staffing levels were structured to meet the needs of the people who used the service. Observations and records identified there were sufficient numbers of staff on duty to meet people’s assessed needs.

The registered manager ensured that staff had a full understanding of people’s support needs and had the skills and knowledge to meet them. Training records were up to date and staff supervisions and appraisals had been planned by the newly appointed registered manager to ensure staff were able to discuss training issues or any areas of concern. There was a robust management structure in place which ensured that staff at every level now received support when they needed it. Staff were clear about their roles and responsibilities and how to provide the best support for people.

People had a plan of care. We saw that care files were in the process of update. The care files that we looked at contained the relevant information that staff needed to care for the person. We could see from the detailed daily records and discussions with people receiving the service that the care provided was person centred and took account of the person’s wishes and preferences.

The activities programme was most innovative and varied and staff ensured that activities were arranged seven days a week

We inspected Prestbury Care Home because we had received information of concern about the staffing levels in the home. We visited the home at 7 a.m. so that we could see the level of night care staffing. We stayed in the home until 3 p.m. so that we could see staffing levels in the day time.

During our inspection we talked with five of the people who lived in the home and with three relatives of people who were visiting at the time of our inspection. We also spoke with seven members of care staff as well as catering and other staff. We met with the registered and assistant manager as well as a member of peripatetic staff who arranges training. We looked at staff rotas as well as training records.

We looked around the building. Prestbury Care Home is purpose built for 75 people arranged over three floors. There were 74 people living in the home at the time of our inspection. The middle floor specialised in the care of people who are living with advanced dementia. Movement between floors is by means of a central lift although there is a second service lift.

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer one of the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found –

Is the service safe?

We found that the staffing levels at Prestbury House Care Home were as described by the manager and that these related to the level of need of the people who lived in the home.

This was a responsive inspection to concerning information and we did not look specifically at other areas.

We inspected Prestbury Care Home on this occasion because when we last visited in August 2013 we found that it was not compliant with requirements relating to protecting people who used services from the risks associated with the unsafe use and management of medicines. We took enforcement action and issued the service with a warning notice. We required that the provider became compliant by 15th October and undertook this inspection to check that this was the case.

We spoke to people who used the service but their feedback did not relate to this standard. We spent time in each of the three units within the home looking the arrangements for the storage and administration of medicines. We talked with staff and with the managers about how they made sure that people who used the service received the medicines that had been prescribed for them. We found that Prestbury Care Home now met the relevant standard relating to the storage and administration of medicines.

When we visited Prestbury Care Home we spent time on each of the three floors so that we could see the different styles of care provided throughout the home. We spent time with the people who used the service on the ground floor whilst they had breakfast, sat in the upstairs lounge during the morning, and saw people on the middle floor joining in activities and seeing visitors in the afternoon.

We spoke to five people who used the service and six members of staff as well as reviewing records relating to eleven people who use the service. We looked around the building and talked to people privately in their bedrooms. People told us “It’s all right living here” and “The staff are excellent – they are so kind – over the top really. I can’t fault it”.

We looked at the arrangements for the storage and administration of medicines but we could not always reconcile some of the records of medicines given out with the stocks which remained.

We found that staff at the home respected the rights of people when offering care and treatment and particularly when that treatment was refused. We found that the relationships between staff and people who use the service were positive and respectful. We talked to staff about the training arrangements at the home and saw that there were good arrangements for this. We looked at arrangements for complaints and found that there was a policy in place for these.

The people who were able to say told us that they were being treated well by the staff members supporting them and that they were happy living in the home. Comments included; “The staff are very good”, “The staff are very good and I have no issues”. A visiting relative told us “I am always made to feel welcome; the staff members are my angels”.

We received two queries from the people we spoke with during our visit; these were discussed with the home manager who has agreed to look into them.

We received wholly positive comments about the staff members from the people using the service and from the visiting relatives we spoke with.

When we visited Prestbury House Care Home we spoke to the people who used the service as well as their relatives. They told us that the staff were friendly and treated people well although there were some adverse comments made about staffing levels and the food.

Staff told us that they enjoyed working at the Home and that “the building is fantastic – there is everything you need – the rooms are a good size”. We were told that as a newly-opened Home, Prestbury House Care Home had built up the number of people living there gradually and that the levels of staffing had had to be phased around this.

We were told that the local Primary Care Trust (PCT) funded intermediate care at the Home and we met staff from the PCT who told us that they were satisfied with the care provided by this part of the Home. One of the people using this part of the service told us “We could do with more places like this”.Other people using the service have a range of requirements including people living with dementia whose care is focused on the first floor of the building.

We talked with the Manager who has managed the Home since 1st November 2012. We also talked with the Operations Director representing Porthaven Care Homes.