This comprehensive inspection took place on 11 and 12 September 2018 the visit on the first day was unannounced. At our last inspection of the service in March 2017 we found a breach of Regulation 12 safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made a number of recommendations to the provider about improving the quality and safety of the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions of safe and well-led to at least good. At this inspection although we found that the provider had made improvements and completed those actions and recommendations we found a new breach of Regulation 17 good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records we viewed on the dementia care unit (Fernyhalgh) were not always current, accurate, properly analysed and reviewed.

Preston Private 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.

Accommodation is provided on the ground floor level and the building is set in its own grounds with parking and an easily accessible, private and secure garden with seating areas. Accommodation and nursing care is provided for up to 106 people. On the day of the inspection there were 92 people accommodated across four units. Fernyhalgh dementia care unit, Durton residential care unit, and two nursing units Longsands and Ladywell.

There was a registered manager 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.

We saw significant improvements had been made to the overall management of risks in the service since the last inspection and that the registered provider had acted on recommendations that we made on a number of areas.

People received their medications as they had been prescribed. Appropriate arrangements were in place in relation to the storage, care planning and records for the administration of medicines. However, we have made a recommendation about reviewing the time taken to dispense medications in the morning on the nursing units. Ensuring there is a consistency across all the units for the written protocols used for ‘as and when required’ (PRN) medication and the implementation of a pain assessment tool for people who have communication difficulties.

There were sufficient numbers of suitable staff to meet people’s needs. However, we noted that the use of agency staff used for night time cover in comparison to day time was much higher. The registeredprovider was actively recruiting for staff and we saw how this was an ongoing process. We also noted at times during the inspection that the deployment of staff on the dementia unit left the communal areas unsupervised for short periods of times.

Staff employed had received sufficient training to safely support and care for people and the provider had a training delivery plan in place which covered refresher training in a variety of topics. However, we noted that the agency staff used in the home were not all trained in the same subject areas. The registered manager took action during the inspection and consulted with the supplier of the agency staff to address this.

Staff were also supported through regular staff meetings, supervision and appraisals.

We saw that the service worked with a variety of external agencies and health professionals to provide appropriate care and support to meet people’s physical and emotional hea

We inspected this service on the 22 and 23 March 2017. We also attended the home on the 24 March to provide the acting manager and quality manager with feedback from the inspection. The first day of the inspection was unannounced, which means the home did not know we were coming to inspect. The home was last inspected on 10, 11 and 12 February 2016, where eight breaches of the regulations were found. The home was previously rated as requires improvement overall and requires improvement for the key questions of effective, caring, responsive and well led. The safe key question was rated as inadequate. At this inspection, we looked to see what work had been completed, to ensure the quality and safety of the service had improved. At the inspection in February 2016, we found there were still outstanding actions from the previous inspection, in July 2015. We ascertained that the action plans developed from the inspection in July 2015, had a deadline for the actions to be completed by April 2016. This was following the date of the inspection in February 2016, as a consequence the completion of these action plans, was also considered as part of this inspection.

We found that improvements had been made at this inspection and many of the actions from the previous two inspections had now been completed. However, we did still have concerns in some areas. At this inspection we found one breach to Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was predominantly around concerns we had at the previous inspection and included; a lack of action to risk assessments, including updating assessments at the point of change and ensuring action identified to reduce risks was implemented and carried out. We also identified a number of actions had begun but were not embedded or needed some further thought to ensure they were practical. This included the consistency of the Personal Emergency Evacuation Plans (PEEPs) and the completed plan for evacuation. We noted work had been done to develop the PEEPs and they were generally person centred, however the overall plan for evacuation was not achievable due to the size of the home. We also had on-going concerns around the electrical installations in the home and had not seen a satisfactory certificate for the last two inspections. We have insisted this work is completed as a matter of urgency and the certificate forwarded to us as soon as it becomes available.

We have also made 12 recommendations. Recommendations are made when a regulation has not breached but are used to encourage improvement. We have made recommendations about staffing and training, dementia care and consent and the availability and use of information. We have also made recommendations about the completion and use of records and their audit and the availability of clinical waste depositories.

The home is a large service which can support up to 105 People. The home has two nursing units, ‘Longsands’ and ‘Ladywell’ a residential unit named ‘Durton’ and a specific unit to support people living with dementia named ‘Fernyhalgh’. At the time of the inspection there were 101 people living in the home.

The main body of the home has not changed in its layout or decoration since the last inspection. The main entrance leads into a small reception area and administration office. From this area you walk onto a wide corridor at a ‘T’ junction. One way leads down to Fernyhalgh, which is the separate unit supporting people living with dementia and the residential unit and the other way leads to the two nursing units, Ladywell and Longsands. Durton and Longsands have an interlinking corridor at the back of the building thus creating one circuit of the home. A number of smaller corridors interlink units. It is very easy to get lost in the home and whilst each unit has a different coloured hand rail this does not help identify where you are or how to get to where you want to be. At the previous inspectio

We inspected this service on the 10, 11 and 12 February 2016. The first day of the inspection was unannounced. The home was last inspected on 20 July 2015 where four breaches of the regulations were found. At this inspection we looked to see what work had been completed to ensure the quality and safety of the service had improved. The provider had told us in their action plans they would have completed all the action required to meet the regulations in April 2016. We found there was still some work to be done and would re-inspect the service when the deadline had passed to ensure the service had improved.

The service is a large building that can support up to 105 people. Support at the home is split into three categories. There is one unit specifically supporting people living with dementia. One unit supporting people with residential care needs and two units supporting people with nursing needs. At the time of the inspection there were 92 people living in the home.

The home has a number of corridors. The main entrance leads into a small reception area and administration office. From this area you walk onto a wide corridor at a ‘T’ junction. One way leads down to the dementia unit which is a stand-alone unit and the residential unit. The other leads to the two nursing units. The residential unit and one of the nursing units also join at the other end of the building. A number of smaller corridors interlink units. It is very easy to get lost in the home and whilst each has a different colour hand rail this does not help identify where you are or how to get to where you want to be.

There is a large laundry in the basement area of the home. All other facilities are on the ground floor including a large catering kitchen and lounge and dining areas for each of the units.

The home has a registered manager who has been in post for 15 months. 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 in July 2015 four breaches of the regulations were found in the areas of; person centred care, good governance, meeting nutritional needs and the environment. The CQC was provided with an action plan stating the areas identified in breach would be addressed by April 2016. We inspected the provider before this date as we had received information of concern by way of complaints and whistle blowers. We did look at the action undertaken so far by the provider to address the concerns but are unable to take any further action until after the deadline has been passed.

At this inspection we found the home were in breach of nine of the regulations. Two of which had been identified previously and a further seven found at this inspection.

We found whilst the staff in post were motivated and committed to delivering a quality service in all but one of the units this was not borne out due to a lack of suitably qualified and experienced staff. People living in the home and their family members told us there was not enough staff and we saw on each day of the inspection circumstances where more staff was required. This included over 20 people still in their bedrooms undressed at 11am. We spoke with a number of these people and some were ok with this situation and others were not. We asked four people if this was usual and were told yes.

People were not routinely asked for their consent before support was given and it was not always given in a timely way when it was requested. We saw people calling out for help when no staff were available. One person told us they were asking for help for up to twenty minutes and eventually the cleaner came in to see what they needed. We saw people were not always treated respectfully and their dignity was not up

We considered our inspection findings to answer 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. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records. The inspection team consisted of three inspectors, a specialist advisor and an expert by experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Is the service safe?

People we spoke with told us they felt safe living at Preston Private. Staff spoken with had an understanding of the procedures in place to safeguard vulnerable people from abuse and had received training on this subject. This meant staff knew how to recognise and respond if they witnessed or suspected abusive practice.

We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. Policies and procedures were in place and training had been provided to guide staff in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However we found assessments of people’s capacity to support best interest decisions and their advanced wishes was not always in line with best practice.

Staffing levels were continually assessed and monitored to ensure there was sufficient staff available to meet the needs of people who lived at the home. However from our observations and from what people told us during the inspection visit, there was not enough staff to meet the needs of people who lived at the home.

Is the service effective?

People were encouraged and supported to express their views about how they wanted their support delivered. This started before the person moved into Preston Private. The staff team worked with the person to plan, communicate and develop relationships so that everything about them, their needs and desires were understood.

People discussed their healthcare needs as part of the care planning process and we noted there was guidance for staff on how best to meet people’s health needs. However we did not find this in all cases. This meant staff were not always aware of people’s medical conditions and may not know to respond if there were any signs of deterioration in the person’s physical or mental health.

Staff had the training and support to meet the individual and diverse needs of the people they supported.

Is the service caring?

We found staff to be caring and compassionate to people who lived at the home treating them with respect. People confirmed to us that staff were caring and told us they were happy with the care and support provided.

Care records we looked at showed people's needs were assessed. We saw evidence that people's needs were assessed before they started to use the service. This ensured staff had the required skills and training to meet people's needs. Assessments included aspects of the person's health, personal and social care needs.

During the morning we observed at times there was limited staff interaction with people who lived at the home. However in the afternoon we saw an activities co-ordinator actively engaging people in a programme of activities. There was also a 1940’s singing group entertaining people on one of the units. We saw people responded positively to this. There was a notice board with information of forth coming events and activities planned.

Is the service responsive?

We observed staff being responsive and attentive to people who required support. This confirmed people who required care and support were being treated with respect and dignity.

People’s needs were assessed prior to their admission to the home. Records showed people and their family members had been involved in making decisions about what was important to them. Each person had a key worker who liaised closely with them and their family members. People’s care needs were kept under review and staff responded quickly when people’s needs changed.

The management and staff at the home worked well with other agencies and services to make sure people received care in a consistent way. This demonstrated the service had an open and co-ordinated approach in ensuring people received the support they needed.

Is the service well-led?

The provider had policies and procedures in place to monitor the quality of the service. These included seeking the views of the people they supported by way of surveys, care reviews and regular monitoring. We saw copies of surveys completed by the people being supported. This meant that people who lived at the home and their family members had the opportunity to give their views about how the service was run.

Records reviewed showed that the service had a range of quality assurance systems in place, to help determine the quality of the service offered. During our inspection there were a number of concerns we had in respect of capacity assessments, record keeping and staffing levels. Through the quality systems, the registered manager had identified a number of the concerns and had actions in place to address them.

We asked if medicines were handled safely. Staff handling medicines had completed training but the home’s medicines policy was not consistently followed throughout the home. We found that the medicines records were not always clearly presented to support and evidence the safe administration of medicines, increasing the risk of mistakes. Home managers had completed audits of medicines handling and were taking action to bring about improvements

We looked at outcomes 1, 2, 4, 11, 12, 16 and 17. At our last inspection we found non compliance with outcome 1. At this inspection we observed that improvements had been made and all outcome areas were assessed as compliant.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care.

People also told us they could choose what and when they did things in the home. People told us they decided how they wanted to be supported with their care and this included the gender of their carer. We saw that there were no rules imposed on people.

People had their needs assessed and we saw that they were asked about their care and support and agreed to it. People told us they were treated with dignity, kindness and respect.

People’s care and support plans detailed their care needs and these were kept under review. We found family members were happy with the care of their relations

People told us that they were consulted about the quality of the service they received and if they had concerns or complaints about their care they knew who to talk to.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people.

On the day of our visit we saw that a church service and group activities had been arranged and people were encouraged and supported to participate.

People had their needs assessed and we saw that they were asked about their care and support and agreed to it. People told us they were treated with kindness and respect. People had care and support plans detailed their care needs. These were kept under review. People also told us they could choose the gender of their carer and staff respected this. The provider had policies and procedures in place to ensure people’s dignity was respected but we observed people were not always treated as such.

We found family members were happy with the care of their relations

There were no rules imposed on people. Staff were trained to protect people and people said they were safe. They told us if they had concerns or complaints about their care but would speak with the manager or the staff if they needed to.

It was clear from talking to people who live at the home that they are happy with the support they receive from caring, competent staff. Comments from people who live at the home included, “A lovely place to be”. Also, “Kind caring people”. We listened to staff who spoke positively about how the home is run and managed. Comments included, “Its much better now”. And, “The support from the management is very good”.

People felt that staff had the skills to care for them properly. “They are never too busy to help you”.

People who live at the home are made to feel encouraged to maintain their independence and one person told us “The staff try as much as possible for us to cope without any help, which makes me feel more independent”.

This unannounced inspection took place on 20 July 2015. Preston Private provides accommodation for up to 106 people who require nursing or personal care. At the time of our visit there were 99 people who lived there. The home provides care and support for people with dementia or physical disabilities.

Preston Private is a purpose built care home set in its own grounds and located in a residential area of Fulwood Preston. All bedrooms are ensuite and located on the ground floor. The home is divided into four distinct areas, known as units. Two units provide nursing care, one unit provides personal care and there is one unit which provides care for people with dementia.

We noted that changes in the way the service was managed and the way in which people’s care needs were assessed and planned for, which had brought about improvements to the service. We also noted that the home’s medication policy was now consistently followed throughout the home, staff induction training was now taking place in a consistent manner, complaints were now dealt with robustly and the home’s management team were providing good leadership. However, at this inspection, different issues where identified, which again meant that the service needed to continue to improve.

The service has a registered manager, and has managed the home for 13 months. 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’s individual needs were not fully met and enhanced by the adaptation, design and decoration of the home, especially the dementia care unit. This area of the home was not particularly `dementia friendly`. Appropriate signage and picture menus for those people in the more advanced stages of dementia were not available, and would have proved beneficial and reflected a more person centred approach to providing care. This was a breach Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Although food and hydration was provided, people’s preferences regarding food and mealtimes were not always fully considered, and further work was needed to ensure people’s needs were assessed fully and met. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Feedback from people at the home, and our observations showed that there were very limited activities provided. The service provider did not ensure that people’s needs were in a person centred manner, and this needed to include ensuring that people’s social and cultural needs were met. This was a breach Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During our visit, we identified a number of key areas were improvement was required, and this had not been identified by the service provider’s quality assurance systems. The service provided must have an effective system in place to ensure that all the systems operated in the home can be robustly assessed and monitored all the relevant Regulations that apply to the home. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff were found to be knowledgeable and the training records showed that staff had received appropriate training in the area of safeguarding. The people we spoke with told us they felt safe living at this home. We found information within people’s care records to show that the risks associated with their care and support needs were managed properly. Our observations found that on the whole, there were sufficient numbers of suitable staff available to keep people safe and meet their needs.

We found evidence to show that medicines were properly managed. The premises and equipment within the home were properly managed, and we show records to show that appropriate safety measures and periodic checks were made on equipment to ensure it was safe to use.

The training plan showed that staff received core training and regular updates to refresh their knowledge, for example in moving and handling and first aid. All new staff members completed a fully recorded induction programme. Staff told us they felt well supported by the registered manager, deputy manager and qualified nurses and that supervisions took place, so that they could discuss their development needs.

We found written records to show that considerations had been made to assess and plan for people’s needs in relation to mental capacity. The registered manager and staff had a good understanding of MCA and DoLS. The home had a suitable complaints policy and procedure that was publicised in its Statement of Purpose and the documentation was provided to new people entering the home.

You can see the action we have taken to ensure that the service provider makes improvements to the service at the end of this report.