This inspection took place on 2 and 3 July 2018 and was unannounced.

Quality Care Management 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. Quality Care Management provides nursing and personal care. It is registered to provide support for up to 38 older people, most of whom live with dementia. At the time of our inspection there were 22 people living at the home. Support is provided in a large home that is across three floors. Communal areas include two lounges and a dining room.

The service 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 our last inspection we had seen significant improvement made but they were still in breach of Regulation 17, Good governance. This was because the care plan auditing process needed further development to ensure it identified all issues that needed actioning. At this inspection further improvements have been made and we found no breaches of the Regulations.

People mostly provided positive feedback about staff. Observations reflected staff were kind and showed them compassion. People’s privacy and dignity was respected and they were encouraged to be involved in making decisions about their care. Although people were supported to maintain some independence this needed further consideration to ensure this met people’s needs. We made a recommendation about this. People were not provided with the support they needed to ensure they received adequate nutrition and hydration.

People were protected against abuse because staff had received training and understood their responsibility to safeguard people. Concerns were reported and investigated. Medicines were managed safely. Risks associated with people’s needs were assessed and action was taken to reduce these risks. People and their relatives felt the home was always clean and well maintained. Equipment was managed in a way that supported people to stay safe and people were supported to maintain good health and had access to appropriate healthcare services. The provider’s recruitment process ensured appropriate checks were undertaken to ensure staff suitability to work in the home. Staffing levels met the needs of people although at times the deployment of these was not effective. The registered manager told us they would look at this.

Prior to people moving into the home, assessments were undertaken to ensure the home and staff could meet the person’s needs. Staff were aware of the need to treat people as individuals and ensure care reflected their individual needs. People told us that how they felt staff had the skills and knowledge to care for them. Staff received supervisions and training to help them in their role. Staff worked well as a team and people were supported to maintain good health and had access to appropriate healthcare services. People told us they were always asked for their permission before personal care was provided. Where needed people’s ability to make decisions was assessed in line with the Mental Capacity Act, 2005 (MCA).

Work had been done on the environment to ensure this was well lit and flooring helped to reduce the risk of falls. However, further work could be done to ensure that the environment was supportive to those living with dementia. We made a recommendation about this.

Care plans were in place, detailed and person centred. End of life care plans had started to be developed but these tended to focus on the person’s support needs now rather than considering what they might want at the end of the

The inspection took place on the 25 and 26 April 2017 and was unannounced.

Quality Care Management Ltd is a registered care home and provides accommodation, support and nursing care for up to 38 people, some of whom live with dementia. Support is provided in a large home that is across four floors. Communal areas include two lounges and a dining room. At the time of our inspection there were 16 people living at the home.

The service 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.

The service has a history of breaching legal requirements. Following an inspection in May 2015 CQC served three warning notices for failing to ensure safe care and treatment, good governance and appropriately skilled and trained staff. In addition to these, requirement notices were issued for failure to ensure safeguarding of people, safer recruitment process, person centred planning and ensuring appropriate consent was sought. A second inspection in December 2015 was carried out to follow up the warning notices. This inspection showed improvements had not been made to the assessment and management of risks for people, staffing and governance systems. CQC took further enforcement action and placed a condition on the registration of the provider which stopped them from admitting any people to the home without CQC's permission. We also placed the service in special measures. A third inspection in September 2016 found ongoing concerns in relation to gaining consent and applying the Mental Capacity Act, understanding Deprivation of Liberty Safeguards, reporting and investigating safeguarding concerns and governance processes. We imposed a condition on the provider requiring them to undertake regular audits and report to the CQC on a monthly basis. The service remained in special measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

People told us they felt safe at the home and staff had a good understanding of their roles and responsibilities in protecting people from abuse. They knew what to look for and the action to take if they were concerned. Staff were aware of risks associated with people’s care and knew the action to take if the risks presented. The thickening of drinks when this was needed to ensure peoples’ safety required improvement and the registered manager agreed a formal analysis of behaviours would be beneficial.

The management of medicines was safe. Staffing levels were sufficient to support people safely and in a calm, professional manner. Recruitment processes were in place to make sure only workers who were suitable to work in a care setting were employed. Staff received training and supervision to make sure they had the skills and knowledge to support people. People had access to health professionals when they needed it and enjoyed their meals.

People were supported to make choices by staff who were kind, caring, and mostly communicated well. Where people were unable to make decisions for themselves the principles of the Mental Capacity Act 2005 were followed. Where Deprivation of liberty safeguards imposed conditions on the provider, these had been met. Support plans provided guidance to staff and people and/or their loved one were involved in the development of these. People received personalised care and support, which was responsive to their current and changing needs.

This inspection took place on 21, 22 and 28 September 2016 and was unannounced.

Quality Care Management Ltd is a registered care home and provides accommodation, support and nursing care for up to 38 people, some of whom live with dementia. Support is provided in a large home that is across four floors. Communal areas include two lounges and a dining room. At the time of our inspection there were 23 people living at the home.

The home 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. An acting manager was in post and had applied to the Commission to become registered. Throughout the report we refer to this person as the acting manager.

Following an inspection in May 2015 the Commission served three warning notices for failing to ensure safe care and treatment, good governance and appropriately skilled and trained staff. In addition to these requirement notices were issued for failure to ensure safeguarding of people, safer recruitment process, person centred planning and ensuring appropriate consent was sought.

A second inspection in December 2015 was carried out to follow up the warning notices. This inspection showed improvements had not been made to the assessment and management of risks for people, staffing and governance systems. The Commission took further enforcement action and placed a condition on the registration of the provider which stopped them from admitting any people to the home without CQC's permission. At this inspection we found that sufficient improvements had not been made and there were still multiple breaches of the regulations.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. This service has a rating of inadequate in the well-led question. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection staff and the acting manager had received training in safeguarding adults at risk. They were able to describe what action they would take if they were concerned. However we found incidents continued not to be reported or investigated. We found a number of unexplained injuries for one

We carried out an unannounced comprehensive inspection of this home on 15 and 19 May 2015. Breaches of Regulation 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. Following this inspection we served warning notices on the registered provider of the service requiring them to be compliant with the Regulations by 7 August 2015.

We undertook this follow up inspection on the 30 December 2015 to check the registered provider had met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Quality Care Management t/a Aquarius Nursing Home on our website at www.cqc.org.uk

Quality Care Management t/a Aquarius Nursing Home is a nursing home where personal and nursing care is provided for up to 38 older people, most of whom live with dementia. The home consists of three Victorian houses linked by a corridor. During our inspection 37 people were living at the home.

A registered manager was 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.

At this inspection we found the service had not met all the requirements of the Regulations to meet the fundamental standards.

Risks associated with people’s specific care needs had not been assessed. Plans of care did not identify how risks to people could be reduced.

Medicines were not always administered in a way which ensured the safety and welfare of people.

Systems were in place to reduce the risk of cross infection as the registered manager had implemented a robust system of audit and review for this.

Staff had not always accessed or completed training to ensure they had the appropriate skills to meet the needs of people.

Whilst the registered provider had systems in place to review the quality of the service they provided and ensure their service met the needs of people, these were not always fully implemented.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of this report

One inspector carried out this inspection on the 5 January 2015. At out last inspection we identified concerns in relation to the management of medicines (regulation 13). We judged this to have a minor impact on people and asked the provider to take action to address the concerns.

At this inspection we reviewed the progress the provider had made in relation to meeting the regulation. We spoke to the registered manager, two trained nurses and three people who lived at the home. We looked at the care plans for four people, medicines records for six people and all records relating to controlled medicines. The home had investigated the concerns we had identified and taken action to ensure staff were trained and competent to administer medicines safely. People who lived in the home were satisfied with the way their medicines support was provided. We found improvements had been made.

At the time of our visit there were 36 people using the service. We spoke to three people who used the service, three staff, the registered manager and the person employed to manage human resource issues. We also reviewed the care records of three people using the service and used our SOFI tool to undertake observations.

We observed staff treating people in a dignified and respectful way. We saw that during a mealtime the environment in which the meal was served caused difficulties for staff in respecting people as individuals. We fed this back to the manager. They told us they would look at this as a team to address how positive changes could be made for people.

We saw that care plans reflected people’s individualised needs. People we spoke with told us they were satisfied with the service they received and that felt their needs were met.

Staff we spoke to told us they felt the information that was provided about people helped them to meet people’s needs. Staff told us that they felt people’s needs were met.

One person told us, “The staff are gentle and hardworking”. Another told us, “Staff are smashing, super”. People we spoke with told us they felt safe at the home.

Staff we spoke to told us they felt supported and that any suggestions they made would be taken seriously.

We found that the provider had effective systems in place to monitor the quality of the service and that people’s views were taken into account and acted upon.

We found that the provider had an effective complaints system in place and any complaints were responded to appropriately.

This inspection took place in response to anonymous concerns that were brought to our attention. These included concerns about maintaining people’s privacy and dignity, infection control procedures and staffing issues.

We visited the home at 0930 on the 10 December 2012 and did not find evidence to support the concerns raised.

We spoke with five people who told us that they were treated well by staff and that they were happy living at the home. They told us that staff gave them the help and support they needed.

We used our SOFI tool and observed that people were treated as individuals and staff used people’s preferred form of address. We saw that their privacy and dignity was maintained and that staff knocked on the door before entering people’s rooms. We also saw that people received appropriate care.

We spoke with five members of staff and also two nurses who were on duty. Nurses and care staff said that the care provided for people was good. Staff told us that they worked well together and that there was a good working relationship between staff.

During our visit we took the opportunity to tour the home. We found that the home was clean and in a reasonable state of repair. There were no unpleasant odours.

We spoke with three people who lived at the Home. They all confirmed that their privacy and dignity was maintained at all times and that staff always knocked on the door before entering their rooms. People told us of instances when their choices had been respected. For example, the home was due to undergo refurbishment at the time of inspection. People told us that they were involved in the process of choosing the décor for their rooms.

We observed that people had their own copy of a Service Users Guide which outlined people’s rights and the provider’s responsibility in protecting them.

We also spoke with one relative who visited the home regularly, always arriving unannounced. They told us that the care was of a high standard and felt that people were well looked after.

To help us understand the experience of people using the service, we used our Short Observation Framework for Inspection tool (SOFI). This allowed us to spend time watching what was going on in a service and to record how people spent their time, the support they got and whether or not they had positive experiences. Using this, we found that staff had the necessary time and skills to care for people well.

People said that they had no concerns about how their nursing and personal care needs were met. They said that if they were unwell then staff would contact a doctor for them. People said staff were available when they needed them and knew what care they required.

We also spoke with other health and social care professionals involved in the care of people. They stated that they had no concerns about how people’s health and care needs were met.

People told us they had a choice about what they had for their meals and could influence menu planning both informally and through resident’s surveys.

People told us that they have no concerns about the care and support they receive.

Staff told us that they feel supported in their role but have not had supervision and training to carry out their roles.

People who use this service spoke positively about their experiences of this service. People told us that the staff are kind and helpful and that the service meets their needs.

Relatives visiting the home told us that they have no concerns about the home, staff are always welcoming and helpful and have been very supportive during difficult times. They told us that they feel people are treated well and with respect.

Staff told us that they feel well trained and supported by the management of the home.

People told us the home made arrangements to reduce their risk of having a fall in future, helping them by providing equipment in their room to assist with mobility. They told us that they had prompt and effective support to maintain their independence.

People who use the service told us that they have plenty to eat and drink. They are happy with the range and quality of meals and their likes and dislikes are incorporated into the meal plans.

One person said that there are some foods they dislike and the staff always make sure they have an alternative meal when this is on the menu. Another person told us that the home always provides an alternative meal that they like

People told us that staff regularly bring a selection of drinks around the home and they have drinks in their rooms.

People told us that they feel safe and staff are helpful and available to talk to if they are concerned about anything.

People told us that they are happy with the their bedroom spaces in the home and that they have been able to personalise their bedroom to make it more comfortable and "feel like home".

People told us that they are supported to get around the home and have different places to go within the home dependent on whether they want to join a larger group or sit in a quieter place.

People who use the service told us that they have received a copy of the complaints procedure in an information booklet.

People told us that they would be able to speak to the manager or one of the staff if they were concerns about something.

A healthcare professional told us that they have a good relationship with the home and care planning has improved in the home.

A member of the safeguarding team told us that there are no current concerns with this home and there have been none for some time.

This unannounced inspection took place on the 15 and 19 May 2015. Quality Care Management t/a Aquarius Nursing Home is a nursing home which offers personal and nursing care for up to 38 older people, most of whom live with dementia. The home consists of three Victorian houses with a corridor which links all three houses together. During our inspection 35 people were being accommodated.

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.

Staff had an understanding of abuse and what action they should take if they felt someone was not receiving safe care; however incidents had not always been reported to the appropriate authorities. Risk assessments relating to people were not always completed and had not been updated as necessary.

Staffing levels and the skills mix were planned and organised to meet the needs of people, however there was a concern extra staff could not be resourced when necessary. Staffing recruitment records did not detail all the necessary information before staff started work to ensure people were safe. The administration of medicines practices in the home were not safe.

People felt staff had the knowledge to care for them effectively. However, staff had not received training in all relevant areas or from staff trained to ensure they had the knowledge to meet people’s needs. Staff had not received regular formal supervision but felt supported. Some staff did not have an awareness of or understand the Mental Capacity Act 2005 and the principles of this had not always been applied.

Some people did not have their nutritional needs recorded but people received adequate support at meal times. Health needs were assessed and the relevant professionals were involved in people’s care provision.

The majority of staff were caring and were mindful to be respectful of people’s privacy. People were not formally involved in discussions about their care. Care plans were not personalised in all areas and in some areas did not provide detailed information to guide staff about the support a person needed. The home had a complaints policy and people felt able to complain.

Quality assurance in the form of auditing was not taking place on a regular basis and it was not possible to establish learning from audits took place to bring about effective change.

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