This unannounced comprehensive inspection took place on 21 January 2019 and was carried out by one adult social care inspector, one adult social care inspection manager and an expert-by-experience.

Ranelagh House is a residential care home registered to provide support for up to 26 older people. At the time of our inspection 24 people were living there. The home is located in the Aigburth area of Liverpool and is near to local amenities and public transport. The accommodation is split over two floors, with a lift for people to use and most bedrooms having en-suite facilities.

People living 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.

On our last inspection in November 2017 we found breaches of Regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to the safety of the environment at the home and ineffective systems to monitor and maintain the safety and quality of service at the home. Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to address the issues identified.

During this inspection we found the home had made some improvements, as set out in its action plan. However, there were continued breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, along with an additional breach of Regulation 19 (fit and proper persons employed).

The safety and cleanliness of the environment had deteriorated. The home was served an enforcement notice by Merseyside Fire and Rescue Service in November 2018. We noted that it was cooperating with the fire service and was in the process of addressing fire safety concerns identified. However, at the time of our inspection the home was not safe from a fire safety perspective. Parts of the home were hazardous and dirty. We also observed some very poor infection control practice.

Medicines were not always administered or stored safely. We observed poor administration practice and the medicines trolley was left open and unattended for a period of five minutes.

Quality assurance processes had improved at the home but they still failed to identify and address the serious issues we identified during our inspection.

Recruitment processes were not robust and did not always gather the evidence required to ensure new staff were suitable to work at the home.

Confidential information was not always stored securely at the home.

The home did not currently have a registered manager. We found the home had had difficulty in recruiting a suitable candidate for the role and were currently advertising the role of registered manager.

People living at the home and their relatives told us that they felt safe there. We saw that there were policies and procedures in place to guide staff in relation to safeguarding vulnerable adults and whistleblowing. Staff had received training on this and information about how to raise safeguarding concerns was readily available in various places throughout the home. Staff at the home took appropriate action when any such concerns arose.

We saw that the staff had a good understanding of consent and capacity issues and that people were actively encouraged to make their own decisions when they were able, in line with the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation.

Staff received regular training relevant to their roles and were supported with regular supervision and appraisal meetings.

People gave us generally positive feedback about the quality and choice of food at the home. They said, “The roast yesterday was quite good”, “The food’s okay” and “I think the choice [of food] is good and it’s cooked well, but it’s a bit ‘sa

This unannounced comprehensive inspection took place on 7 and 8 November 2017.

Ranelagh House is a residential care home registered to provide support for up to 26 older people. At the time of our inspection 24 people were living there. The home is located in the Aigburth area of Liverpool and is near to local amenities and public transport. The accommodation is split over two floors, with a lift for people to use and most bedrooms having en-suite facilities.

The home had recently recruited a new manager who was in the process of registering with the Care Quality Commission. 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 new manager was absent at the time of our inspection so the deputy manager and operations manager assisted us in their absence.

We last inspected the home in September 2016 and gave it an overall rating of ‘requires improvement’. On that inspection we found breaches of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that parts of the environment were not safely managed and the systems in place for auditing the quality of the service provided were not always effective.

During this inspection we also found breaches of regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches relate to the safety of the environment at the home and ineffective systems to monitor and maintain the safety and quality of service at the home.

For services rated Requires Improvement on one or more occasions, we will take proportionate action to help encourage prompt improvement. Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires a provider to give us information – when we ask them to do so - about how they plan to improve the quality and safety of services and the experience of people using services. You can see what action we told the provider to take at the back of the full version of the report.

The safety of the premises and the quality of care provided was checked through a range of audits. However, at the time of our inspection these audits were not up-to-date and were ineffective, as they had failed to identify a number of issues that we saw on our inspection. Failure to identify and act upon these risks to people’s health and safety meant that the environment at the home was not always safe.

People living at the home had personalised care plans and risk assessments. People’s care plans and risk assessments had been regularly reviewed by the previous registered manager until they left their role around September 2017. However, these reviews had not been kept up-to-date in the time since the previous registered manager leaving the home and our inspection. This meant that people’s care plans and risk assessments potentially contained information that was not up-to-date or accurate.

Staffing levels during our inspection were sufficient to meet the basic needs of the people living there. However, we saw that there was a significant lack of interaction between staff and the people living at the home.

The activities at the home were limited to watching daytime television in the communal lounges. We saw that people were left in these rooms for long periods of time without interacting with any staff. We noted that the home had recently recruited an activities coordinator to improve in this area and they were due to start soon after our inspection. We were told that the home had not employed anyone in this type of role for around 12 months and we saw this was desperately needed.

Staff training records at the home were not up-to-date and there was not a clear system to doc

This inspection was carried out on 27 and 30 September 2016. The first day of the inspection was unannounced.

Ranelagh House was registered to provide support for up to 26 people. At the time of our inspection 23 people were living there. Situated in the Aigburth area of Liverpool the home is near to local amenities and on bus routes. Seventeen of the bedrooms have en-suite facilities. Accommodation is over two floors with a passenger lift available for people to use.

The home required a registered manager. At the time of our inspection 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. A manager had been appointed in June 2016 and was awaiting interview with the Care Quality Commission (CQC) to become the registered manager of the home.

During the inspection we spoke individually with six of the people living at the home and with two of their relatives. We spoke individually with seven members of staff who held different roles within the home. We examined a variety of records relating to people living at the home and the staff team. We also looked at systems for checking the quality and safety of the service.

We found breaches relating to the premises and equipment being safe to use and being used in a safe way. You can see what action we told the provider to take at the back of the full version of the report. Ranelagh House provided a comfortable environment for people to live in with adaptations available to support people with their health care needs. However parts of the environment were unsafe for people. This included wedges being used to keep fire doors open in high risk areas and a lack of a current gas certificate.

Systems were in place for auditing the quality of the service but these had not always worked effectively. For example they had not identified issues with the safety of the homes environment, the need to update some of the information available in the home and a need to ensure all staff received one to one supervision.

A choice of meals were available for people and staff ensured people had sufficient to drink throughout the day and night. However people did not always like the quality of meals provided, describing this as variable. Action was being taken by the manager to address this issue.

People who lived at Ranelagh House told us they felt safe living there and were confident to raise any concerns or complaints they had with staff. Staff had received training in safeguarding adults and knew how to report any safeguarding concerns that arose.

People received the support they needed with their personal and health care and their medication was safely managed.

There were sufficient staff working at Ranelagh House to meet people’s needs although staff felt that at times they were too busy to spend as much time as they would like with the people living there. Robust recruitment procedures were followed to check the suitability of new staff. A training programme for staff had commenced with further training planned to increase staff knowledge and skills.

People living at the home liked and trusted the staff team and told us they were always responsive to requests for help. Staff knew people well and provided support based on people’s individual needs and choices.

Staff supported people to make every day decisions for themselves. This was backed up with good care plan documentation which described the person’s ability to make certain decisions. Where people lacked the ability to make larger decisions for themselves, such as where to live then the home had followed regulations to ensure the person’s legal rights were protected.

People knew the manager well and found her

We considered all of the evidence we have gathered under the outcomes we had inspected. We used the information to answer 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?

Is the service safe?

People were cared for in a general environment that was safe, and a refurbishment programme had just started in the home. The manager was available on call in case of emergencies and to provide advice and support out of hours.

CQC monitors the operation of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of the inspection the manager told us that no applications had been made by the home. However, we found that for people who had been deemed not to have capacity with some decision making that best interest meetings had not been recorded.

We looked at the use of equipment in the home and found that in relation to the use of the bedrails and protective bumpers that a review of their use and the systems involved was required. This was because there were gaps between the mattresses and the rails and meant that the people using them were at an increased risk of entrapment of their limbs. The manager of the service must ensure that the equipment is used by the staff members in line with the guidelines issued in December 2013 by the Medicines and Healthcare Products Regulatory Agency, and that they understand the practices that they should adhere to.

Is the service effective?

We spoke with three relatives and four people who lived at the home who told us that they were happy with the care provided and did not have any concerns. We saw that staff had a good understanding of people's care and support needs and knew them well. For people who needed specific care such as monitoring of food and fluid intake we found that this had been carried out. Staff required training in the use of bedrails and further training in moving and handling to enable them to effectively and safely met the needs of the people living at the home.

Is the service caring?

We spent time in all areas of the home where we observed staff to care for people with dignity and respect. People living at the home were settled and well cared for and did not raise any issues of concern with us. One person visiting the home told us ''the staff keep us very involved'' and another ''the home has a lovely atmosphere''. A visiting health professional told us that their guidance to staff was always followed in caring for the people living at the home and they thought that a good service was provided.

Is the service responsive?

People's needs were assessed before they moved into the home and records confirmed people's preferences, interests and health needs were recorded. We saw that when peoples needs changed they had been referred appropriately to the relevant health professionals such as the G.P. chiropodist and dietician. A family member told us that their relatives care and surroundings had been reviewed and altered according to their changing needs and a visiting health professional told us that any issues that they had raised had always been dealt with straight away.

Is the service well led?

The home had a registered manager in post and staff had a good understanding of what was required of them in their role and the good standards of care that they were expected to deliver. We saw that people living at the home and their relatives had completed customer satisfaction surveys and comments included, ''I have no problems'' and ''the home is very well managed, staff are very focussed given the demanding circumstances''. Staff told us that they could talk to the manager and they all worked well together.

We had previously inspected this service on 21 August 2012. We found areas of non compliance for which compliance actions were set. During our visit we found there had been improvements in the outcomes inspected.

We spoke with three people who used the service and four relatives. People told us that the care they had received had been delivered in a way that respected their privacy and dignity. Their comments included:

"Overall I am very pleased with the care".

"Staff are brilliant".

"The staff are very pleasant".

During our visit we saw evidence that all the care plans had been reviewed, were detailed and people had been involved in planning their own care in line with their individual needs and wishes.

People who we spoke with told us that they felt safe and had no concerns about the care and treatment they received from staff.

Since our last visit, improvements had been made to provide opportunities for people who used the service, and their representatives, to give feedback on the standard of care and treatment provided at Ranelagh House.

The provider had systems in place to maintain and monitor the care and safety of people using the service.

We spoke with five people living in the home and a relative. Everyone we spoke to said that staff maintained their privacy and dignity when providing care, and treated them with consideration and respect. All said that a senior member of staff from the home had come to visit them before admission and discuss their needs and what the home could provide.

The people we spoke with said that they felt well cared for and were happy in Ranelagh House. One person said "I like it here, the staff are very good and the meals are good too". Another said "Everyone's very nice, I've no complaints". A relative said "I can't fault the care and they always contact me if mum's not well".

The home had sufficient staff to meet the care needs of the people living there. We observed that staff were pleasant and respectful in all their interactions. We saw that staff were aware of the needs of most of the people who used the service and provided appropriate care.

People told us they were comfortable in the home. The home was clean and adequately decorated. The garden was well maintained and attractive.

However, we found that there was a lack of consultation with people about the running of the home and the ongoing care provided. Also, there was little support or encouragement for people to take part in any social activities.