This inspection took place on the 21 January 2019. The inspection was unannounced, and started at 6:55 am to allow us to meet with the night staff, be present at the staff handover and see how duties were allocated for the day.

Redmount Residential Care Home is a ‘care home’ without nursing, operated by Your Health Limited. 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.

People living at Redmount Residential Care Home were older people, many living with long term health conditions or dementia. The service accommodated up to 36 people in one adapted building, with a two passenger lifts to access the rooms on the first, second and lower ground floors. At the time of the inspection there were 23 people living at the service.

At the time of the inspection the service was in a whole service safeguarding process. This meant the local authority safeguarding team were monitoring and working with the service to ensure people were protected from abuse and their rights safeguarded.

The service had 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. People told us they liked the registered manager and were sorry she was leaving.

At the last inspection of the service on 19 and 26 May 2016 the service was rated as ‘good’ in all areas. On this inspection we identified concerns and four breaches of legislation and have rated the service as requires improvement as a result.

People could not be confident of experiencing consistently safe of high quality care because systems to assess, monitor and mitigate risks and provide high quality care were not operating effectively. We found concerns that had previously been identified by the service’s own internal auditing systems or through the provision of support from the Quality improvement team from the local authority but had not yet been resolved. Although actions had been taken in many cases we found learning had not been sufficient to avoid repetition of the concerns. This meant some systems were not being operated in line with good practice. People’s records, including those for the administration of medicines were not always accurate, up to date or completed in line with good practice.

People were not always receiving support to mitigate risks from their health and care needs. Risks from people’s care had not always been fully assessed and mitigated. Records relating to people’s dietary intake when they were at risk from poor nutrition were not completed in enough detail. Other records in relation to the management of risks to skin damage were not clear, or backed up with important information needed to make a judgement on how to reduce risks.

People told us they were not always supported by sufficient staff to meet their needs, although they spoke positively about the staff caring for them. Staff were recruited safely with a robust system in place to ensure they were suitable to be working with people. We have made a recommendation about re-assessing staffing levels.

People did not always benefit from an environment adapted to meet their needs, particularly in relation to people living with memory impairment. Redmount is a large adapted building set over four floors. People’s rooms were mainly en-suite which afforded people additional privacy, but we saw little adaptation or signage to help people understand their environment or orientate themselves when they had some memory loss. We have made a recommendation about the adaption of the environment to meet the needs of people living with memor

Redmount residential care home provides accommodation and personal care for up to 40 older people who may be living with a dementia. At the time of our inspection there were 21 people living at the home. The service offers both long stay and short stay respite care.

This inspection took place on the 19 and 26 May 2016, and was unannounced. The inspection team consisted of two adult social care inspectors. The service was previously inspected on the 29 May and 3 June 2015, when we found improvements had been made, but further improvements were still needed in relation to medicine administration and some areas of record keeping. Following that inspection the provider sent us an action plan telling us how they were going to meet this regulation. At this inspection in May 2016, we found that improvements had been made.

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.

People said they felt safe and well cared for at Redmount their comments included “I do feel safe” “the staff are very kind and would do anything for you” “they call the doctor right away” I’m very happy here”. Relatives told us the staff were brilliant, people are safe and well looked after. One relative said “I wouldn’t change a thing I’m perfectly happy with the care of [person name].

One health care professional said the staff were very caring and compassionate and people were safe and well looked after. We saw people were happy to be in the company of staff and were relaxed when staff were present.

People told us they were happy living at the home, staff treated them with respect and maintained their dignity. Throughout our inspection, there was a relaxed and friendly atmosphere within the home. Staff spoke affectionately about people with kindness and compassion. People and relatives told us they were involved in identifying their needs and developing the care provided. People's care plans were informative, detailed and designed to help ensure people received personalised care. Staff knew how each person liked to be addressed and consistently used people’s preferred names when speaking with them.

People who used the service told us they knew how and were able to raise concerns and there were systems to help ensure people were protected from all forms of abuse. Staff had received training in safeguarding vulnerable adults and whistleblowing. Staff demonstrated a good understanding of how to keep people safe and how and whom they would report concerns to.

People told us there were sufficient staff on duty to meet their needs one person said there was always someone around and they have time to “sit and talk”. The registered manager used a dependency assessment tool to review staffing levels which was based on people’s changing needs and adjusted the rota accordingly.

People were encouraged to take an active part in the running of the home. We saw that two people had recently been appointed to the home’s interview panel of future employees. Recruitment procedures were robust and records demonstrated the registered manager had carried out checks to help ensure that staff employed were suitable to work with vulnerable people.

People received their prescribed medicines on time, in a safe way, and given the time and encouragement to take their medicines at their pace. There was a safe system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely when they were no longer required. We saw from records, changes of directions had been appropriately documented and double signed on MARs and recorded in people’s care plans. Staff had received training in the safe administration of medicines.

We inspected Redmount Nursing Home in response to concerns we had received about people’s care and welfare, issues with the staff team and poor record keeping. We found that many of the concerns were substantiated but that the provider had already identified them as needing urgent attention and action was already under way to address them.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found:

Is the service caring?

People we spoke with who lived at the home told us that staff were caring and looked after them well. A relative told us “if I had had any concerns I would have moved (my relative). But the care here is really wonderful, its very clean and there is no smell.” A person who lived at the home told us “I couldn’t ask for better. They really are excellent.”

We saw staff laughing and joking with people who lived at the home, but still remaining respectful and courteous. We watched a member of staff help a person walking down a corridor. We saw that they were patient and supportive and encouraged the person who was finding the walking difficult. We saw another member of staff supporting a person to eat. We saw the staff member engaged their attention and touched their hand each time to see if they were ready for more food. We saw the person ate well as a result.

We saw one person at the home had been identified as having mental health issues and that they presented behaviours that challenged staff. We spoke with a member of staff and asked them how they supported this person. They told us they could remember the person from before their mental health deteriorated and they spoke about them with compassion and a caring attitude. They told us that they would try to support the person but if they were resisting care or distressed they would make them comfortable and leave them, returning later to try again.

This demonstrated to us that the staff were patient and caring towards the people who lived at the home.

Is the service responsive?

We identified instances where the home had been able to respond to people’s deteriorating health quickly. One person told us “I felt I had a chest infection in the morning, I saw the doctor at lunchtime and had the antibiotics by tea time. You can’t get better than that.”

However we also identified concerns that changes in people’s care needs had not always been responded to appropriately or in a timely way. As an example we found that some referrals to other agencies such as the dietician had not been actioned despite being identified as being needed. This left people at risk of not having their healthcare needs addressed in a timely way.

We found the home’s management were responsive to concerns from outside agencies or relatives. We saw a meeting had been held with relatives to share what actions the home’s management was taking to ensure people’s care and welfare needs were being addressed. One relative told us “The care here is excellent – second to none. I was worried as a lot of staff had left. But we have had a meeting and they have reassured me about what they are doing.”

Is the service safe?

We identified concerns over the ways in which records and care plans were maintained. Many were incomplete or inconsistent about people’s care needs. At times when the home was heavily reliant on agency staff, the lack of cohesive and accurate care plans or management systems put people at risk of unsafe or inadequate care.

We identified concerns over the systems for obtaining consent to care or recording of best interest decisions where people lacked capacity to consent.

We found there were enough staff on duty to meet people's needs. Although there was a high use of agency staff the home manager had taken steps to reduce the risks associated with this.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. On this inspection we did not identify anyone who was deprived of their liberty, but the home’s management agreed to review people to ensure their rights were respected.

Is the service effective?

People told us their needs were met. However we identified issues of concern with regard to the updating of assessments of people’s needs.

We found that specialist referrals for example to district nurses or dieticians had not always been made in a timely way and actions taken were not always recorded. This could lead to unsafe care or needs not being followed up appropriately.

We found that records were poorly organised. This meant that some information could not be located in an emergency.

Is the service well led?

On 25 February 2014 we served a fixed penalty notice on Your Health Limited for failing to have a Registered Manager in place at Redmount Nursing Home. A fine of £4000 was paid. On this inspection the home had a manager in post. However they had not made a successful application to the Care Quality Commission for registration as the manager. Therefore the home still did not have a Registered Manager in post.

We saw that the new manager was trying to push forward developments at the home with a limited permanent staff team and having to work as a Registered Nurse on shifts due to the staffing issues at the home. Support was being provided by the organisation’s head office throughout the week and new staff were being recruited to replace the dependency on agency staff.

We found that some of the management systems were ineffective or poorly understood, records were out of date and policies and procedures needed reviewing to ensure they were current and accurate.

We found action was being taken by the organisation to address the concerns.

At the last inspection in June 2013 we identified concerns with certain aspects of the supervision of staff and the assessing and monitoring the quality of service provision. At this inspection we found significant improvement had been made.

Redmount is registered to provide accommodation, nursing and personal care for up to 42 people. However, the provider took the decision to cease providing nursing care on 30 August 2014. The service offers both long stay and short stay respite care. This inspection took place on 29 May and 3 June 2015 and was the first inspection since the service stopped providing nursing care. Nursing care is now provided by the district nursing service.

A registered manager was employed at the service. 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 previous inspection in May 2014 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We found there were not suitable arrangements in place to obtain people’s consent to receive care, people’s needs were not assessed and planned for, medicines were not obtained, recorded and administered appropriately and records relating to people and the running of the service were not well maintained. At our inspection in May and June 2015 we found that improvements had been made in all areas, but that further improvements were still needed in relation to medicine administration and some areas of record keeping.

Information recorded on people’s food and fluid charts was disorganised. Some sheets were not named, were not kept chronologically and fluid entries had not been totalled. This meant it was not possible to confirm people had received sufficient food and fluid. Poor record keeping in relation to people’s care and treatment meant that staff could not judge if the care and treatment they were providing was effective. It also meant that staff were not following the new procedures that had been put in place.

There were a number of quality assurance systems in place, but these had failed to highlight the concerns relating to people’s records. The registered provider had failed to act following concerns raised by the registered manager about the call bell system.

The registered manager produced a weekly walk around report. They spoke with each person and asked if there was anything they wanted or needed. Staff told us the manager was accessible at any time for help and advice and there was an open culture within the home. One staff member told us they provided individualised care to people and another told us there was a culture of promoting independence.

A monthly newsletter informed people of any changes within the home and any upcoming events. The April 2015 edition welcomed several new members of staff and let people know about the new ‘snack stations’ that had been put in place for people to help themselves to.

The service had a positive risk taking policy and risk assessments contained good details of how any risks were to be minimised. The registered manager had highlighted the need for a new call bell system in order to ensure staff could respond promptly to any emergencies.

There were sufficient staff on duty to safely meet people’s needs in a timely manner. People were protected from the risks of abuse because staff knew how to recognise and report any incidents of abuse. Robust recruitment procedures minimised the risks of recruiting unsuitable staff.

Staff asked for people’s consent before undertaking any personal care. Staff were patient, kind and understanding in their approach. Throughout our inspection we heard choices being offered to people. For example, people were asked where they would like to sit or if they wanted to go to their room.

People had differing needs and staff had received training to ensure people’s needs were met. For example, staff told us about the dementia care training they had received and how this helped them care for people living with dementia. Staff told us they received regular supervision. The registered manager held both group and individual supervision sessions. All sessions were recorded and were used to ensure staff had an understanding of their role and responsibilities and they remained competent to carry out their role. Staff told us they felt well supported by the registered manager.

Staff had a clear understanding of the Mental Capacity Act 2005 (the MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. The registered manager was aware of recent change to the interpretation of the deprivation of liberty safeguards, which are in place to ensure people are not unlawfully restrained. They had made appropriate applications where needed.

People were supported by caring staff. People told us staff were “nice and polite”, “speak nicely to me and are very respectful” and “look after me well”. One person said “They [staff] need a medal!” One visitor told us staff were “tolerant and caring” and that the care their relative received was very good – “solid”. Visitors told us they felt staff had the skills and knowledge they needed. One visitor told us “They [staff] understand dementia and treat everyone as a person. They understand people’s behaviour and why they do things”. Staff knew people well, what their needs were and how people liked their needs to be met. One person told us staff knew how they liked things done “and if they don’t – I tell them!”.

People’s privacy and dignity was upheld. One member of staff had recently been appointed as a ‘Dignity Champion’ and told us they would be aiming to raise the importance of ‘respecting and supporting people’s dignity’. People were supported to make choices about the clothes they wore and we saw people’s nails were clean and hair their was groomed. All personal care was provided in private and when staff supported people in communal areas they did so in a discreet and respectful manner. Staff spent time engaging with people. Staff sat with one person and helped them with their knitting. Other staff spent time chatting with people. One visitor told us staff “have a bit of fun and treat everyone as a person”.

Care plans were based on people’s assessed needs and reflected their needs and preferences. They contained detailed individual information on how staff should meet a variety of needs. For example, one person’s care plan told staff how to help them if they became aggressive. Another person’s care plan detailed how staff should manage a particular health issue. Signatures on care plans indicated people and or their representatives were involved in planning and reviewing their care.

We found a breach 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.