This inspection took place on 25 October and 2 November 2018 and was unannounced. We previously inspected the service on 29 June and 4 July 2017 and we rated the service requires improvement. This was because the service was not meeting regulations relating to safe care and treatment, good governance and staffing. Following the last inspection we asked the registered provider to complete an action plan to show what they would do, and by when to improve the key questions of whether the service was safe, effective, caring, responsive, and well-led.

During this inspection we identified the home had made some improvements. People had appropriate risk assessments for how they were supported to move. Staffing levels were appropriate to support people’s needs and were reviewed regularly. However, the service remained in breach of regulations relating to safe care and treatment, good governance and staffing. We found the service had failed to identify inaccuracies in certain aspects of the home’s management and staff did not receive regular supervisions and appraisals. This is the third time the service has been rated as requires improvement overall. You can see what action we told the provider to take at the back of this report.

Roberttown Care Home is a ‘care home’. 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.

Roberttown Care Home provide care and support to older people, some of whom are living with dementia. The home has a maximum occupancy of 29 people. On day one of our inspection there were 25 people living at the home and on day two of our inspection there were 26.

The service had 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.

People told us they felt safe and staff were aware of the importance of reporting concerns to senior staff. The records kept by the service did not always evidence how the registered manager responded to these concerns.

Care plans contained individualised risk assessments, however not all had adequate information to ensure people’s care and support was safe. Personal emergency evacuation plans (PEEPs) did not contain up to date information.

Premises were maintained safely and appropriate checks completed.

Systems were in place to reduce the risk of employing staff who may not be suitable to work with vulnerable people, however in some instances gaps in people’s employment history had not been checked.

An electronic medicines administration record (EMAR) was in place to monitor and manage the administration of medicines. This was used safely however the administration of topical creams were not always recorded consistently.

New staff received an induction to the home which included mandatory training and shadowing more experienced colleagues. Staff received ongoing training, however they did not have access to regular supervisions and appraisals.

Mental capacity assessments were decision specific and people were deprived of their liberty lawfully. Staff awareness of mental capacity was good.

People were offered a good choice of meals. Their nutritional risks were assessed and weight loss monitored and appropriate action taken when necessary.

People had appropriate and timely access to external healthcare professionals.

People told us staff were caring and kind. Staff were knowledgeable about people and encouraged people to make choices about their daily lives and retain a level of independence. Staff were aware of the need to maintain people’s privacy, dignity and confidentiality, however we observe

The inspection of Roberttown Care Home took place on 29 June and 4 July 2017. We previously inspected the service on 16 December 2015; we rated the service Requires Improvement. We found the registered provider was not meeting the regulation relating to safe care and treatment. On this visit we checked to see if improvements had been made.

Roberttown Care Home provides care and support to older people, some of whom are living with dementia. The home has a maximum occupancy of 29 people. On the days of our inspection 28 people were living at the home.

The service had 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.

During this inspection, we identified the service was breaching regulations related with safe care and treatment, staffing and good governance.

People told us they felt safe and staff were aware of the importance of reporting any concerns to more senior personnel.

Care plans contained a variety of risk assessments although they did not all contain adequate detail to ensure all aspects of peoples care and support were safe. Where people had an airwave mattress on their bed there was no information recorded as to what the setting should be to ensure they were effective. We identified two mattresses that were not set correctly.

External contractors were used to service and maintain equipment. A number of internal checks were also completed, but checks on the emergency lights had not been recorded as completed since February 2017 although we were assured this was a recording error.

There were systems in place to reduce the risk of employing staff who may not be suitable to work with vulnerable people. Staff were continually busy and did not have time to sit and chat with people or with us as part of the inspection process. We saw people were left unsupervised and their needs were not always met in a timely manner.

An electronic system of managing and recording the administration of medicines (EMAR) had been recently introduced. We found medicines were stored safely and staff administered them in a caring and attentive manner. We identified one incident where staff had failed to follow the registered provider’s policy in regard to the safe administration of controlled drugs. We also identified discrepancies with the prescribed instructions for the application of creams and the records of administration.

New staff received an induction which included orientation to the home, training and shadowing of more experienced colleagues. Staff received on-going training and supervision. However, not all training may be fully effective as we observed an incident with a person where staff did not identify an escalating situation and only acted when an incident occurred.

We found not all mental capacity assessments were decision specific and the recorded evidence of the assessment process was not specific to the decision which was being assessed. We have made a recommendation about mental capacity assessments.

People were offered a choice at breakfast and lunch. At tea time, although soup was on the menu, we did not see it being offered to anyone. Peoples nutritional risk was assessed and action taken where weight loss was identified. Food records were completed, but they did not evidence the amount of food provided to people.

People had access to external healthcare professionals.

People told us staff were caring and kind. Staff encouraged people to make choices about their daily lives and retain their level of independence. Staff were aware of the need to maintain people’s privacy, dignity and confidentiality, however, we saw examples where one person’s dignity was potentially compromised and peoples

This inspection took place on 16 and 21 December 2015 and was unannounced. We had previously inspected the service on 26 February 2015 and at this inspection the service had breached the legal requirements relating to safe care and treatment, staffing levels, consent, person centred care, good governance and safeguarding. We found significant improvements had been made at Roberttown since our last inspections and they were meeting the regulations apart from the management of medicines.

Roberttown Care Home provides personal care and nursing care for up to 29 people. At the time of our inspection there were 24 people living at the service. The home provides accommodation over three floors with lift access between floors. There is a garden area to the rear and parking to the front of the home.

At the time of our inspection the manager was awaiting registration 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.’

We found medicines were stored appropriately and medicines in the monitored dosage system were administered appropriately. However, we found boxed medicines had not been administered safely and the system for auditing and signing for medicines was not robust as errors had not been picked up. This was a breach of regulation 12 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 the report.

Staff we spoke with demonstrated a good understanding of how to ensure people were safeguarded against abuse and they knew the procedure to follow to report any incidents

We found risk assessments in the care files we reviewed for choking, medication administration, moving and handling, falls, pressure ulcers and for the use of the bath hoist which demonstrated the home had a system in place for assessing and managing risk to the people living there.

We were told by staff and people using the service there were enough staff to meet their needs. However, we observed at busy times such as when medicines were being administered that people had to wait to be assisted.

At our previous inspection we found the service was not working within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. At this inspection we checked and found improvements had been made and appropriate Deprivation of Liberty Safeguards (DoLS) applications had been made. We found mental capacity assessments were not all decision specific.

Staff were receiving supervision and there was an appraisal system in place. Staff had either received or were in the process of receiving training appropriate to their roles to ensure they had the knowledge and skills to provide a good service.

People told us how much they enjoyed the food and they were offered choice at mealtimes. We found there was a delay in meals being served and people were sitting for a long period before being offered their meal. People were offered drinks and snacks throughout the day to ensure hydration and nutrition was maximised.

Staff knew how to support people in line with their views and preferences.

We found staff to be caring and compassionate towards people using the service and they knew how to ensure privacy, dignity and confidentiality were protected at all times.

Recording practices had improved and people's records reflected the care they were receiving, with the exception of two areas. The recording of moving and handling practices and decision specific mental capacity assessments lacked the required detail to ensure the people living there were cared for appropriately.

We found at the time of our inspection organised act

This was an unannounced inspection carried out on the 26 February 2015. At the last inspection in September 2014 we found the provider had breached one regulation associated with the Health and Social Care Act 2008. We found people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained or stored correctly. The provider told us they would have met the regulations by the end of October 2014.

Roberttown Care Home Limited provides personal and nursing care for up to 29 people. The home is in the Liversedge area and is close to the high street. The home has three floors with lift access. There is a garden area to the rear and parking to the front of the home.

At the time of this inspection 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 were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines safely.

The service did not always assess risks for people’s safety and welfare.

Staff records showed staff were not receiving appropriate training, support or completed induction. The provider could not be sure all staff understood how to deliver care safely and to an appropriate standard.

The registered manager had not made applications to the local authority for assessments under the Deprivation of Liberty Safeguards procedures appropriately. Where there had been such an application, there was no formal recording of this in the care plans we looked at. There were, in some people’s care plans references to people ‘lacking the mental capacity to make decisions’ but these were not decision specific as required by the Mental Capacity Act 2005.

We found care plans did not contain sufficient, relevant and personalised information to indicate that people were protected against the risks of receiving care that was inappropriate to meet their needs or compromised their safety.

There were not always effective systems in place to manage, monitor and improve the quality of the service provided. The management team had failed to protect people from inappropriate or unsafe care and treatment as effective analysis of accidents, incidents, complaints and audits had not been actioned.

There were enough qualified, skilled and experienced staff to meet people’s needs. However, it was not clear on the day of our inspection how the staffing compliment was reached and the registered manager and the operations manager told us they would review the staffing numbers immediately.

There was a programme of activity for people to join in with; however, there was limited stimulation and meaningful activity for people living with dementia.

We saw there were systems and processes in place to protect people from the risk of harm.

Suitable arrangements were in place and people were provided with a choice of suitable healthy food and drink ensuring their nutritional needs were met.

People’s physical health was monitored as required. This included the monitoring of people’s health conditions and symptoms so appropriate referrals to health professionals could be made.

Staff had good relationships with the people living at the home and the atmosphere was happy and relaxed. Staff knew how to respect people’s privacy and dignity.

People we spoke with did not raise any complaints or concerns about living at the home.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which has since been replaced by 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 the report.

This visit was carried out by one inspector and we asked our 5 questions;

• 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.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

There were systems were in place to monitor the service. Auditing tools were completed by the manager at the service and regional managers for the organization.

We found the home to be clean with no offensive odours in communal areas.

We found there were enough skilled, qualified or experienced staff at the home, during each shift.

Is the service effective?

People’s care records were assessed with their involvement or with the involvement of relatives and other healthcare professionals.

We found that people’s care records were up to date. However, we did find some issues with record keeping at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw staff showed patience and gave encouragement when supporting people. People we spoke with said staff were kind and caring.

People’s needs had been recorded in care records, with details of how to care for and support each person who lived at the home.

Is the service responsive?

We saw people partaking in activities at the home. We saw staff members sat with people who lived at the home and carried out activities, including drawing, arts and crafts and reading newspapers. People told us there were lots of opportunities to become involved with activities at the home.

Is the service well led?

Audits at the home were up to date. There was clear documented evidence of the provider’s management of the service. We saw regular audits were carried out and actions identified were followed up and completed.

Staff told us they were clear about their roles and responsibilities.

Our inspection team was made up of two inspectors. We asked our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

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 who lived at the home, staff members and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were not always treated with respect and dignity by staff.

Systems and auditing measures were in place to ensure managers and staff learned from events such as accidents, incidents and concerns. However, these systems and audits were not always completed or followed up.

The registered manager set staff duty rotas, taking into account people’s care and treatment needs when making decisions about staffing numbers. However, issues we found in this area would suggest the deployment of staff to different areas of the home requires consideration in order to ensure people’s needs are able to be met.

Is the service effective?

We found no evidence to show that people, or where appropriate, their relatives, had been involved in the assessment process or in the development and review of care plans and records.

Is the service caring?

We observed some staff members lacked a kindly manner and were not always attentive toward people’s needs. However, we observed good care from other members of staff at the home.

Is the service responsive?

On the day of our visit people were not engaged in activities other than watching television or looking at magazines. We observed people sitting in lounges with no interaction from staff for up to three hours. Two people told us they were bored.

Is the service well-led?

The service had quality assurance systems in place. However, these were not always completed or followed up. As a result, some issues that had been identified during the managers’ audits had not been resolved. This meant the quality of the service was not being well maintained.

On the day of our visit there were 13 people living at the home. Six required nursing care, six required residential care and one was in hospital.

The manager showed us around the home and explained there were plans in place to move people requiring nursing care to the first floor and people requiring residential care to the ground floor. All of the bedrooms on the second floor were empty on the day of our visit; redecoration work was in progress. We looked in eight people’s bedrooms, communal bathrooms and toilets and the two sluice rooms. We saw all these rooms, and the communal areas of the home, looked clean and smelt fresh.

When we looked around the home we saw that several people were already out of bed and sat in the ground floor lounge. During our visit we observed care being given in the ground floor lounge and dining area and in people’s bedrooms. We also observed lunch being served in the ground floor dining room and in people’s bedrooms. We saw people appeared relaxed in their surroundings. We observed positive interactions between people living at the home and care staff. People appeared well-dressed and well cared-for.

We looked at four people’s care files we saw their individual needs were assessed thoroughly and care and support was developed from an assessment of their needs.

During the day we spoke with the nurse on duty, three care assistants, seven people who lived at the home and two visitors (who were close relatives of people who lived at the home), the home manager and the area manager. The operations (area) manager arrived at the home later in the morning.

We found that the home manager had been in post for nine weeks. They informed us they had completed their application to the Care Quality Commission to become the registered manager at the home. Both of the relatives we spoke with told us they felt the new manager was already making a difference.

People we spoke with told us they received good care. Comments included:

“The carers are very good to me. I think they look after me very well.”

“I get everything I need here.”

When we spoke with care assistants they told us they felt confident the service provided to people living at the home was good and they had a good staff team. Care workers received appropriate training for their role and told us they felt well-supported by the new manager.

One care assistant told us “Things are much better now; we have a new manager and less people using the service.” Another said “We’re not rushing around like we used to. It’s nice to have more time for people.”

On the two days of our visit there were 22 people living at Roberttown Care Home.

During our visit we observed people using the service interacting with staff in the lounges and dining areas on the ground floor and first floor. We also spoke with the deputy manager, who was also the nurse on duty, the operations manager, activities coordinator, laundry assistant, hairdresser, a nurse, the handyman and three care assistants. We also spoke with eleven people using the service and five sets of relatives. We spoke with people in the communal lounges, dining areas and in their bedrooms.

We found that the previous temporary manager had resigned a month prior to our visit, on the 13 May 2013. This post was being recruited to and, at the time of our inspection, second and third interviews were taking place. The previous registered manager had left the service in November 2012.

During our inspection we looked at the care records of 11 people using the service. We also looked in at least 10 bedrooms, all of the bathrooms, shower rooms, toilets, sluice rooms, kitchen, laundry and garden area. We also spent time observing care and mealtimes in the lounges and dining rooms on the ground floor and first floor.

The care staff we spoke with told us they felt confident the care provided was good. Staff told us they would be happy for a friend or family member to be cared for at the home.

When we asked people using the service about activities they told us:

“The sing-alongs are the best. I’ve been here a year and we’ve had two. The next one is in August and I’m really looking forward to it.”

“I like reading and I’ve got lots of books, but sometimes you like a change. I like bingo and we have had a game, but I can’t remember when.”

“I like reading, but I’ve read all the books now.”

“I like to go to my room after lunch because there’s not a lot to do.”

“The carers will tell us after lunch if there’s anything going on in the afternoon. But it doesn’t happen very often.”

“It’s a lovely day outside and I’d like to go for a walk, but I haven’t got any visitors today, so I’ll just have to wish!”

“I don’t like going to the lounge because it gets a bit noisy with some of them (other residents) shouting. They can’t help it, but it’s not a place to relax.”

“It’s nice to chat to you. It makes a change to speak to someone.”

We spoke with five people’s relatives about the activities they had observed taking place at the home. Comments from the relatives included;

“They’re all bored stiff.”

“There’s a lovely garden and I’ve never seen anyone go out in it.”

“There’s not much to do so I know our relative prefers to watch TV in their room.”