This inspection took place on 29 January and 1 February 2018. Roborough House is a ‘care home’ trading as Roborough House Ltd which is owned by CareTech. CareTech community services is a large national organisation providing a wide range of social care services for people, with a head office in Hertfordshire. 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.

Roborough House is registered to provide accommodation for 51 people who require nursing and personal care. The service currently has a capacity of 44 whilst accommodation is being re-furbished. At the time of the inspection, 40 people were living at Roborough House.

The service is a specialist unit and provides nursing and personal care for people with complex needs such as mental health disorders including Schizophrenia, progressive diseases such as Huntington’s and Motor Neurone, acquired brain injury and Korsakoff’s disease (brain injury due to alcohol) and learning disability. The registered manager also told us how links had been made with a local stroke specialist unit and a new rehabilitation partnership was planned, to offer further placements for people affected by strokes who required more long term rehabilitation outside a hospital environment. The premises is a large, spacious building with accommodation and communal spaces over three floors. There are three units, Maristow 17 people, Bickham 10 people and Lopez 13 people, accessed using electronic key pads, which those people, who are able, have access to. The registered manager, who was newly employed at the time of the last inspection in December 2016, said they were pleased to have the opportunity to turn the home around since the last inspection and they enjoyed the challenge. They welcomed our inspection to show us what improvements had been made.

During the last inspection in December 2016 we found the areas of safe, effective and well led required improvement with a breach of Regulation 11, Need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At that time people's capacity was not always assessed and best interest processes were not always followed in line with the principles of the Mental Capacity Act. In December 2016, aspects of the service were not always safe. Infection control practices were not always safe and some areas of the service were visibly dirty. People were not always kept safe within the environment, due to potentially hazardous items not being securely stored. Some areas of people's healthcare needs were not always effectively monitored. At that time, audits were carried out, but the actions taken were not always documented and views on staff morale were mixed.

During this inspection we found that all regulations had been met. We found Roborough House to be providing a good service, especially in meeting people’s very individual and complex needs, often on a one to one basis. A visiting psychiatric nurse told us they had no concerns about the complex support provided to people they visited at Roborough House. They told us, “I think the staff do a good job, we work together as a team. They are accommodating to suggestions and have their finger on the pulse, nothing is too much trouble.” The premises required extensive re-furbishment to promote a more homely, less institutional feel to the large spaces but this was confirmed by the operations and registered manager as having been approved by the provider and scheduled for March 2018 in phases. The premises were therefore slightly shabby, however areas were clean and hygienic. We discussed the décor with the registered manager who assured us they were in the process of promoting a more homely feel, removing institutionalised notices, improving signage and creating individual door plaques for people’s rooms as

This inspection took place on 5 and 6 December 2016 and was unannounced.

Roborough House is a care home that also provides nursing care. Roborough House can accommodate a maximum of 51 people with dementia, learning disabilities, mental or physical health needs, sensory impairment and substance misuse needs. At the time of the inspection there were 40 people living at the service.

At the comprehensive inspection on 13 and 14 January 2016, people were not always protected from risks associated with their care, and documentation related to people's risks was not always reflective of their needs. The management of medicines was not always safe and it was not always clear whether people had received their medicines as prescribed and at the right time, we asked the provider to take action to make improvements to medicines management. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation of the breaches. We undertook a focussed inspection on 9 June 2016. This was to check the provider had followed their plan and to confirm they now met the legal requirements. We found that whilst many aspects of medicine management had improved, people’s medicines were not always managed safely. We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a manager in post 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.

People were not always kept safe within the environment at Roborough House. We found some concerns relating to cleanliness and infection control. In addition, we found some potentially dangerous items which could have been used to self-harm or to injure others, which were not securely stored. There were some concerns about areas being cluttered, and an emergency exit which was blocked, which may have been problematic in the event of an evacuation of the building.

Although people’s medicines were administered, stored and disposed of safely, we found some concerns relating to the administration of medicines by agency staff. We found that there was a high staff turnover at the service, a high use of agency staff and a shortage of nursing staff. This could have led to a higher incidence of medicines errors. Morale amongst staff was mixed.

People who lacked capacity to make certain decisions for themselves may not have always been sufficiently protected as mental capacity assessments were not being undertaken. It was therefore not possible to know whether decisions made were in their best interest or the least restrictive available.

People’s health care needs were not always recorded appropriately. Screening tools were used inconsistently and these were not always used to inform the person’s care plan. It was therefore not always possible to know if the person received appropriate care and treatment in response to health concerns. We have made a recommendation about record keeping.

Staff had undergone training in order to carry out their role. New staff received an induction and all staff were supported by an on-going programme of supervision, competency checks and an annual appraisal. There were staff meetings which provided a forum for open and honest communication and for sharing ideas and best practice.

People told us they felt cared for and interactions between people and staff were positive, warm and compassionate. Positive relationships had formed between people and staff. People’s dignity was respected and they were enabled to have their voices heard and to exercise choice and control. People understood how to make a complaint and felt any issu

We carried out an unannounced comprehensive inspection of this service on 13 and 14 January 2016. Breaches of legal requirements were found and enforcement action was taken. This was because people were not protected from risks associated with their care and risk assessments were not reflective of people’s current risks. People were also at risk of not receiving their medicines as prescribed. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation of the breaches.

We undertook this focussed inspection on 9 June 2016. This was to check the provider had followed their plan and to confirm they now met the legal requirements. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Roborough House on our website at www.cqc.org.uk.

Roborough House provides nursing care and accommodation for up to 51 people. On the day of the inspection 38 people were using the service. Roborough house provides nursing, rehabilitation and residential care for people with mental and physical health needs including acquired brain injury and degenerative conditions.

There had been no registered manager at Roborough House April 2015. 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 at Roborough House had been in post since October 2015 and was currently going through the Care Quality Commission registration process to become the registered manager of the service.

Many aspects of medicine management had improved. A medicine policy had been developed and staff were aware of the policy and procedures in place. Further medicine training for staff had occurred, and competency checks were ongoing. Stock control had improved and there were audits in place which were identifying some issues and improving the management of medicines. People were given their medicines safely by staff and people’s care plans had guidance in them which reflected their medicine needs. This helped staff meet people’s individual needs.

However, people’s medicines were not always managed safely. We found storage temperatures were not always within the recommended range which could affect the medicine; the directions available for staff to guide them with administering skin creams was not always in place or consistent across the service. This meant people might not have their skin creams as prescribed. Medicine records had been signed for by staff but we found in some cases, medicines had not always been given to people. This meant people may not have had their medicines prescribed by their doctor. Some people’s medicine records had been changed altering the amount they were receiving but it was not always clear who had authorised these prescription changes. The manager had identified this on one person’s case and was investigating and taking action following inspection feedback.

People’s risks were well known and managed. People’s risk assessments had been updated and were being regularly reviewed. Risk assessment summaries were now in place and comprehensive.

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 report.

The inspection took place on the 13 and 14 January 2016 and was unannounced.

Roborough House provides care and accommodation for up to 51people. On the day of the inspection 42 people were using the service. Roborough House provides nursing, rehabilitation and residential care to people with mental and physical health needs including acquired brain injury and degenerative conditions.

The service had a new manager in post that started at Roborough House in October 2015. The new manager was going through the Care Quality Commission registration process to become the registered manager.

People’s medicines were not always managed safely. People had not always received their medicines as prescribed and there were gaps in people’s medicines administration records. People’s regular medicines were not always in stock; this meant some people did not have their medicines when they required them as prescribed.

People’s care records including their risk assessments were not reviewed frequently or as their needs changed. Records were not well organised, information was held in different places, gave conflicting instructions about people’s care and staff found it difficult to find information when they needed it. Staff told us they did not have time to update people’s care records.

There were quality assurance systems in place but these had not been effective over the past year in maintaining the quality of the service. The service had an open and transparent culture. Staff felt listened to and able to contribute ideas to the development of the service to drive improvement.

Staff received a comprehensive induction programme which included shadowing more experienced staff. There were sufficient staff to meet people’s needs; however there was a reliance on agency staff at the time of the inspection. There was a physiotherapist and occupational therapist to complement the staff team. Some staff had not completed training deemed as essential by the provider which meant there was a risk of them not providing care based upon best practice. We observed staff used the correct techniques to transfer people and staff demonstrated good communication skills and most staff had a good knowledge of the people they cared for.

People were relaxed throughout our inspection. There was a busy but pleasant atmosphere. People were seen laughing, engaging in activities and we saw kind, patient interactions between people and staff. People and relatives told us the care was good at the home and people enjoyed living in the home. Some people had lived at the home for many years and they were happy.

People were promoted to live full and active lives where possible and were supported to be as independent as they could be. Activities were meaningful, individualised and reflected people’s interests, the seasons and their hobbies.

People consented to their care and treatment and the correct legal processes were followed if people were unable to consent to their care.

People were supported to maintain good health through regular access to health and social care professionals, such as GPs, social workers and mental health nurses.

People and their relatives told us they felt safe. All staff had undertaken training on safeguarding vulnerable adults from abuse. Staff displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff confirmed they felt confident any incidents or allegations would be fully investigated.

People were protected by the service’s safe recruitment practices. Staff underwent the necessary checks which determined they were suitable to work with vulnerable adults, before they started their employment.

People and those who mattered to them knew how to raise concerns and make complaints. People told us they had no concerns. The manager informed us any complaints would be thoroughly investigated and recorded in line with the complaints policy.

Staff, relatives

We visited Roborough House due to anonymous concerns we had received. We spoke with three people who used the service and fifteen members of staff across the day and night shift. We looked at seven people’s care records, seven staff files and observed staff working with people.

We found that there were sufficient numbers of staff on duty during our visit to meet the health, safety and welfare of people living at Roborough House. Staff were knowledgeable about the people they were working with and had access to on-going training and development.

At our last inspection we found there was not a system of regular supervision and appraisal for staff. We found that a supervision structure was now in place to support staff and the majority of staff had received supervision over the past three months.

We saw that staff spoke to people in a way that demonstrated a good understanding of people's choices and preferences. We saw that care planning was person centred, respected people’s dignity, maintained self-esteem, took account of published guidance and considered all aspects of a person’s individual circumstances.

We found that all records were held securely, remained confidential and were monitored and reviewed to ensure they remained fit for purpose.

We found significant improvements had been made at Roborough house since our last inspection on the 18 and 24 June 2013.

We found people living at Roborough House were involved in the running of the home. People living at Roborough House were involved in the running of the resident meetings, recruitment and in some of the refurbishment which had occurred since our last visit. People were involved in planning their care and treatment and able to express their views about the service. People told us that they felt involved in service improvements and felt listened to and their views and wishes were respected by staff.

We found progress had been made to people's care planning. Staff were knowledgeable about the people who lived at the home, understood their needs, were aware of their potential risks and carried out their work alongside people respectfully. Health and social care professionals were involved with people's care and reviews to ensure their care needs were met.

We found the home had made significant improvements to the cleanliness of the environment meaning the risk of infection at the home was reduced. Staff had received recent training in infection control procedures, checklists to monitor the cleanliness of the home had been developed and new cleaning staff had been appointed to maintain the cleanliness of the home.

We carried out this visit after concerns were identified at a safeguarding meeting and to follow up a compliance action made at a previous inspection. We were accompanied by a CQC Pharmacist Inspector on this visit; this was to follow up on the compliance action for medication made at our last visit.

We did not talk to all the people using the service on this occasion; however we did observed some staff interaction with people as they were unable to communicate with us. We talked with staff and checked the provider's records. We spoke to the registered manager, who was due to leave the next day, the interim manager and the company’s national operations manager who was available on the day of our visit.

We spoke with staff about their understanding of what constituted abuse and how to raise concerns. They demonstrated a good understanding of what kinds of things might constitute abuse.

We spoke to staff about the change of management of the home. Staff made positive comments including, “I think things are improving for the better”.

We did not speak to any people living in the service at this review.

The people living at Roborough House informed us they were very happy with the service they received. Further information about people’s experiences in the home was given to us by visiting relatives and management of the home. We also spoke to professionals about their views and experiences of this home.

During our visit we observed people enjoying themselves and interacting positively with the staff and manager supporting them.

Several people said; they liked living in the home, enjoyed their regular visit by family members, the activities arranged and that the staff were very good.

One regular visitor to the home said, “Everyone has been so helpful and kind and they are always friendly” and went onto say, “Nothing is too much trouble and I always get offered drinks when I visit”.

One professional stated that, “they are approachable if I need any information”.

People living in the home told us, “They have all been really good to me”, another said, “The staff are great” and many of the other people living in the home agreed that the staff were very good or excellent.

The people we met told us they liked living at Roborough House. We found staff to be caring, kind and committed to wanting to improve the service.

Although some improvements had been made and people were more involved in the running of Roborough House through the residents meetings, people were unsure what was in the care plan and had not been involved in their care plans. We found new team meetings had started which reviewed people's care needs and treatment plans. The staff we met knew people well and therefore knew what care and support people needed, most people's care plans and the information available about people was confusing, difficult to find and not regularly reviewed.

We found that there were not good systems in place to ensure the cleanliness and hygiene in the home, this posed a risk to staff and people living at Roborough House. We found staff who were employed went through a recruitment process but that there were gaps in essential training within the current staff team although there were plans in progress which were addressing these areas. We also found there were not regular supervision and appraisals in place for staff.

We found that there were systems being established to improve the quality monitoring which occurred at the home.