About the service: Rydal Care Home is a nursing care home registered to provide accommodation for up to 60 people. The home is split into three units. Two of the units specialise in providing care to people living with dementia and the third was not in use. At the time of this inspection 40 people were living at the service.

People’s experience of using this service: Improvements had been made to the service following our first inspection in December 2017 and the focused inspection we completed in September 2018. The provider and registered manager had improved the systems for assessing the performance of the service.

Staffing levels met people’s assessed needs however, the provider was reviewing the current dependency tool, as it was not fit for purpose. Staff had received a wide range of training including around working with people who may display behaviours that challenge. Checks were made on the ongoing competency of staff.

The cook and staff had received ‘focus on under-nutrition’ training. Staff were encouraging people who were under-weight to eat fortified foods. We found a range of menu choices were available and consideration had been given to ensuring people from different cultures received acceptable meals.

People participated in a range of activities that met their individual choices and preferences. Staff provided the structured support people required. This promoted a good quality of life. However, we noted that more could be offered to support people from different cultural backgrounds.

Staff effectively investigated and reported any safeguarding matters. The registered manager had acted on concerns, and complaints received by the service and had taken steps to resolve these matters. They ensured that all incidents were critically analysed and from this review lessons were learnt and embedded into practice.

All the people we spoke with told us that the registered manager and staff listened to their views, acted to resolve concerns, when needed, and met people’s needs. We found that staff needed to consistently record capacity assessments and ‘best interests’ decisions.

Works were underway to create a more dementia friendly environment. An enclosed garden area had been created, which would provide sensory stimulation and meaningful occupation for people.

Rating at last inspection: Requires Improvement (report published 17 October 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service had improved and was rated Good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Six people had contacted us to express concerns that there was not enough staff on duty overnight to safely manage the service. In response we carried out this focused inspection on 17 October 2018 and it was unannounced. This meant staff and the provider did not know that we would be visiting. We looked at whether the service was safe and well-led.

We carried out an unannounced comprehensive inspection of this service on 6 and 12 December 2017. This was the first inspection since the new provider registered to operate this service. We rated the service to be Requires improvement in two domains. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to having good governance systems in place.

Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve.

Rydal Care Home is a ‘care home’. People in care homes receive accommodation and 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. Rydal Care Home accommodates up to 60 people across three separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia. At the time of this inspection 45 people were using the service, of which 26 people required nursing care.

The manager became the registered manager in March 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like 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 last inspection we found the quality assurance procedures in place lacked ‘rigour’. Although some auditing and analysis had been carried out, this was not always effective. We highlighted that the way staff completed the dependency tool would benefit from review, as the information could lead to insufficient staff deployed to meet people’s needs.

At this inspection we found that overnight at times there were seven staff on duty. We found on each unit high numbers of people who needed two staff to support them. To evacuate the building with current staffing levels it would take six staff at least five journeys using three of the six evacuation chairs to move people from the upstairs unit.

There was a lone worker on one unit who could not readily call for assistance due to the nurse call alarm not being connected to the other two units.

The area manager and registered manager told us that the expectation was that eight staff were on duty overnight and they would ensure this was always the case. They also undertook to review staffing levels to ensure these were adequate to support people in the event of an emergency.

The staff we spoke with did not know the fire evacuation plan and we found they would benefit from practicing this as a drill.

The registered manager told us they would immediately ensure day and night staff completed a simulated evacuation. They told us that this would be incorporated into the routine fire drills.

People were happy and told us they felt safe.

The registered manager was aware of risks within the service and was undertaking an analysis of risks. The staff had a clear understanding of safeguarding procedures and ensured that action was taken if any concerns arose. Staff ensured any risks were closely managed.

Appropriate recruitment checks were carried out. But we discussed how the application form could be enhanced. The area manager confirmed changes would be made to the forms.

The provider ensured maintenance checks were completed for the equipment and premises. Works were underway to decorate the service in ways that were dementia friendly. An enclosed garden area was being creat

This inspection took place on 6 and 12 December 2017 and was unannounced. This meant staff and the provider did not know that we would be visiting.

This was the first inspection since the new provider registered to operate this service.

Rydal Care Home is a ‘care home’. People in care homes receive accommodation and 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. Rydal Care Home accommodates up to 60 people across three separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia. At the time of this inspection 50 people were in receipt of care from the service.

No registered manager had been in post since April 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like 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 new manager had been in post since September 2017 and had recently submitted an application to the Commission to become the registered manager.

The regional manager had been in post since July 2017 and when they had taken on oversight of the service they had found a number of issues had arisen following the departure of the previous registered manager. They found staff morale had been low and a number of staff were looking to leave. Within a few weeks they had ensured the service stabilised and since then had worked hard to make improvements to the service.

We found the quality assurance procedures in place lacked ‘rigour’. Although some auditing and analysis was carried out, this was not always effective. For instance, the tool the provider had supplied for monitoring care records did not assist staff to look at wider issues, so they had not considered if the current process of using care plans to assess people’s needs and dependencies was effective.

On the whole people and staff felt there were sufficient staff on duty each day to meet people’s needs but we observed that at times staff were stretched. We found the way staff completed the dependency tool would benefit from review, as they were judging people who required one-to-one support as ‘medium dependency’, which was incorrect. Using this information could lead to the provider’s dependency tool calculating that less staff were needed than was actually the case. The quality assurance checks to monitor and improve standards at the service had not picked up that the staff were not completing accurate dependency assessments.

Appropriate recruitment checks were carried out. Staff were supported to constantly develop in their roles and all the staff discussed the wide range of training they had been able to complete. However, staff had not received training around how to support people who may become anxious and display behaviour that challenges others. The manager and regional manager were aware of this gap and were sourcing courses for staff.

The provider ensured maintenance checks were completed for the equipment and premises. They completed health and safety checks and adhered to fire safety guidance. However, we found that one of the two lifts had been broken since before the providers had taken over the service but this had not been repaired. The regional manager told us action was being taken but the previous provider had initially told them they would deal with this issue but had not. We found that effective quality monitoring processes would have identified the impact the lack of a lift was having for the management of the downstairs unit on the general nursing unit and resolved this in a timely manner.

People were happy and told us they felt safe. The relatives we spoke with felt the service delivered safe care but at times