We carried out an unannounced comprehensive inspection of this service on 4 and 7 December 2015. During this visit a breach of legal requirements was found. We found the provider was failing to ensure the management of medication was safe and failing to ensure people’s legal consent in relation to their care was always obtained. We issued the provider with requirement actions at this inspection.

Requirement actions require the provider to make the necessary improvements to ensure legal requirements are met within a timescale they agree is achievable with The Commission. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach and agreed appropriate timescales for completion.

We undertook this inspection on the 5 and 6 January 2017. This inspection was also an unannounced comprehensive inspection. During this visit we ensured we followed up the breaches identified at inspection in December 2015. We found that the manager had taken appropriate action to meet all of their legal requirements in relation to the service.

Sandstones is registered to provide personal care and accommodation for up to 35 people. The home is situated in Wallasey, Wirral and is a purpose built facility. There is a small car park and garden available within the grounds. The home is close to Liscard town centre. A passenger lift enables access to bedrooms located on the first floor for people with mobility issues. Bedrooms are single occupancy and each bedroom has its own en-suite toilet facilities. Communal bathrooms with specialised bathing facilities are available on each floor. On the ground floor, there is a communal lounge and dining room for people to use. The home is decorated to a good standard throughout.

On the day of our visit, there was 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.

During our visit, we observed a medication round and saw that the administration of medication to people who lived at the home was now safe. People’s care files contained clear information about people’s medications and any medications the person was allergic too. This was good practice as it alerted staff to the fact that these medications should not be prescribed.

We found however that there was a discrepancy in relation to the quantity of medication in stock in respect of some people’s medications. A set of eye drops had also not been dated when opened so it was impossible to know if they were still safe to use. This aspect of medication management required improvement.

We reviewed the care files of four people. We found them to be well organised and easy to follow. Staff were given relevant information in relation to people’s needs and risks and clear guidance on how to support them. We saw that people’s risks were appropriately managed and professional advice sought appropriately as and when required or when people’s needs changed. For example, we saw evidence of the involvement of district nurses, tissue viability teams, falls prevention teams and mental health services in relation to people’s care.

We checked whether people’s legal consent to the care they were provided with had been sought in accordance with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards legislation and we found that it had. People’s capacity had been assessed for specific decisions about their care and best interest meetings held to ensure any decisions made were in the person’s best interests.

People were offered a varied menu to choose from at mealtimes and offered snacks and drinks regularly throughout the day to promote their diet

We were concerned during our last visit in September 2013 that staff were not receiving regular training, appraisal and supervision. We found there was a lack of systems in place to monitor which staff members had received appraisal, supervision and training and a lack of evidence in staff files to demonstrate staff were appropriately supported or trained. We discussed this with the manager in September and an action plan was put in place to improve the support arrangements for staff.

We looked at the training, appraisal and supervision arrangements again as part of this visit to check that suitable arrangements were now in place. We saw evidence to indicate that there were now systems in place to record and monitor the appraisal, supervision and training of staff. We also reviewed three staff files and found that staff members had received appropriate support in relation to their job role. This assured us that the provider now had suitable arrangements in place to ensure staff members were supported to deliver care safely and to an appropriate standard.

We spoke with three people who lived at the home. They told us the care was very good and that they were treated with dignity and respect. We saw people’s needs were assessed and regularly reviewed. Care records were personalised, contained information about a person’s individual needs and preferences and promoted the person’s independence where possible. We observed people were well cared for and treated kindly.

We saw people were offered a balanced diet and a choice of menu options. People’s dietary requirements were assessed and adequate nutrition and hydration provided.

We noted during our visit that an allegation of abuse had not been reported to the local authority safeguarding team. We spoke to the manager, staff and people who lived at the home. We found the manager and staff were knowledgeable about signs of abuse and the process to follow when an allegation of abuse was made, appropriate safeguarding policies were in place and people we spoke with said they felt safe with staff. The allegation of abuse was followed up by the manager without delay.

We checked the administration of medication at the home and found that medicines were stored and disposed of appropriately and medication was administered safely.

We reviewed three staff records. We saw that records relating to induction, supervision, appraisal and training were inconsistent and the provider lacked suitable systems to evidence staff were appropriately supported in their job role.

We spoke to four people who used the service. They said they were well looked after and happy with the service received. They were positive about the staff that supported them. Some comments made were:-

“It’s fantastic here. The staff are very nice.”

“The staff are very nice and very caring.”

“The staff look after me very well. It’s an excellent service.”

We spoke to one relative who told us that they were happy with the care and support provided.

We spoke to two social care professionals during our visit. They both said they were happy with the standards of care and support provided at the service.

There were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received.

Records showed that people had been assessed before they began to use the service and they had a care plan in place which gave clear guidance to staff on the support they needed.

There were practices in place to ensure that staff recruitment supported the welfare of the people who used the service.

We asked Wirral LINKs* and Wirral Borough Council for information about how the service operated. No current information was available at the time of writing this report.

*LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers.

We spoke to 5 people using the service. They all said that the staff respect their wishes and feelings and treat them with dignity. They said that their requests and preferences are listened to and acted upon.

All said they are asked their views about the service provided and some gave the example of the chef recently asking them about whether the meals offered meet their requirements. All knew that residents meetings take place, although not all would choose to attend.

All 5 people spoken with knew how they could make their views known if they are not happy with the service provided. They said that information about making a complaint and the service on offer is available in their bedrooms.

The 5 people spoken with were happy with the care they are receiving and felt that they are getting the care they need. Some comments made were;

"I am contented. The home is very good. The staff are very good. If something doesn’t suit I tell them and they fix it."

"I am happy with the service I get. The staff are lovely, the food is great, the bedrooms are nice, the home is warm and cosy."

"I am very satisfied. The staff are very caring, nothing is too much trouble for them."

"I couldn’t be in a better place. Its very homely."

"Its very pleasant, the staff are extremely friendly, the food is good and the home is kept very clean."

The people spoken with said that if they need any health or social care professional support then this is arranged by staff following their request.

All were very complimentary about the standard of food provided at the home. They said that the meals are varied. There is a choice. They are asked what meals they would like.

The 5 people spoken with all praised the standards of cleanliness at the home. Some comments made were:-

"The home is spotlessly clean."

"There are good housekeeping standards. The staff come to my room every day and clean"

The 5 people spoken with said that there is always a member of staff available when they are needed. They described the support they get from the staff positively. Some comments made were:-

"The staff are caring and kind."

"The staff are very good, nothing is too much trouble for them."

"There are good staff here, the staff are extremely friendly."

"We are very well looked after here, the staff are very helpful."

We undertook this comprehensive inspection on the 4 and 7 December 2015. The first day of this inspection was unannounced.

Sandstones is registered to provide personal care and accommodation for up to 35 people. The home is situated in Wallasey, Wirral, close to Liscard town centre. The home is a purpose built with a small car park and garden available within the grounds. The home is. A passenger lift enables access to bedrooms located on the first floor for people with mobility issues. Communal bathrooms with specialised bathing facilities are available on each floor. On the ground floor, there is a communal lounge and dining room for people to use and the home is decorated to a good standard throughout.

On the day of our visit, there was 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.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulated Activities 2014. These breaches related to medicine management and the implementation of with the Mental Capacity Act 2005. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 as the provider had not always reported notifiable incidents to the Care Quality Commission.

We looked at the arrangements for the safe administration of medication to people who lived at the home. We saw that medication records matched what had been administered and that staff had received training on how to administer medication safely. We observed two medications rounds however and saw that the way some staff administered medication was not consistently safe.

We reviewed the care records belonging to three people who lived at the home. Where people had mental health conditions that may have impacted on their capacity to make specific decisions, their capacity had not been assessed appropriately. This meant that the Mental Capacity Act 2005 legislation had not been followed to ensure people’s legal consent was obtained. Care records also lacked sufficient guidance on how to provide person centred support to people who became emotionally distressed or displayed behaviours that challenged.

Care files provided sufficient guidance to staff on people’s health needs and risks. People’s independence was promoted in the delivery of care and their care plans gave staff an understanding of the person they were caring for and their preferences in day to day living. People’s care had been regularly reviewed and records showed that people had prompt access to other healthcare professionals when needed.

People who lived at the home said they were well looked after. We saw that people looked well dressed and content. We saw that staff supported people in a patient, unhurried manner. Support provided in such a way as to promote the person’s ability to be independent and staff were observed to be warm and compassionate.

The home had been without an activities co-ordinator for several months despite attempts to recruit to this post. The manager told us staff had helped out with activities during this time and one the day of our visit staff and people were enjoying festive activities. The atmosphere at the home was social and homely. People sat in companionship in the communal lounge and interactions with staff were good humoured. It was obvious that staff new people well and genuinely cared for the people they looked after. People told us they felt safe and had no worries or concerns.

Records showed staff were recruited safely. There were sufficient staff on duty to meet people’s needs and staff received the training and support they needed to do their jobs effectively.

Staff spoken with, were knowledgeable about types of abuse and what to do if they suspected abuse had occurred. We found however that some accident and incidents and allegations of abuse had not been appropriately reported to the Care Quality Commission in accordance with legal requirements.

People had access to sufficient quantities of nutritious food and drink throughout the day and were given suitable menu choices at each mealtime. People’s special dietary requirements were catered for and people we spoke with told us the food was good.

People were provided with information about the service and life at the home. Information about how people could make a complaint required the contact details for who people should contact in the event of a complaint, to be clarified.

The premises were well maintained and the home’s equipment was properly serviced to ensure it was safe and suitable for use.

We observed the culture of the home to be open and inclusive. The staff team had a ‘can do’ attitude, were confident in their roles and worked well as a team. The management team were ‘hands on and people’s feedback about the service, gained through residents meetings and the use of satisfaction questionnaires, was consistently positive. This demonstrated good staff management and leadership in the delivery of care.

There were a range of audits in place to assess and monitor the quality of the service provided. We found some of these audits were not consistently effective. For example, care plan audits in place had not picked up that people’s mental capacity had not been assessed where appropriate. Medication audits had not picked up that the way in which some staff administered was not consistently safe and other incident audits had not picked up some notifiable incidents had not been reported to The Commission. This aspect of service management required improvement.