This comprehensive inspection took place on 24 July 2018 and was unannounced. We last inspected this service in February 2017 where it was rated ‘Requires Improvement’ overall and ‘Requires Improvement’ in the Responsive and Well-Led key questions. Following the inspection in February 2017 we identified two breaches of regulation, corresponding to regulation 9, person-centred care and regulation 17, good governance. During this inspection in July 2018 we found that sufficient action had been taken to improve on these areas and the service was no longer in breach of regulations.

Southbourne Care Home (referred to in this report as Southbourne) is a ‘care home’. 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. Southbourne accommodates up to 21 people in one adapted building. At the time of our inspection there were 17 people living in the home.

The service 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.’

Following our previous inspection in February 2017 Southbourne had employed a new manager who provided day to day management and had made a number of improvements. Therefore, the rating at Southbourne improved to ‘Good’ in all areas and ‘Good’ overall.

People and relatives praised the staff and management of Southbourne. Comments we received included; “I have to say that the care here is fantastic. They are very caring with mum. She’s being really well looked after” and “The care is fantastic. Really caring.” People were held in high regard, had a good quality of life, had freedom to make choices and were supported to be independent. People were encouraged to go out into the community where possible. Staff treated people with respect and kindness.

People who lived in Southbourne were protected from risks relating to their health, mobility, medicines, nutrition and possible abuse. Staff had assessed individual risks to people and had taken action to seek guidance and minimise identified risks. Staff knew how to recognise possible signs of abuse. Where accidents and incidents had taken place, these had been reviewed and action had been taken to reduce the risks of reoccurrence. Staff supported people to take their medicines safely and staffs’ knowledge relating to the administration of medicines were regularly checked. Staff told us they felt comfortable raising concerns.

Action had been taken to ensure staff understood the Mental Capacity Act 2005, the principles of the Act and how to apply these. We found people were involved in all aspects of their care and their consent had been sought prior to any care being delivered. Where people had been unable to make a particular decision at a particular time, their capacity had been assessed and best interests decisions had taken place and recorded. Where people were being deprived of their liberty for their own safety the registered manager had made Deprivation of Liberty Safeguard (DoLS) applications to the local authority.

Improvements were in the process of being made to the environment and large building work was underway. Although the premises looked a little tired during our inspection, clear signage and door colours had been implemented in order to help people navigate the home and find their bedrooms. The plans for the future environment at Southbourne had been designed with people’s needs in mind. The manager told us about the new upcoming features which would improve the lives of the people who lived in the home, such as more outside space people could access and easily accessible fa

Southbourne is registered to provide accommodation and personal care for up to 21 people. People who live at the service are older people, some of whom have memory loss or dementia. There were 18 people living at the service on the first day of inspection.

The inspection took place on 27 and 28 February 2017 and the first day was unannounced.

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. The registered manager was also one of the directors of the company that own the service and they were also registered as manager of another service owned by the provider. They were supported in their role by a recently appointed manager who had day to day control of the service.

Southbourne was rated as requires improvement at the comprehensive inspection in November 2014 and again in December 2015. CQC issued warning notices to the provider telling them they must take action. Although sufficient action was taken at that time to make improvements, these have not all been sustained.

At this inspection in February 2017 we found improvements to the quality assurance processes had not been sustained. Systems had not been established that ensured the provider could identify where person centred care had been compromised. For example, the systems had not identified the how the lack of personalised information in care plans had impacted on the person centred approach to people’s care. Also, the discrepancy with people’s finances had not been picked up. There was contradictory information with regard to some risks assessments. Improvements to the general environment such as signage had been needed for some time and had not been addressed. Issues relating to cleanliness in people’s bedrooms had not been identified and addressed.

People did not always receive care that was personalised for them. Some aspects of peoples care had been assessed and were being met. However, there was little evidence people were assessed as a whole person and plans put in place to put the person at the centre of their care. There was little information on care plans for staff to help them meet people’s social care needs. Some information about the person’s life, the work they had done, and their interests was recorded in their care files and this could have been used to develop personalised ways of stimulating and occupying people.

Only three hours staff time per week were allocated to providing activities. Four outside entertainers were booked each month. Staff did tell us that they had time to sit and chat with people and people confirmed this. We saw staff had some time to spend sitting with people. We also saw that one person was taken out shopping each week by a member of staff.

The financial records for three people contained small discrepancies between the records and the amounts of cash held. Following the inspection the manager sent information telling us the discrepancies had been accounted for in the way balances had been recorded and plans had been put in place to minimise the risk of this reoccurring.

One member of staff, whose first language was not English could not understand the questions we asked about reporting abuse. The management team told us they always ensured the staff member was on shift with other staff whose first language was the same. Following the inspection further systems were put in place to ensure all staff knew how to report any suspicions of abuse. We also raised concerns that staff whose first language was not English would not be understood by people living with dementia. However, we saw no evidence that this was the case. Interactions we saw were positive with many smiles and nods.

Risk

Southbourne Care Home provides care for up to 21 people. People living at the home were older people, many of whom were living with dementia.

This inspection took place on the 20 April 2016 and was an unannounced focussed inspection.

The home had previously been inspected on 17 and 18 November 2014 in response to concerns we had received. At that time we identified concerns over keeping people safe, staff training, staffing and staff recruitment. Breaches of legislation were identified in relation to quality assurance, person centred care, cross infection and record keeping.

In December 2015 we carried out a comprehensive inspection at the home to see what progress had been made. We found that although there had been improvements there were still areas that caused us concern. The provider and registered manager had not completed all areas of their action plan. The home was rated as ‘requires improvement’ overall, and breaches of legislation were identified.

Following the inspection of 2 December 2015 we issued the provider and registered manager with a warning notice in relation to Regulation 17 (1) and (2) (a) (b) and (c) of the Health and Social Care Act (Regulated Activity) Regulations 2014 (Good Governance). The provider and registered manager needed to comply with the warning notices by 25 March 2016.

The registered manager sent us an action plan telling us what actions they had taken to improve.

This focussed inspection was carried out to ensure the provider had met the detail of the warning notices for Regulation 17 (Good Governance). Other areas for improvement identified during the inspection of 2 December 2015 remain part of the home’s ongoing action plan, and will be looked at on the next comprehensive inspection.

We found that the provider and registered manager had taken sufficient action to meet the requirements of the warning notice.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

Staff recruitment processes and records had been strengthened to help protect people and provide greater assurance of their character and work performance. References had been obtained and disclosure and barring service (police) checks had been undertaken before any new staff started to work with people. Systems had been put in place to assess any risks in relation to staff recruitment and gaps in people’s employment history had been explored. The provider was taking steps to see this was backdated for staff that had been employed by the home for some time.

Systems for the management and assessment of risks had been improved. Records of risk assessments had been strengthened, spot checks were taking place and regular audits were being carried out to identify risks, for example from the environment. Where risks were identified there were management plans in place to reduce them where possible. New systems had been put into place to ensure the risks of cross infection were reduced. This included more regular audits, cleaning schedules and improved equipment.

Records, policies and procedures had improved. People’s care plans reflected their needs, wishes and aspirations regarding their care in more detail, and inconsistencies in people’s plans had been removed.

Action plans for the development of the service had been implemented and had been or were being completed. These had been shared amongst the management team so that clearer objectives that were measurable and achievable were in place. The registered manager and trainee manager (who was in day to day control of the home under the supervision of the registered manager) were meeting regularly to review the plans and ensure they had been completed and improvements wer

This inspection took place on 2 December 2015 and was unannounced. It started at 06:30am to allow us to meet with the night staff, and observe a handover to the morning staff.

Southbourne is a care home, registered to provide accommodation for up to 21 people needing personal care. People living at the home are older people, most of whom are living with dementia. Some people at the home were receiving intermediate care. These people were being supported by community staff with a view to returning to their own home.

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. The registered manager for Southbourne visited the home regularly, but the person in day to day charge at the home was a trainee manager, who was previously the home’s deputy manager. They told us they were working towards becoming the next registered manager.

The home was previously inspected on 17 and 18 November 2014 in response to concerns we had received. We identified a number of concerns in relation to keeping people safe, staff training, staffing, and staff recruitment. Breaches of legislation were identified in relation to quality assurance, person centred care, cross infection and records. Following the inspection the provider sent us an action plan telling us what changes they intended to make. We met with the provider to discuss the improvements that needed to be made.

This inspection was undertaken to review the progress the home had made in relation to the concerns and breaches. We found that although there had been improvements there were still areas that caused us concern. The provider and registered manager had not robustly completed all areas of their action plan.

Recruitment procedures at the home were not always safe or robust enough to protect people.

People were supported by sufficient numbers of staff. However, staff did not always receive the support and training they needed to do their job. Staff understood their responsibilities with regard to safeguarding people, and told us they would act upon any concerns that they had. However not all staff had received training in how to protect people from abuse. People were not always being asked for their consent to care and we saw staff did not always speak with staff before carrying out tasks that affected them.

Medicine practices were not always safe or clear. For example, we identified concerns over a lack of clear guidance for staff about the administration of some “as required” medicines. One person’s care plan contained contradictory information about the administration of a prescribed item.

Risks to people were being assessed, and actions taken to minimise the risks of harm. People had access to community healthcare services to meet their needs.

The trainee manager was working to develop a positive culture at the home and had a good understanding of the standards they wanted to achieve. However the home had not been assessed against best practice in dementia care or current legislation, and some records were still not well maintained or had not been updated. Some improvements to the systems for quality and risk management had been put in place. However, the systems for governance, including assessing and managing the quality and risks at the service and maintenance of records were not yet effective in ensuring standards were maintained and risks were mitigated.

People’s needs were assessed prior to their admission and care plans were reviewed regularly. However plans did not always accurately record people’s needs consistently or reflect the impact of their dementia across all aspects of their care. Improvements had been made to the provision of activities at the home, with daily activities underway. People told us they enjoyed these.

People were consulted about the operation of the home and how improvements could be made. Some quality assurance systems were in place, including questionnaires for stakeholders to enable them to have a say in how the home was run. Complaints and concerns were managed with systems and policies in place.

Work was under way to improve the premises and further adapt it to make it suitable to meet the needs of people living with dementia. This included some areas of cleanliness and odour control, as well as improved signage and access. Significant work had been undertaken to provide an internal lift, improved garden areas and some internal décor.

We found a number of breaches 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.

We inspected Southbourne Care Home as a part of our scheduled inspection programme. We had also received some concerns about the home following a change of ownership in March 2014. This was the first inspection of the home under the new ownership. The registered manager named on the front of this report has informed us they left the company and have no current involvement with the operation of the home. We are awaiting an application to remove them from the registration.

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 who were able to speak with us told us they were very happy with the level of care and support they received. One person told us “People are very kind. They’ve a big job to do.” Another said “The girls are sweethearts”. Staff we spoke with told us they enjoyed working with people who lived at the home. One told us “I like everything about (my job). I just love looking after the people”.

We observed staff communicating with people clearly and at an appropriate pace about their care. For example we saw that staff explained clearly and slowly to one person about how they could manoeuvre their walking aid independently. We saw they walked with the person to help them walk independently. This told us that staff took the time to ensure the person was supported and communicated with about their care in ways they could understand.

Is the service responsive?

Prior to the inspection we had received concerns that activities were no longer being provided at the home since the change of ownership. We had been told this was because staffing levels had been cut. We found that there were not enough activities or stimulation being provided for people to meet their needs for social interaction. One visitor told us about their experiences with their relation. They told us “We came and took her out every day. We got her wheelchair out on the bus and she was able to speak to people. She was really happy and chatty and smiling. She doesn’t really have anyone to talk to in there. The residents are almost always asleep in the lounge.” This demonstrated to us that people would benefit from appropriate and targeted activities being provided. We saw that some action had been taken by the manager to respond to concerns raised with her about the lack of activities provided, but that this was very much ‘work in progress’.

During the inspection discussions with a person who lived at the home highlighted a concern about the way they had been spoken to by a staff member. We discussed this with the manager, who informed us they had been made aware of the concern by the person two days previously. No action had been taken to investigate the concern further or give feedback to the person who raised the concern. This told us the provider had not always responded to complaints and comments about the home or services provided.

Is the service safe?

Staff and visitors told us they were concerned that there were not enough staff on duty at certain times of the day, and that they had raised their concerns with the provider. We saw there had been repeated incidents where people had fallen and injured themselves that had been unwitnessed. We found that there were not enough staff on duty to provide care or observation for people to support them safely. We found that the provider had not responded to the concerns raised to identify the risks to people from the staffing levels in place.

We found that many people’s risk assessments or care plans had not been updated since February or March 2014. This gave us concerns that people’s up to date care needs or risks had not been identified or included in plans of care. This left people at risk of unsafe or inappropriate care.

We found that where some people lacked capacity to make decisions the provider had not acted in accordance with legislation to ensure people’s rights were protected. This was because they had not ensured that best interest decisions had been made and recorded.

CQC is responsible for monitoring the deprivation of liberty safeguards which applies to care homes. No-one at the home was subject to an authorisation by the Court of Protection. However the home manager was aware that following a recent Supreme Court judgement, applications would need to be made to ensure that where people had been deprived of their liberty, through for example locked doors, this was lawful. No action had yet been taken to do so, and the provider had not taken advice about appropriate actions they should be taking. This meant that the provider had not acted to ensure that people’s rights were protected and that where people were being deprived of their liberty this was not in accordance with the protection of legislation.

We saw routine maintenance and risk assessments of the premises had been undertaken.

Is the service effective?

We saw that people were receiving healthcare from community medical and nursing services. However, we found that people’s care plans and assessments had not been regularly updated since the new provider had taken over the home. This meant that people’s up to date needs could not be identified or met effectively. Care given was not being evaluated so the provider could not assure us that it was effective.

We found that records overall were poorly maintained. Some records were poorly completed or did not link to other records. This led to difficulties in tracking people’s current care needs or identifying risks.

We did not see that the home had responded to people’s needs and put clear strategies in place to support people with their confusion or ensure any risky behaviours were managed. This left people at risk of receiving inconsistent or inappropriate care.

Is the service well led?

Since the last inspection the home had changed ownership and the registered manager had left. A manager had been moved from another home owned by the provider to manage Southbourne and they had been there for about four weeks when we inspected the home. Prior to that management was being provided by another manager from within the company. The manager in post told us they had not yet made an application to register as the manager at Southbourne but intended to do so. They are referred to throughout this report as the manager.

People we spoke with told us they liked the manager. They told us she was approachable and felt confident speaking with her. One said “The manager is very understanding and I could report anyone to her.”

We identified concerns over the lack of clear management systems at the home. We saw that there were plans in place to carry out effective audits to ensure the quality of the services provided. However we saw these had not started or been completed at Southbourne. This meant we could not clearly identify the quality of the services or systems provided.

We found there was a lack of documentation and a lack of consistency with record keeping. This told us that proper systems were not in place to ensure records were managed, completed or used effectively to safeguard or improve people’s care.

We were told by the provider that they did not yet know what the clear direction was for the future of the home with regard to dementia care. This gave us concern that the home’s management were not clear about the home’s admission criteria or what developments were needed.

Southbourne Care Home was purchased by the current provider in March 2014. The home provides accommodation and personal care for up to 21 people. People who live at the home are older people, some of whom will have memory loss or dementia.

This inspection took place on 17 and 18 November 2014. The first day was an unannounced evening visit.

It is a condition of the home’s registration that a registered manager is employed at the home. A manager who was registered with the Commission for another service had been appointed but had not yet registered their change of location with the Commission. Following our inspection an application was received from another registered manager to add Southbourne as a location to their registration. 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.

Southbourne had last been inspected by the Care Quality Commission (CQC) on 12 June 2014. At that inspection we asked the provider to take action to make improvements in relation to staffing levels, quality assurance systems and record keeping. Some improvements had been made in these areas. We also asked the provider to take action to make improvements to the way people’s capacity to consent to care and treatment was assessed and the way people’s care was planned. Following the inspection on 12 June 2014 the provider sent us an action plan telling us about the improvements they were going to make and that they would be completed by 15 August 2014. Actions specific to these areas had been completed.

Prior to our inspection we had received information of concern relating to staff working long hours, not always enough staff on duty to meet people’s needs, infection control issues, the home not having hot water or heating and people having to pay a large amount of money each month for toiletries. We found staffing levels were not sufficient to meet people’s needs in a timely manner on the evening of our first visit and there were issues with infection control. People paid a small amount over six months for toiletries and there had been a problem with the hot water which had been fixed. There had been no problems with the heating.

During this inspection we found a number of other areas of concern. We found the provider had not made arrangements to ensure the risks to people choking were minimised and poor infection control procedures put people and staff at risk from cross infection. Some aspects of medicine management needed improvement. Recruitment procedures were not entirely robust. Evening staffing levels were not sufficient to ensure people’s needs were met in a timely manner.

We found improvements were needed to care plans as they were not always reviewed in a timely manner. This meant staff may not have the most up to date information about people’s needs. The environment needed improvement to make it more suitable for people living with dementia.

Improvements were needed to the way in which people’s privacy was maintained.

Care plans did not always contain correct and sufficient information to help staff respond to people in a personal manner and people and their relatives were not routinely included in the planning for care needs. We found that there was limited opportunity to participate in social activities. There was limited effective monitoring of the quality of the service provided.

Throughout the day people were offered choices and we saw that ‘best interest’ decision forms had been completed where people did not have the capacity to consent to care as specified in their care plan. People had access to healthcare professionals to ensure their healthcare needs were met.

Staff were aware of and were able to respond to people’s individual preferences and people told us they thought the staff were caring. Throughout the inspection we heard friendly, appropriate chatter between staff and people living at the home. People told us they felt safe and there were good arrangements in place to deal with emergencies.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the full version of this report.