The inspection took place on 30 May and 8 June 2018 and was unannounced.

Sowerby House is a ‘care home’ in the village of Sowerby on the outskirts of Thirsk. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides residential care for up to 51 older people and younger adults and specialises in supporting people with a physical disability or who may be living with dementia. Accommodation is provided in one adapted building with bedrooms spread across two floors. There is a passenger lift to access the first floor.

The service had a registered manager. They had been the registered manager since March 2018, but had worked as the deputy manager before taking this role. 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. The registered manager was supported by a regional area manager and deputy managers in the management of the service.

The service had previously been rated Inadequate in October 2016. At the last inspection in April 2017, significant improvements had been made, but we rated the service ‘Requires improvement’ overall. This was because we needed to see evidence of consistent good practice and that the improvements made could be sustained over time. At this inspection, we found the improvements had been sustained and the service was ‘Good’ overall.

Improvements were needed to ensure medicines were managed safely. Medicine stock levels were not always accurate. This meant we could not be certain people had taken their prescribed medicines. Protocols were not always in place to support staff on when to administer medicines prescribed to be taken only when needed. We made a recommendation about managing medicines. Although the registered manager responded to our concerns and acted to make improvements, the improvements need to be embedded and sustained to evidence medicines are managed safely.

At the time of our inspection work was in progress to replace ceilings, to improve fire safety, and to redecorate and update the home environment. This work caused some disruption, with contractors in the building and areas of the service closed for renovation, but the work had been managed in a sensitive way. Appropriate risk assessments and management plans were in place and the provider and registered manager had taken proactive steps to minimise the disruption and ensure people’s needs continued to be met.

People who used the service told us they felt safe. Staff were safely recruited and enough staff were deployed to meet people’s needs. Staff completed training to help them identify and respond to safeguarding concerns. Risk assessments helped staff to provide safe support to meet people’s needs.

The environment was clean and well-maintained. Maintenance checks ensured the home and equipment used were safe.

Staff completed training and received regular supervision and an annual appraisal of their performance to support them to provide effective care. The registered manager used competency checks to make sure staff were providing effective care and following best practice guidance.

We received generally positive feedback about the food and staff provided effective care to ensure people ate and drank enough.

Staff supported people to make decisions. People’s rights were protected in line with the Mental Capacity Act 2005 and best practice guidance. Applications had been made when necessary to deprive people of their liberty.

Staff worked closely with healthcare professionals. They sought advice and guidance when needed to help people mainta

Sowerby House is a residential care home in the village of Sowerby on the outskirts of Thirsk. The service is registered to provide residential care for up to 51 older people some of whom may be living with dementia. There were 17 people using the service at the time of our inspection.

At the last inspection in October 2016, we identified breaches of regulation around safe care and treatment, safeguarding people from abuse and improper treatment, meeting nutritional and hydration needs, the need for consent, staffing and the governance of the service. Due to the significant and wide spread concerns we had about the quality and safety of the service, we rated Sowerby House inadequate, placed it in 'Special Measures' and told the registered provider to take immediate action to make improvements.

Services that are in Special Measures are kept under review and are inspected again within six months. We expect services to make significant improvements within this timeframe. This unannounced inspection took place on 25 April 2017. During the inspection, the registered provider demonstrated that improvements have been made. For this reason, the service is no longer rated as inadequate overall or in any of the key questions and is no longer in Special Measures.

During the inspection we found that action had been taken to improve safety. People’s needs were assessed and risk assessments put in place to support staff to provide safe care and support. Risk assessments were generally detailed and comprehensive; however, we identified some examples where more information was required. Accidents and incidents were reported, recorded and analysed to identify any patterns or trends.

People were protected from the risk of abuse by staff who were trained to recognise and respond to safeguarding concerns. Sufficient staff were deployed to meet people’s needs in a timely manner. Medicines were managed safely.

People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice. Staff received an induction, on-going training, supervision and appraisal to support continued professional development. Training courses had been scheduled to address gaps in staff’s training.

We received positive feedback about the food provided at Sowerby House. We observed that people were supported to ensure they ate and drank enough. People’s weight was being appropriately monitored and advice and guidance was sought, where necessary, from external healthcare professionals.

Staff were described as kind, caring and attentive to people’s needs. We observed that staff were respectful and supported people in a way which maintained their privacy and dignity. People had choice and control over their care and support.

The registered provider is required to have a registered manager as a condition of registration for this 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. At the time of our inspection, the service did not have a registered manager. However, there was a new manager in post and they had applied to become the service’s registered manager.

We received positive feedback about the new manager and the improvements they had made. The registered provider had ensured a range of quality assurance checks and audits were completed to monitor the care and support provided and to drive improvements.

Whilst improvements had been made, we have not rated this service as 'Good', because to do so requires evidence of consistent good practice over time and the improvements made need to be sustained to demonstrate this.

This inspection took place over three days on 13, 14 and 19 October 2016 and was unannounced. The service was previously inspected in February 2015 and at the time was meeting all regulations assessed and was rated ‘Good’.

Sowerby House Nursing Home is registered to provide residential and nursing care for up to 51 older people some of whom are living with a dementia. At the time of this inspection, 27 people were living at the service 11 people were receiving nursing care and 16 people were receiving residential care. We were told that one person, receiving residential care, was in hospital.

The service did not have 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 inspection was prompted in part by the notification of two separate concerns following the deaths of two people living at the service. The Coroner had asked North Yorkshire Police to conduct a review of the deaths. These incidents are currently being assessed by the police to determine any levels of criminality. As a result this inspection did not examine the circumstances of these incidents.

However the information shared with CQC about the incidents indicated potential concerns about the management of people’s nutrition and hydration and general standards of care. This inspection examined these issues.

At this inspection we found that there were breaches of six of the Fundamental Standards of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, nutritional and hydration needs, consent, safeguarding, staffing and the overall oversight and governance of the service.

Also, there was a failure to meet the requirements of the Care Quality Commission (Registration) Regulations 2009 regulation 18 - notification of other incidents and a breach of the provider’s conditions of their registration – the requirement to have a registered manager.

The registered provider had failed to ensure all of the people who used the service had received safe and effective care and treatment. We found they had not taken reasonable and practicable steps to mitigate the risks posed to people who used the service.

Because of our concerns about people’s care and treatment during the inspection, we made 12 individual safeguarding referrals to North Yorkshire County Council. We will monitor the outcome of these investigations.

The service did not have sufficient numbers of skilled and competent staff to meet people’s needs. There was a lack of nursing oversight and the service was reliant on agency nurses which meant people’s clinical care needs were not sufficiently met.

Medicines were not being safely administered in line with prescribing instructions.

People’s nutritional and hydration needs were not being met and there was a lack of oversight or monitoring to ensure people received the support they needed.

The service was not following the principles of the Mental Capacity Act 2005. We did not see consent recorded within people’s care plans and when people were unable to give consent best interest decisions had not taken place. People were being deprived of their liberty without the required safeguards in place.

Care plans were difficult to follow; reviews were not up to date and did not consistently reflect people’s current needs. They did not provide staff with sufficient detail to deliver person centred care. People’s changing needs were not always responded to effectively.

The registered provider did not have effective systems in place to monitor the care being delivered to people. We found record keeping was poor and management oversight at the service was not effective in ensuring

We carried out this inspection in order to follow up improvements against compliance actions issued at the previous inspection carried out in May 2013. The compliance actions related to the care and welfare of people and to the environment. We found the provider was now compliant.

We had also received anonymous concerns that there may be insufficient staff on duty to meet people’s needs and that senior staff may not be helping to care for people. Other issues raised were that people may be being left in wet beds. Also that the washing machines were not working and laundry gas dryers were not being observed when in use. We looked at all of these issues and found that there was no evidence of none compliance.

We undertook this unannounced visit with a representative of North Yorkshire County Council. We used a number of different methods to help us understand the experiences of people using the service, including talking to people and observing the care being provided. We also looked at some records and staff rotas.

People we spoke with said “The staff are here to help to get things for me. The staff are very good. It is very good here at the moment.” Another person said “Some people are so demanding. The staff are so kind. People may not be patient. I never wait long. We have comfortable rooms. There have been problems with the laundry. I understand they are trying their best.”

During our inspection we saw that staff respected people's privacy and dignity and that people were given some control over decisions regarding how they wanted to be cared for and supported. People told us that they were "Well cared for". However, when we looked at some people's care records and observed the care they were receiving on the day of the visit we had some concerns that we raised with the acting manager and senior managers within the company and asked them to improve in this area.

We saw breakfast and lunch being served. People had a choice of what they wanted to eat and people told us that the food was "Nice and hot and tasty."

We looked at the administration, recording, storing and arrangements made by the home to ensure that people's medication is administered properly and safely and found this to be in good order.

We looked around the home and found that some areas such as the communal bathrooms and corridors were shabby and in need of redecoration and modernisation. We have asked the provider to improve in this area also.

People told us that the staff were "Brilliant" and "A great bunch of people". People also commented that they thought that they were "Good at their jobs". Staff told us that things were improving regarding support and said the acting manager listened and was very approachable.

We spoke to six people who use the service, who were able to tell us about their experiences. They told us “generally, staff are fine” and “the food is good”. Although people looked clean and well cared for physically, there was significant negative feedback from people who use the service about the quality of staff interactions with comments including “Staff are in and out and they don’t stay to talk”, and “they do their duty and that’s it - there’s no camaraderie”.

We spoke with five relatives of people who use services. Some positive feedback was received, including: “the staff have been supportive and they do keep you involved” and “90% of the time its lovely here”.

Care plans for residents have improved and now show that the home has carried out an assessment of people’s needs to ensure the planning and delivery of appropriate care.

We couldn’t speak with many people living at Sowerby House, because their complex needs meant they were not able to tell us their experiences. We did speak with three people who told us that overall they were happy living there. One person told us “The staff are polite to me”. And “I think the staff know what they’re doing.” Another person said that care staff were always there when they needed help. And a third told us they were happy and the meals were nice. All the people we spoke with commented positively about the quality of the meals.

People also provided us with some less favourable comments. Two of the three said that some care workers were much more caring than others. They said they knew which ones to approach if they wanted something. One person added that they knew the service was ‘under new management.’ They said improvements were being made, but the service ‘wasn’t there yet.’

We spoke to two visitors who provided conflicting views. One person told us that their relative was always neat and tidy when visiting. And that staff were “always welcoming and kind to people.” On the other hand the second visitor told us staff needed to talk and generally interact more with people living there. They added “Maybe it’s me being fussy but it’s important to talk with people.” Both visitors thought that there were insufficient care staff to meet the needs of people. One added “People have to wait when they need the toilet, because the staff are busy elsewhere.”

This inspection took place over two days, 19 February 2015 and 8 April 2015. Both visits were unannounced.

We previously inspected Sowerby House in September 2014, and found the service was not compliant in the following areas:

1. People’s views and experiences were not taken into account in the way the service was provided and delivered in relation to their care. People’s privacy, dignity and independence were not always respected.

2. People were not protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

3. People were not adequately protected against the risks associated with medicines because the provider did not have appropriate arrangements in place.

4. There were not enough qualified, skilled and experienced staff to meet people’s needs.

5. Care and treatment was not always planned and delivered in a way that was intended to ensure people’s safety and welfare.

6. People were not protected from the risk of infection because appropriate guidance had not been followed and people were not cared for in a clean environment.

7. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

For items 1 – 4, we asked the provider to make improvements and provide us with an action plan setting out how they would address these shortfalls and the date by which they would be compliant. For items 5 – 7, because of the potential impact this could have on people living at Sowerby House we issued three warning notices. A warning notice is a legal document which sets out the evidence showing what the shortfalls are and gives a timescale for the shortfalls to be addressed. If the provider thinks the warning notice has been wrongly served or that the warning notice should not be widely published then they can make representations within ten working days. On this occasion no representations were made by the provider. The provider was given until 10 November 2014 to make the necessary improvements. Where a service fails to achieve compliance within the timescale, further action can be taken by the Care Quality Commission to make sure that compliance is achieved.

Sowerby House offers nursing and personal care for up to 51 older people and is owned by Orchard Care Homes.com (3) Limited. The service is in the village of Sowerby, adjacent to the market town of Thirsk.

There was a registered manager at Sowerby House. 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.

Since the inspection in September 2014, we noted significant improvements had been made in the service, that there had been a change to the way the service was run and managed and a number of new staff had been recruited. One member of staff told us, "This is a completely different place to what it was last year; it has come on leaps and bounds since then. We pulled together and each one of us wanted the place turned around, and we did it."

The service was safe. When we spoke to people who used the service they told us that they felt safe. We found that staff had been recruited in a safe way and that there were enough staff to meet people’s needs. The environment was kept safe through regular maintenance and checks being carried out. Medicines were administered safely.

This service was effective. We saw that care plans were personalised and that people who used the service were involved in planning their care where they were able. People’s mental capacity had been assessed by an authorised person and we saw evidence that best interest decision making was made as necessary. Staff were adequately trained to carry out their individual roles. The environment, despite the challenges associated with adapted buildings, was suitable for people who used the service.

The service was caring. People told us that staff were kind and caring. We saw numerous examples of staff having meaningful and positive relationships with the people who lived in the service throughout our two visits. Staff we spoke with had a good knowledge of people, their life histories and their preferences. People were spoken to in a respectful, friendly and inclusive way.

This service was responsive. People said they felt their individual needs were addressed. We saw that the care plans were reflective of the person and each person had a care plan that was personal to them. These were reviewed with the person on an ongoing monthly basis. People had access to a full programme of activities, including the opportunity to sit in the grounds or venture further into the local community. People were given clear information about how to make a complaint and relatives and people who used the service were encouraged to share their views about the way the service was run or how improvements could be made.

This service was well led. There was a clear management structure at the service. The registered manager monitored the quality of the care provided by completing regular audits. All the staff we spoke with, some of who had recently started work at Sowerby House, told us they felt supported by the manager and deputy and that they enjoyed their work. Staff were aware of the roles of the management team and they told us that the registered manager was approachable, enthusiastic about his work and had a regular presence in the home. Staff meetings were organised for all designations of staff.