About the service: St Helens provides residential and nursing care for up to 28 older people who may be living with dementia or mental health needs. Eighteen people were receiving support at the time of this inspection.

People’s experience of using this service: People were at increased risk of harm because the provider and registered manager had not done everything they should to assess and manage risks.

Records about people’s needs and in relation to accidents, incidents, mental capacity assessments and best interest decisions did not support staff and management to effectively manage risks.

Audits had not always been effective in monitoring the quality of the service and identifying where improvements were needed. Although the registered manager and provider were responsive to feedback and started to deal with concerns during the inspection this was reactive rather than proactive management.

CQC had not been notified of the outcomes of applications to deprive people of their liberty as legally required. It is important to send these notifications so that we can check appropriate actions had been taken. We are dealing with this matter further outside of the inspection process.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around safe care and treatment and the governance of the service. Details of action we have asked the provider to take can be found at the end of this report.

Staff were kind and caring in the way they supported people. They were person-centred in their approach and showed genuine concern for people’s wellbeing. People’s personal care needs were met by attentive staff who listened to people and made sure they were comfortable and felt well cared for.

People responded positively to staff and enjoyed their company. Staff encouraged and supported people to take part in a range of activities.

There were effective systems in place to support staff to assess and meet people’s wishes and needs approaching the end of their life.

The environment was warm, welcoming, clean and free from malodours. Improvements were being made to ensure there were appropriate facilities to dispose of waste and clean equipment.

People had access to a varied and balance diet, which included regular drinks and snacks. Staff monitored people’s weights and worked with healthcare professionals to make sure people received medical attention when needed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were encouraged to make choices about their care. Staff were respectful in their approach, they explained what they were doing and listened to people. People felt confident speaking with staff or the registered manager if they wanted to complain.

Staff understood how to identify and respond to safeguarding concerns. Staff were safely recruited, and enough staff were deployed to meet people’s needs.

The registered manager was approachable and supportive of the staff team. They were responsive and keen to continue to improve the service in response to feedback.

For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.

Rating at last inspection: The service was rated Good (report published 7 September 2016).

Why we inspected: This was a planned inspection based on the pervious rating.

Enforcement: Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will ask the provider to submit an action plan detailing the steps they intend to take to ensure the required improvements are implemented. We will also 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.

This inspection took place on 5 July 2016 and was unannounced. We previously visited the service on 30 May 2014 where we found that the provider was meeting regulations relating to all areas of care that we inspected.

The service is registered to provide nursing care for up to 28 older people who were living with dementia or had a mental health condition. On the day of the inspection there were 24 people living at the service. The service is situated on the south side of Scarborough, close to bus routes and shops. There is a small garden area where people can sit and the service is very close to public gardens. There is a passenger lift so people can access the upper floors of the premises.

There was a manager who was registered with the Care Quality Commission (CQC) 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.

On the day of the inspection we saw that there were sufficient numbers of staff employed to meet people's individual needs. New staff had been employed following robust recruitment and selection policies and this ensured that only people considered suitable to work with vulnerable people worked at St Helens

People and their families told us that they were safe living at the service. People were protected from the risks of harm or abuse because there were effective systems in place to manage any safeguarding concerns. The registered manager, nursing and care staff were trained in safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm. The staff worked within the principles of the Mental Capacity Act (MCA) and we saw that where it was necessary applications had been made for deprivation of liberty safeguards to be put in place.

Risk assessments identified any areas of concern in respect of people’s care and support needs, and there were management plans in place to reduce these risks and inform staff.

Staff received thorough induction training when they were new in post and told us that they were happy with the induction and on-going training provided for them. Training included fire safety, moving and handling people, dementia awareness, nutrition and health and safety.

We checked medication systems and saw that medicines were recorded, stored, administered and disposed of safely. Staff who had responsibility for the administration of medication had received appropriate training and people received their medicines safely.

People who lived at the service and their relatives told us that staff were caring and that they respected people’s privacy and dignity. We saw that there were positive relationships between people who lived at the service, visitors and staff. Visitors told us they were made welcome at the service and kept informed about their relative’s well-being.

Care plans recorded people’s individual needs and how these should be met by staff. Staff had a good understanding of people’s specific needs and how they wished to be supported.

We saw that people’s nutritional needs had been assessed and we observed that people’s individual food and drink requirements were met and that they were offered a choice.

The complaints procedure was available to people. No complaints had been received by the service. There were systems in place to seek feedback from people who lived at the home, relatives and staff.

There was an effective quality assurance system in place at the service. Quality audits undertaken by the registered manager were designed to identify any areas of improvement to staff practice that would promote people’s safety and well-being.

We carried out an inspection at this service following a visit in January 2014 when we asked the provider to make improvements in the way they cared for people with a dementia and improvements to the cleanliness and hygiene practices within the kitchen area. The provider sent us an action plan and when we visited we could see that improvements had been made.

We considered our inspection findings to answer questions that we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found-

Is the service safe?

We observed that people were treated with respect and their dignity was respected. We observed staff asking people what they wanted to eat, drink and how they wanted to spend their time.

When concerns were raised staff followed an effective policy and procedure. We saw evidence of alerts that had been raised with the local authority. The service made appropriate notifications to the Care Quality Commission as required by law.

The manager was aware of the requirements of the Mental Capacity Act 2005 and associated deprivation of liberty safeguards(DOLS). They were aware of how to make a request to deprive someone of their liberty but none had been made. The manager was aware of the recent judgement in the Supreme Court March 2014 which gave guidance about who may be considered to be deprived of their liberty. They told us that they were going to speak with the local authority's DOLS officer to gain clarity on how to proceed following that judgement.

The service had maintained equipment to ensure people were safe. The service had been inspected by an Environmental Health Officer and was satisfactorily meeting Food Standard Agency standards in the kitchen.

Staffing levels were sufficient to meet the needs of the people who used the service and the service followed safe recruitment practices.

Is the service effective?

People's relatives told us that they were satisfied with the care provided to their family member and that their needs were been met. One person said"They are meeting my dad's needs here".

It was clear when we spoke with staff that they understood people's needs and preferences. The provider and manager had undertaken to complete a course which specifically looked at ways of working with people who had a dementia. They were sharing their knowledge with staff which meant that people who used the service benefited from staff who were up to date with current legislation, guidance and practice.

Is the service caring?

Staff demonstrated kindness and patience towards people. They responded quickly and politely when people wanted something. We observed that staff engaged with people throughout the day in a positive way. They smiled at people and chatted to them.

A visitor told us, "I used to come more often but I don't feel that I need to come as much as I'm confident about the care he gets".

Is the service responsive?

We could see during this visit that the service had responded when we had asked them to improve at an inspection in January 2014. We could see that there were activities going on throughout the day. One relative told us, "There is more going on here".

No complaints had been logged since the last inspection but there was a clear policy and procedure for the manager to follow if a complaint was received. People told us that they would know who to complain to if they had any concerns.

We looked at a person's file which showed a recent admission to hospital. The records showed that this was well planned with the persons family and the person had been supported well by the staff at this service.

Is the service well-led?

All the staff we spoke with had a good understanding of how the provider and manager wanted the service to change and improve particularly in relation to care of people with a dementia.

The service had a quality assurance system which was being improved to reflect emerging practice. The manager was aware of changes to the way in which CQC were developing inspections and recent judgements about deprivation of liberty safeguards. The manager was maintaining and developing their knowledge and practice and people who used the service and staff were benefiting from a change in practice and culture.

We observed staff asking people who lived at this service for their consent before giving any support. It was clear when observing the staff that they knew people well and were able to gain consent either through receiving a ' Yes' or ' No' answer or by observing the body language or facial expressions of people.

Overall people's physical health needs were well met but the service was not reflecting research evidence and guidance in relation to dementia care.

We could see when we looked at the care files that the service had exchanged information with other providers of care services that a person had needed to use.

The service had systems in place to prevent and monitor the risk of infection. We saw that the service followed the North Yorkshire and York Infection Control policy and guidance and that the service had a named infection control lead person.

However when we visited the kitchen we found that some areas were not clean.

We were only able to gain a verbal opinion from a small number of people who lived at the home. We spoke with two people who told us they were content in the home. Although most comments did not relate to the outcome areas covered in this inspection, both people showed signs of well being. We observed that staff treated people with respect and spoke with them in a way which showed they understood their needs and were interested in their welfare.

We saw that people enjoyed having free access around the ground floor of the home. This covered a large area and was broken up into several lounges and communal spaces. There were interesting objects for people to observe and pick up, for example soft toys and magazines. People took an interest in these and appeared to enjoy being engaged in purposeful activity. People were relaxed with the staff and contented with what was happening around them.

We also spoke with a relative of a person living at the home. They were positive in their comments about care. This relative told us they felt the home cared for people safely and that staff understood dementia and how to address people’s physical and mental health needs. They told us that the manager often asked them for feedback about the service, and if they had any concerns she was quick to put things right.

People said that the home staff involved people in their care. A relative said 'I have written a life history for my husband and the staff have all read it and talk with him about it, even the bank nurses know.' A visitor said: 'The staff really understand dementia and are good with each person.' She stated that staff are quick to call a GP when they consider it necessary.

A relative commented that the food was 'great.' She said her husband enjoyed the home-made puddings and the staff had taken notice of what her husband prefers to eat.

One person commented that the staff made sure her relative was given his medication on time: 'This is so important for his condition,' she said and added that this gave her reassurance that he was being well cared for.

People said they felt there were sufficient staff around to make sure they were cared for properly. People said staff seemed confident in their care of people. One person commented on how staff had been trained to assist a person from the floor with the hoist and that they all seemed to know how to do this safely.