This inspection took place on the 28, 29 November and the 3 December 2018. The first day of the inspection was unannounced and the second and third days were announced. At the last inspection 25, 26 April 2018 and the 1 May 2018. The service was rated Inadequate overall. We found six breaches of the Health and Social Care Act 2008 (Regulated Activities).

At the last inspection there was no effective management and oversight of the service. The three separate units operated in isolation and there were no systems in place for managers and staff to work together to share good practice and learn from mistakes. Although some checks were being completed by some managers, there were no formal systems in place to assess the overall quality of the service. Therefore, shortfalls on some units in relation to the completion of care records, medication administration records (MARS), staff recruitment files, staff supervision, staff appraisals, health and safety checks and the business continuity plan had not been identified.

At this inspection we found that a lot of work had taken place and improvements to the way the home is managed and effective systems implemented to ensure the health and safety and wellbeing of the people living there. There is a plan of ongoing improvements that we were shown and discussed throughout the three-day inspection.

Following the last inspection in April 2018 we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, caring, responsive and well led to achieve a Good rating. We received an action plan and a business continuity plan.

Stapley Residential and Nursing 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.

Stapely Residential and Nursing Home consists of three large Victorian Houses, two of which have been extended at the back. It is set in extensive gardens. The home was originally provided specifically for people of the Jewish community, however it now also accommodates people who are not of the Jewish faith. The first building was known as the nursing unit, the second building as the residential unit and the third building as Fernlea. The home is registered to accommodate up to 97 people at the time of the inspection 63 people were living there of whom 28 were receiving nursing care.

There was no registered manager in place, however a manager who had been working at the home for over 20 years has applied with the Care Quality Commission to become the 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.

We toured the home and visited all areas. There is still a lot of work taking place internally to link the home directly with the Fernlea building. A plan was provided with regular cyclical works and continuing works to be completed by early 2019. Time was spent with the electrician who completed all fire safety alarms throughout and ensured the home was safe under the fire regulations and we were provided with the official correspondence by the provider from the Merseyside Fire and Rescue Authority that stated they had withdrawn the enforcement notice as works had been carried out.

The medication procedure for safe storage and temperature records was not being followed in two of the units and medication was not being sent back to the pharmacy for surplus stocks. There were gaps in medication records that when checked however showed that the relevant medicine had been administered but staff had omitted to sign the medication record.

This inspection took place on the 25, 26 April 2018 and the 1 May 2018. The first day of the inspection was unannounced and the second and third days were announced.

At our last inspection on 13 and 14 February 2017 the service was rated Requires Improvement overall. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Regulations 12 and17. This was because the registered provider had failed to ensure a there was a robust system to monitor and assess the effectiveness and safety of the service and that people were fully protected from the risk of unsafe premises and equipment. After that inspection the provider wrote to us to say what they would do to meet it legal requirements. At this inspection we identified that improvements had not been made, regulations continued to be breached and additional breaches were identified.

We will update the section at the end of this report to reflect any enforcement action taken once it has concluded.

Stapley Residential and Nursing 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.

Stapley Residential and Nursing Home accommodates up to 97 people in two separate buildings. One building contains the nursing and resident units and one houses a unit called Fernlea. At the time of this inspection 73 people were living at the service 29 of whom were accommodated in the nursing unit and receiving nursing care.

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. In addition to the registered manager there were four unit managers. One was based in Fernlea unit, one on the residential unit and two in the nursing unit. Following our inspection the provider wrote to us to inform us the registered manager was no longer working for them.

There was no effective management and oversight of the service. The three separate units operated in isolation and there were no systems in place for managers and staff to work together to share good practice and learn from mistakes. Although some checks were being completed by some managers, there were no formal systems in place to assess the overall quality of the service. Therefore shortfalls on some units in relation to the completion of care records, medication administration records (MARS), staff recruitment files, staff supervision, staff appraisals, health and safety checks and the business continuity plan had not been identified. Some of these shortfalls had been brought to the attention of the registered manager by the local authority as part of a quality monitoring visit of the service in October 2017 but had not been addressed.

Recruitment practices were not safe. Appropriate identity and security checks had not always been completed before staff started work. Although some staff received regular training and supervision from their line manager others had not.

The fire authority identified serious concerns in relation to the safety of the premises in the event of a fire. Immediate action was taken to mitigate these risks and further improvements were being made, however the providers own systems had failed to identify these concerns.

Records containing people’s personal information and other records relating to the on-going management of the service were not always stored securely.

People told us that they enjoyed the food that was available to them at meal times but people on the nursing unit were not always treated with dignity and respect at mealtimes. All meals were prepared and s

The inspection was carried out on 13 and 14 February 2017. The first day of the inspection was unannounced.

Stapely Care Home consists of three large Victorian Houses, two of which have been extended at the back. It is set in extensive gardens. The home was originally provided specifically for people of the Jewish community, however it now also accommodates people who are not of the Jewish faith. The first building was known as the nursing unit, the second building as the residential unit and the third building as Fernlea.

The home is registered to accommodate up to 97 people at the time of the inspection 72 people were living there of whom 33 were receiving nursing care.

The home has 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.

We spoke individually with ten of the people living there. We spoke with nine relatives or visitors and with 12 members of staff who held different roles in the home. We examined a variety of records relating to people living at the home and the staff team. We also looked at systems for checking the quality and safety of the service.

We found breaches of regulations relating to the safety of the premises and systems for assessing and improving the quality of the service provided. You can see what action we told the provider to take at the back of the full version of the report.

Parts of the environment at Stapely were unsafe. This included fire doors that did not close correctly and windows that were unrestricted.

Work on refurbishing and improving the premises was on-going with recent work including replacing the boilers. Some parts of the home were of a high standard and other parts were shabby. A full refurbishment of the remainder of the home was planned to take place in phases with an eventual goal of the whole home being of a consistently high standard.

Systems for formally obtaining the views of people using the service and assessing the quality of the service were not always followed or effective at obtaining people’s views and ensuring the building was safe.

There were enough staff working at the home to meet people’s needs. Staff knew people well and had built good relationships with them. People living at the home and their relatives liked and trusted the staff team. They found them responsive and caring.

People received the support they needed with their personal and health care. They also received their medication as prescribed. People’s care needs were assessed and care plans were in place to guide staff on how to support people.

All meals were prepared and served to ensure they met kosher requirements. People liked the meals and received support to eat and drink when they needed it. Snacks and drinks were served regularly throughout the day.

Systems were in place and followed for dealing with concerns, complaints and potential incidents of abuse. People living at Stapely and their relatives felt safe living there and were confident to raise any concerns they had.

People’s ability to consent to their care and treatment had been assessed and support had been provided to safeguard people who lacked the ability to consent.

A number of activities took place at the home however some people living there would like to see these increased.

The home had a manager who was registered with CQC. The manager and the representative of the trustees had a detailed knowledge of the people living there and were a visible presence within the home. As the home has recently increased in size additional support for the registered manager would be beneficial in ensuring paperwork remained up to date and records were completed in a timely manner.

The inspection took place on the 27 April 2016 and was unannounced. Stapely Residential and Nursing Home (Stapley) is registered to provide accommodation for persons who require nursing or personal care.

At our last inspection in August 2014 we identified breaches of legal requirements. We issued the provider with compliance actions to meet the breaches. The breaches related to care and welfare and quality monitoring. At this inspection we found that the provider had improved quality monitoring systems.

The manager was registered with the Care Quality Commission. 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 and associated Regulations about how the service is run.

The home is registered to provide accommodation and care for up to 60 people, there were 60 people living at the home at the time of this inspection. The building is split into two units. The ground floor is for people who require nursing care. The first floor is for people requiring residential care.

We looked at records relating to the safety of the premises and its equipment, which were correctly recorded. We spent time conducting a full tour of the home; the basement area was not safe. It was used as a storage space for food freezers. The basement was also used as an office for the maintenance person.

People received sufficient quantities of food and drink and had a choice in the meals that they received. Their satisfaction with the menu options provided had been checked. Where people had lost weight this was recognised with appropriate action taken to meet the person’s nutritional needs; however two records checked were not fully completed to inform staff of the required food and fluid intakes consumed at the end of the day.

Menus were flexible and alternatives were always provided for anyone who didn’t want to have the meal on the menu for that day. People we spoke with said they always had plenty to eat. We observed the lunch time meal where staff were observed not to communicate with two people they were assisting to eat their lunch.

The provider had complied with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and its associated codes of practice in the delivery of care. We found that the staff had followed the requirements and principles of the Mental Capacity Act 2005 (MCA). Staff we spoke with had an understanding of what was their role was and what their obligations where in order to maintain people’s rights.

We found that the care plans and risk assessment monthly reviews records were all up to date in the six files looked at however there was limited information that reflected the changes of people’s health.

People were not having person centred activities provided by the provider to promote their wellbeing.

People told us they felt safe with staff and this was confirmed by people’s relatives we spoke with. The registered manager had a good understanding of safeguarding. The manager had responded appropriately to allegations of abuse and had ensured reporting to the local authority and the CQC as required.

Accidents and incidents were recorded and monitored to ensure that appropriate action was taken to prevent further incidences. Staff knew what to do if any difficulties arose whilst supporting somebody, or if an accident happened.

We found that medicines were managed safely and records confirmed that people received the medication prescribed by their doctor.

The staffing levels were seen to be adequate in all areas of the home at all times to support people and meet their needs and everyone we spoke with considered there were adequate staff on duty. However staff did not have time to provided activities or one to one stimulus to promote wellbeing.

The home used safe systems for recru

We received concerning information from a whistle blower in relation to the way a person was being communicated with by staff. There were issues around clothing inventories not being recorded appropriately and a person not wearing their own clothes. We were informed that the meals provided were in small portions.

We spent time talking to staff and five people living at Stapley Residential Home, looking at records and two care plans. We spent time walking around the home and observing staff interactions with the people living there.

We considered all of the evidence we have gathered under the outcomes we had inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

On the day of our visit we found the environment clean and fresh.

We saw adequate staffing on duty to meet the needs of the people living at the home and were told that a senior staff member or the manager was always available either working in the home or on call in case of emergencies.

A safeguarding policy and procedure was in place to advise staff what they should do if they suspected abuse and staff received regular training in safeguarding. We spoke to three staff members who all demonstrated a good understanding of types of abuse and how to protect the welfare of vulnerable people.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. Proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one. We discussed the Best Interests of people at the home and were told that the social services and staff would attend. The manager told us that no one currently residing at the home was subject to a DoLs authorisation.

Is the service effective?

People told us that they were happy with their care. We spoke with staff and found that they knew the people living in the home well. The people who lived at the home were given a choice as to how they lived their lives at the home. People's comments included, "Staff always treat us respectfully", "Staff are really good" and "Very nice staff".

Is the service caring?

We spent time in all areas of the home and saw and heard staff to be kind and patient to the people who lived there. We saw that the people who lived in the home were comfortable in the company of staff and happy to have a chat with them. One person told us, “I’m happy here, I would rather be in my own home but I’m not safe there".

We saw that workers were patient and gave encouragement when supporting people. Our observations confirmed this. One person told us about the staff, "They are really lovely".

Is the service responsive?

People's needs had been assessed before they moved into the home and were frequently reassessed whilst they lived there.

Records confirmed that people's preferences, interests, aspirations and diverse needs had been recorded, however we found little information was recorded in monthly reviews. Other professionals, such as speech and language therapists, continuing care and district nurses were involved in people’s care when necessary. We saw that relevant referrals were made to other professionals as and when required.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives. Stapley has direct links with the Jewish community and the majority of people living there are Jewish and attend services regularly. People of other faiths were supported to practice their religious observances. All of the people we saw appeared happy and content in the home and communicated well with staff.

Is the service well led?

The home had a registered manager in post which indicated that the person had undergone the relevant checks with the CQC.

Staff had a good understanding of the ethos of the organisation and quality assurance processes were in place. However no quality assurance surveys had been completed for the people living at the home or their relatives for over 18 months to inform and evaluate the service provision. The manager and senior staff undertook a range of quality audits that were in place to ensure that any risks to people's health, safety and welfare were identified and managed. However we found an identified risk assessment had not been acted on as required.

We were told that the members of the board of the service spend a lot of time in the home. People who lived in the home told us that they are always available for a chat.

We considered all of the evidence we have gathered under the outcomes we had inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Not sure if it really matters but for the sake of consistency across all reports I think we should have them in the order of safe, effective, caring, responsive well led as per the guidance

Is the service safe?

People were cared for in an environment that was safe. The nursing care situated on the ground floor required the domestic team to ensure lower level and above eye level cleaning was carried out. The rest of the home including the residential floors was clean and hygienic. Equipment at the home was well maintained and serviced regularly. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was always available on call in case of emergencies.

Staff personnel records we looked at for training, supervision and appraisal CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications had been made by the home, proper policies and procedures were in place. Staff were trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of people’s care and support needs and knew them well. One person told us. "I have all of my needs met wonderfully by the staff here. I could not be happier”. Staff had received training to meet the needs of the people living at the home.

Is the service caring?

We spent time in all areas of Stapley where we observed staff to be kind and patient to the people who lived there. Care staff and nursing staff were patient with people, asking them what they wanted and not telling them, but encouraging them in the right direction. One person told us “It’s a fantastic caring place and I wouldn’t want to be anywhere else”. A relative told us “The staff are very caring, I go home knowing my husband is so well cared for. It gives me a lot of comfort knowing this”.

Is the service responsive?

People’s needs were assessed before they moved into the home. People told us that all staff were very attentive and understood what was important to them. Records confirmed people’s preferences, interests, aspirations and diverse needs were recorded and care and support provided in accordance with people’s wishes. People had access to activities that were important to them and were supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. People told us they had completed a customer satisfaction survey, and if they were unhappy with anything staff would always listen. Staff told us they were clear about their roles and responsibilities. They said the management team and trustees always consulted with them before implementing changes to the management of the home and their views were taken into consideration. One member of staff said “We work as a team so all of the people living here have a good quality of life; we provide good care and would not tolerate bad practice”.

People who used the service and their relatives gave us good feedback about the service during our visit. People's comments included “It’s nice here the staff look after me well” and “The care has been excellent”. People told us they felt well supported with their personal care and their health care. People described staff as caring and they told us staff had responded quickly if they were feeling unwell.

Each of the people using the service had a care plan which provided a good description of the person’s needs and how to meet these. We saw some good examples whereby staff had requested specialist advice and support to meet people's needs.

We found there were enough care staff on duty to meet people’s needs in a timely manner. However the service was running with some staff vacancies which the manager was in the process of recruiting to fill.

The manager regularly checked on the standards of the home and the provider was in the process of making improvements to the systems for checking quality. People who used the service were asked their views on the home as part of the quality checks.

We spoke with a number of people living at the home and we observed the care and support people were being provided with. We also spoke with a number of visiting relatives. Overall the feedback from people living at the home and their relatives was that people were being provided with a good service.

People told us they felt well supported with their personal care and their health care. They also told us staff were respectful towards them and protected their privacy and dignity and their independence. Relative’s opinion on the care and support provided was similar and they also told us that they were kept informed about any changes to their relative’s needs.

Everyone we spoke with told us that they had a choice of meals and could request an alternative. Comments regarding the quality of the meals provided ranged from, “Fantastic food” and “Food is nice” to “I don’t always like it. We do get a choice”.

People told us they felt safe living at the home. One person commented “Yes, I’ve no worries now I live here”. People generally told us that they felt they could discuss any problems or concerns with staff or with the manager. One person explained, “If I had a complaint I would tell them and they would make it right”.

People living at the home and their relatives told us they felt the building was always kept clean. Their comments included, “They’re always cleaning” and “My room is spotless”. A relative of one person expressed the view that “The building is not great” but explained that they felt it was “Always kept clean and tidy”.

We saw that forthcoming activities were advertised on notice boards. A number of people were out in the afternoon attending a club. One person told us they were going to the local library later in the day and would be accompanied by a member of staff in the mini-bus. Another person told us that there were “often things like bingo” happening in the home. We saw that some of the people living at home and their visitors were enjoying an afternoon music sessions with a member of staff playing the guitar and singing.

People told us they felt there were enough staff available to meet their needs. One person explained, “There’s always someone about” and another told us staff “Always help me”.

People described staff as caring and they told us staff treated them with respect and dignity. People’s feedback was positive with comments such as "The staff are very good, they’re always smiling" and “They’re very helpful, nothing is too much trouble for them”.

Three people living at the home who require personal care said the staff were extremely respectful and did all they could to protect their dignity and privacy. One person accommodated for nursing care said the staff were respectful and kind.

Three people who live in the residential unit, and one relative, confirmed that the deputy manager, and the care staff, spent time with them, discussing their care and how they would like it to be given. One person on the nursing unit said that neither the manager nor the staff had discussed their care with them.

People living the residential unit said they received good care from a very efficient staff team. Two people in the nursing unit said that the care was generally good but this was dependent on which member of staff was providing that care.

One person living at the home said that the meals were not always hot and they had not been offered the opportunity to speak with the chef regarding their food preferences.

People spoken to said they felt safe in the home.Three people said that the home looked brighter since the redecoration but two people said that they hadn’t noticed any difference.

People said that they could not remember if they were given information about the service prior to being admitted. A relative said that the care plan had not been discussed with them but they trusted the staff. People living at the home spoke positively about the staff team.

We were contacted by Liverpool City Council who advised us of concerns regarding the decor and maintenance of the premises and also that concerns had been raised by Merseyside Fire Authority regarding the services failure to ensure the safety of the people accommodated at the home. They told us that concerns regarding the premises had been identified over a number of years and that the planned move to new premises had not taken place nor had the premises been improved during this time.