The inspection took place on 17 and 18 September 2018. The first day of the inspection was unannounced, on the second day of inspection the manager, staff and people knew to expect us. The Martlets is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Martlets is situated in East Preston in West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. The Martlets is registered to accommodate 80 people. At the time of the inspection there were 58 people accommodated in one adapted building, over three floors, which were divided into smaller units comprising of ten single bedrooms with en-suite shower rooms, a communal dining room and lounge. These units provided accommodation for older people, those living with dementia and people who required support with their nursing needs.

The home did not have a registered manager. A registered manager is a ‘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 home is run. Since the previous inspection on 29 and 30 January 2018, the registered manager had left. A manager from one of the provider’s other homes had been managing The Martlets for six months and was in the process of applying to become registered manager. The management team consisted of the manager, a deputy manager, a clinical lead and team leaders. An operations manager also regularly visited and supported the management team.

At the previous inspection on 29 and 30 January 2018 the home received a rating of ‘Requires Improvement’ for a third consecutive time. The provider was found to be in breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following the last inspection, the provider completed an action plan. This informed us of what they would do and by when to improve the key questions of safe, effective, responsive and well-led to at least good.

There were concerns with regards to the management of medicines. There were sometimes insufficient stocks of medicines. People, who required their medicines to be administered at specific times, consistently had their medicines late. There was a lack of guidance and inconsistent information to inform staff’s practice in relation to when to administer ‘as and when required’ medicines.

Records for people who had been assessed as being at high-risk of developing pressure wounds and those that required their fluid and food intake to be monitored, were not completed accurately. It was not evident if people had received appropriate care or if staff had failed to document their actions.

Assessments and reviews, to ensure that the guidance provided to staff was up-to-date and met people’s current needs had not always been completed in a timely way.

There was a lack of understanding about the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People had mixed experiences with regards to stimulation and meaningful activity to occupy their time.

Complaints that had been raised had not always been dealt with in accordance with the provider’s policy. There was a lack of stimulation, interaction and engagement to occupy people’s time.

There were concerns about quality assurance procedures and oversight. Feedback about the leadership and management was poor. Audits had not always identified the shortfalls that were found at inspection. When these had been identified, there had not been sufficient action to ensure improvement.

At this inspection, it was evident that the management team and staff had worked hard to implement improvements. Feedback about the leadership and management of the home was overwhelmingly positive. There was a positive, welcoming atmosphere.

The inspection took place on 29 and 30 January 2018. The first day of the inspection was unannounced, on the second day of inspection the registered manager, staff and people knew to expect us. The Martlets is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Martlets is situated in East Preston in West Sussex and is one of a group of homes owned by a National provider, Shaw Healthcare Limited. The Martlets is registered to accommodate 80 people. On the first day of inspection there were 69 people and on the second day of inspection there were 71 people which accommodated in one adapted building, over three floors, which were divided into smaller units comprising of ten single bedrooms with en-suite shower rooms, a communal dining room and lounge. These units provided accommodation for older people, those living with dementia and people who required support with their nursing needs. There were gardens for people to access and a hairdressing room.

The home had a registered manager. A registered manager is a ‘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 home is run. The management team consisted of the registered manager, a unit manager, a clinical lead and team leaders. An operations manager also regularly visited and supported the management team.

At the previous inspection on 6 and 19 December 2016 the home received a rating of ‘Requires Improvement’ and was found to be in breach of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following the last inspection, we asked the provider to complete an action plan to inform us of what they would do and by when to improve the key questions of safe and well-led to at least good. This was because there were concerns with regards to the management of medicines. Areas in need of improvement related to the deployment of staff and the timeliness of assessments when people’s needs changed, incomplete records to document the care people had received and ineffective audits that had not always identified the shortfalls that were found at the inspection. At this inspection we continued to have concerns and the registered manager was found to be in breach of the regulations.

People did not always receive their medicines on time and systems to improve this demonstrated a service that was not person-centred. Records to document the administering of medicines were not always complete and did not always reflect the actions of staff. In addition, guidance to inform staff’s practice on the administration of ‘as and when required’ medicines was not always consistent. The management of medicines was an area of practice that continued to be a concern.

People’s needs were not always assessed nor care plans devised in a timely manner to ensure that staff were aware of people’s needs and preferences. When there were changes in people’s needs, care plans and risk assessments were not always reviewed to reflect the changes to ensure that people were provided with appropriate care to meet their current needs. Care plans lacked detail, particularly in relation to people’s social and emotional needs. People’s life history, background and preferences were not documented to inform staff and did not provide an insight into people’s lives before they moved into the home.

Some people, particularly those who were less independent, spent large amounts of time with very little stimulation or interaction with staff, other than when providing support to meet their basic care needs. Although sufficient staff to meet people’s physical needs, the provider had not ensured that staffing levels enabled staff to spend quality time with people, engaging in meaningful conve

The Martlets is registered to provide accommodation and nursing care for up to 80 people. The service supports people who have nursing needs, older people and those living with dementia. On the day of our inspection 71 people were living at the home.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (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 and associated Regulations about how the service is run.

At our last inspection to the service in November 2015 we found two breaches of regulations. We found the service did not have sufficient staff to support people effectively and the registered person did not ensure the care and treatment of people was person centred. We asked the provider to take action and the provider sent us an action plan in December 2015 which told us what action they would be taking.

At this inspection we found that improvements had been made to safe staffing levels. However, further improvements were needed to ensure that staffing deployment would be based on changes in people’s dependencies. The registered manager told us that staffing levels were in accordance with people’s dependency levels. However not everyone’s dependency levels had been assessed if their needs had changed so it was not possible to establish what the correct staffing levels should be. We have made a recommendation that the provider establish dependency levels of people who's needs had changed in order to ensure staffing levels remain safe.

At this inspection we found improvements to person-centred care had been made and the requirement was now met.

The arrangements for managing medicines (including obtaining, prescribing, recording, handling, storing, security and disposal) did not always keep people safe.

People told us they felt safe. Relatives told us they had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm. Risk assessments were in place to help keep people safe and these gave information for staff on the identified risk and guidance to mitigate the risks. Safe recruitment practices were followed and recruitment procedures ensured only those suitable to work in care were employed.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There were 29 people living at the home who were currently subject to DoLS. The registered manager understood when an application should be made and how to submit one. We found the provider to be meeting the requirements of DoLS. People were generally able to make day to day decisions for themselves. The registered manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.

Staff had undertaken training to ensure that they were able to meet people’s needs. The provider supported staff to obtain recognised qualifications such as Qualifications and Credit Framework (QCF). or Health and Social Care Diplomas (These are work based awards that are achieved through assessment and training. To achieve these awards candidates must prove that they have the ability to carry out their job to the required standard). All staff completed an induction before working unsupervised. Staff had completed mandatory training and were encouraged to undertake specialist training from accredited trainers. Staff received regular supervision and monitoring of staff performance was also undertaken through staff appraisals.

Each person had a plan of care which was person centred and provided staff with the information they needed to support people. However new

This was a follow- up visit to check compliance with staffing levels as the home had not been compliant at our last inspection of May 2013. The home on this occasion was compliant.

We spoke with people who told us they were happy with the care in the home. They also confirmed that they participated in activities and outings at the home. One relative told us that their family member had enjoyed lunch in the garden and a trip to a garden centre recently. One person told us "They [staff] try to keep you smiling".

Care staff had been redeployed to improve care worker numbers with the people. The home had a recruitment drive and had recruited 10 new care staff. This would reduce homes reliance on agency staff.

We spoke with eleven people, four staff, the manager, the clinical lead and one relative. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person told us "Staff always explain what needs to be done". Another person told us "I get asked about care and treatment and I could refuse if I wanted to"

We saw evidence that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

A pharmacy inspector saw evidence that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

There were not enough qualified, skilled and experienced staff to meet people’s needs. People told us there was often not any staff in the sitting room so they had to wait for assistance. During our SOFI observation we saw that for some people there was not any staff interaction for long periods of time.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

We observed care, spoke with eight people in the home, four relatives, five staff and the manager. We looked at care records for eight people. People told us they were happy with the care in the home.

We spoke with four relatives who were all happy with the care but one expressed some concerns regarding pressure relieving equipment use. Another told us that the home was always asking his family member about wishes in relation to food and bathing habits and that they were very good at dealing with any challenges.

A social work professional visiting to review one of the people living in the home told us that they were very happy with the persons care in the home and that the relatives who were also in attendance for the review were very pleased with their family members progress.

There were enough qualified, skilled and experienced staff in the home to meet people’s needs.

The home was clean and warm and has units painted in different colours to help people know where they are in the home.

The Martlets is a purpose built care home providing accommodation, nursing and personal care for up to 80 older people, some of whom are living with dementia. It is set out over three floors. The ground floor is for older frail people, the first floor is for people living with dementia, and the second floor is for people who require nursing care. Each person had their own en-suite bedroom including toilet and wet room and each floor included a comfortable lounge and dining area. Everyone had free access around their floors and people on the ground floor were also able to access the garden area and to go out into the local community. For people living on the first and second floor staff assistance was required to go into the garden or to leave the premises. The Martlets is situated in East Preston West Sussex.

The person currently managing the home had not yet registered with the Care Quality Commission (CQC). They have submitted an application applying for registration but this has not yet been processed. We have referred to this person as ‘The manager’ throughout the report. 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.

Staffing levels were not maintained at a level to meet people’s needs at all times. People and staff told us there were not enough staff on duty and we observed that at times there were not sufficient staff available to provide timely support to people.

People told us they felt safe. They had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm. Appropriate recruitment checks were carried out to check staff were suitable to work with people.

Care records contained risk assessments to protect people from any identified risks and helped to keep them safe. These gave information for staff on the identified risk and guidance on reduction measures. There were also risk assessments for the building and contingency plans were in place to help keep people safe in the event of an unforeseen emergency such as fire or flood.

People were supported to take their medicines as directed by their GP. Records showed that medicines were obtained, stored, administered and disposed of safely

Staff were supported to develop their skills by receiving regular training. The provider supported staff to obtain recognised qualifications such as National Vocational Qualifications (NVQ) or Care Diplomas. A number of staff had completed training to a minimum of (NVQ) level two or equivalent. People were well supported

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager and staff understood their responsibilities in this area and acted in people’s best interests if they did not have capacity to consent to their care and support.

People were satisfied with the food provided and said there was always enough to eat. People had a choice at meal times and were able to have drinks and snacks throughout the day and night. Meals were balanced and nutritious and people were encouraged to make healthy choices. However some people told us that due to the time taken to deliver meals food was tepid or cold.

Staff supported people to ensure their healthcare needs were met. People were registered with a GP of their choice and the manager and staff arranged regular health checks with GPs, specialist healthcare professionals, dentists and opticians. Appropriate records were kept of any appointments with health care professionals

People told us the staff were kind and caring. Relatives had no concerns and said they were happy with care and support their relatives received. Staff respected people’s privacy and dignity and staff had a caring attitude towards people.

Before anyone moved into the home a needs assessment was carried out. However only three people knew a care plan had been prepared for them and only one person said they were included in their development.

People’s care plans provided information for staff on how people should be supported. However care plans were task orientated and not person centred. There was little or no evidence that people were consulted and involved in the planning of their care so people were not always involved. This meant that care may not always be delivered in the way they preferred.

We observed a range of activities taking place for people and there were three activity co-ordinators employed. A weekly activity plan and timetable was displayed on each floor of the home,

People told us the manager and staff were approachable. Relatives said they could speak with the manager or staff at any time. The manager operated an open door policy and welcomed feedback on any aspect of the service. Regular meetings took place with staff, people and relatives.

The provider had a policy and procedure for quality assurance. The manager and senior staff carried out weekly and monthly checks to help to monitor the quality of the service provided. Quality assurance surveys were sent out to people, relatives and staff each year by the provider to seek their views on the service provided by The Martlets.

We found two 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.