This inspection took place on 7 and 9 March 2018. The first day of the inspection was unannounced. The last inspection took place on 14 December 2016 and four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. This was because the administration of medicines was not undertaken in line with best practice and the quality of person centred information was not consistent within people’s care plans. In addition, risk assessments were not sufficiently detailed to ensure safe care and the decision making process for people who lacked capacity to consent, was not in line with legislation. Following the inspection, the provider submitted an action plan to show how the shortfalls would be addressed.

At this inspection, the majority of shortfalls had been addressed but further work was required in some areas. This meant the service had not been compliant with regulation since the registered manager gained their position in 2015. Other shortfalls were identified in 2014 and 2013. Whilst there was a quality auditing system in place, this had not identified all shortfalls noted at this inspection.

The Old Parsonage 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. The service is registered to provide personal care and accommodation and treatment of disease, disorder or injury for up to 22 older people with dementia or other associated mental health needs. At this inspection 18 people were living at the home. The service was run by Roseville Care Homes (Melksham) Limited.

The Old Parsonage accommodates people in one building. People's bedrooms were located on the ground and first floor with communal toilets and bathrooms. A small passenger lift was available to enable easier access. There were two communal lounges and separate dining room. The kitchen and laundry room were located on the ground floor.

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. The registered manager was available throughout the inspection. A regional manager was present on the first day.

Risks to people’s safety had not always been identified and addressed. For example, one person’s risk of choking had not been reassessed after a recommended action had not been successful. Other records gave conflicting information about the use of thickeners and the texture of people’s food.

All care plans were being transferred to a new electronic system. However, this process was not complete and some information was insufficient in detail. The electronic system had generated some formats but these were not accurate and did not clearly inform staff of the support the person required. The lack of person centred information was identified at the last inspection.

People were able to personalise their bedrooms but the environment was not reflective of recognised dementia care. This was because flooring and décor were similar in colour and there was limited texture or stimulation to gain people’s attention as they walked around.

Some areas of the home had marks on the walls and there were stains on the stairs carpet. The windows on the first floor were fitted with restrictors to reduce the risk of people falling from height. However, the restrictors were made of thin chains, which did not meet current health and safety guidance. Staff had opened the windows in some bedrooms and on the corridor on the first floor. These were still open at 17.00, which made some areas of the home cold.

Less visible areas of the home

The last inspection of this service took place in August 2015 and at that time, two breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to training and recruitment.

At this inspection we found four new breaches of regulations. The previous breaches from the last comprehensive inspection in August 2015 had not been repeated. The five new breaches were in relation to good governance, safe care and treatment, need for consent and person centred care.

The Old Parsonage provides accommodation and care, including nursing care, for up to 22 older people who have dementia and other associated needs in relation to their mental health. On the day of our inspection, there were 19 people living at the home.

There was a registered manager in place at the time of our inspection; 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.

Overall we found that quality and safety monitoring systems were not fully effective in identifying and directing the service, to act upon risks to people and ensuring the quality of service provision.

The administration of people's medicines was not in line with best practice.

Care plans were not all person centred. Peoples' risk assessments and the associated parts of the care plan did not provide adequate detail to enable safe and effective care.

Monitoring of peoples’ fluid intake was not completed effectively.

Staff we spoke with had a variable understanding of the Mental Capacity Act 2005 and DoLS. There were no examples of best interest decision making on behalf of people who lacked capacity to agree to the delivery of their care.

The registered manager had made applications for Deprivation of Liberty Safeguards (DoLS ) where they had been assessed as being required. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely.

Staff had received regular supervision and training.

The staff had received training regarding how to keep people safe and they were aware of the services’ safeguarding procedures.

People had access to healthcare professionals and records demonstrated that the service had made appropriate referrals when there were concerns.

There were enough staff to meet peoples' needs. We received positive feedback about the care staff and their approach with people using the service.

Recruitment procedures were followed appropriately. The provider had a complaints procedure and people told us they could approach staff if they had concerns.

The registered manager had made appropriate statutory notifications. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

We found four breaches of regulations at this inspection and will be asking the provider to send us a report of the improvements they will make.

People told us they liked living in the home and felt cared for. One person said “the girls are so nice to me here.” A visitor told us they were “quite impressed by the amount of care” given to their relative. We saw staff managed people who experienced challenging behaviours, in a safe, appropriate manner.

The home had made many improvements in hygiene. This included installing a sluice room and refurbishment of both cleaners’ cupboards. The home now smelt fresh and looked clean. All of the equipment used in the delivery of care we looked at was clean, with intact wipeable surfaces.

The provider had taken full action to ensure fire safety in the premises. This was following reports and visits from the local fire and rescue service.

Some records used in care were not dated and signed to show they were current. Some matters relating to people’s nursing and care were known to the staff. However people’s care plans had not been up-dated to show this information so all staff could be made aware of relevant matters about people’s nursing and care.

Staff respected people’s dignity and encouraged them in being independent. A person told us they liked to have their meals in their own room. They said care workers always brought their meals to them there.

People had care plans about their dementia and other needs. One person commented on how staff “notice if you look tired.” There was a lack of consistency in care planning, particularly relating to people’s physical and nursing care needs. This included systems for prevention of pressure ulcers.

People told us they liked their meals, describing them as “very good”. A meal we observed was calm and organised. The provider had made improvements in the home’s staffing levels. This included there being enough staff to support people when they heeded help at mealtimes.

The home did not have appropriate systems to ensure cleanliness of the environment and equipment. We saw a range of issues which we had also identified at the last inspection such as the cleaning of commodes. Cleaning schedules had been put in place but they did not include all relevant areas. Some areas such as the suction machine had a record to show it had been cleaned when it had not been left clean and dry.

The new manager had begun to put processes in place to improve the system for reviewing the quality of the service provided. These included a review of the home’s procedures and development of audits for such areas as incidence of falls.

People told us they liked living in the home. One person told us “I like it fine”. A relative told us “It’s a very nice place” and another described the staff as “very good here”. We observed staff consistently treated people with respect.

Records of people’s care needs were clear and completed at the time care was given. Staff worked with people and their relatives to gain consent to care. This was not documented, so full assessments of capacity were not in place.

The home did not have adequate systems for cleansing of items used in care, such as commode inserts. Staff did not have access to current guidelines on prevention of spread of infection.

The provider is making many improvements to the home environment. However certain areas, particularly checks on fire safety precautions had not been addressed.

The provider did not have systems to take the dependency of people into account when setting staffing levels. This meant some people did not receive the support they needed including at mealtimes, the provision of recreational activities and supporting frail people in the sitting rooms.

The provider did not have written systems to review quality of care and treatment in the home. This meant some risk factors were not identified and relevant action taken. This included having relevant and up-to-date policies and procedures to support people’s care and treatment.

We were told before our visit that staff at the home were using unsafe manual handling techniques to move people rather than using equipment such as a hoist. The person raising concerns stated that care plans did not identify people’s moving and handling needs. They said there were also problems with the hot water systems. This meant staff had to take bowls of hot water to people’s bedrooms rather than using hand wash basins. The person alleged there was a bed rail which was tied together, which created a health and safety hazard.

Within our visit, we found evidence to support the above concerns. Whilst all staff had received up to date training in the safe handling of people, unsafe techniques were being used. Not all care plans were up to date and there was conflicting information about people’s manual handling needs. Building work had affected the home’s hot water temperatures and in some bedrooms staff were providing people with bowls of hot water rather than using their hand wash basins. One person had a bed with a broken bed rail. The manager told us a new bed had been purchased, which was awaiting assembly by the home’s maintenance person.

Due to their dementia, people were unable to give us detailed feedback about the service they received. Some people told us they liked the staff. One person told us they were “quite happy” and the meals were good.

Whilst looking at care plans, we found that the information lacked clarity. The plans did not describe the support people needed to meet their needs. Within one care plan, documentation about a wound and its management was very limited. Inadequate record keeping, particularly in the area of wound care was identified at our last review. Due to this, we set a compliance action to ensure the provider makes improvements in this area.

Due to people’s frailty and their dementia, we were not able to talk to people about the care they received. We saw however, that people looked relaxed and comfortable within their surroundings. People were well dressed with coordinated clothing, clean nails and freshly brushed hair.

At our last review of this service, we identified a number of shortfalls within the care provided to people. People were placed at risk through the inadequate management of behaviours that challenged. They did not have bumpers on their bed rails so their safety was compromised due to potential entrapment. There was also a risk of error with people’s medicines as staff were not consistently following the policies and procedures, which ensured the safe management of medicines. People’s dignity was compromised as their preference of receiving intimate personal care by either a male or female member of staff had not been identified.

At this review, we noted that improvements had been made to all of the above areas. Staff had received training in abuse awareness, challenging behaviour and the safe handling of medicines. People’s care plans had been updated to include strategies to manage challenging behaviour more effectively. People had been asked about their preferences of having a male or female carer to support them. This was recorded in care plans so that staff were fully aware of people’s individual wishes. People’s risk of injury due to their bedrails had been significantly reduced, as bumpers had been purchased and were now in place.

Due to their frailty and health care conditions, people were not able to tell us about their experiences of the service they received. We therefore spent the majority of our time, observing people’s general wellbeing and the interactions they had with people around them.

We saw that people were generally relaxed and content within their surroundings. People appeared comfortable and well groomed with fresh, well laundered clothing and clean hair and finger nails. We saw that two people were being supported in bed. They looked comfortable and had received regular support to maintain their personal hygiene needs and to minimise their risk of developing a pressure sore. One person displayed challenging behaviour, which presented an element of risk to others.

Some people received good interactions from a staff member when being supported to make cakes. At other times, interactions and general stimulation were more limited. Some people spent periods of time asleep within the lounge.

There was a long delay in serving lunch and the ways in which people chose their meal was not conducive to their needs. We saw that people enjoyed their lunch, which was fresh, homemade and appetising. People had regular drinks throughout our visit but did not have a choice of what they had.

People had the required equipment to meet their physical needs. Staff used the equipment correctly and explained its use to people when supporting them. People’s environment had been enhanced through the refurbishment of two bathrooms. The refurbishment had been undertaken to a high standard. Some people did not have bumpers on their bedrails. This increased people’s risk of injury through entrapment when using the rails.

This inspection took place on 26 and 27 August 2015 and was unannounced. Our last inspection to the service was in December 2014. This was a follow up inspection and shortfalls in care planning, decision making and respecting people were identified. At a previous inspection in June 2014, all eight areas we looked at were non-compliant with significant shortfalls. The provider was also non-compliant at an inspection in March 2014 with all six areas looked at. Due to the significance and severity of the on-going failures to meet the required standards, we took enforcement action in terms of warning notices and a notice of proposal to cancel the provider’s registration. At this inspection, improvements had been made. However, these improvements need to be sustained over a period of time and in conjunction with full occupancy at the home.

The Old Parsonage provides accommodation and care, including nursing care, for up to 22 older people who have dementia and other associated needs in relation to their mental health. On the day of our inspection, there were nine people living at the home. The Old Parsonage has bedrooms on the ground and first floor. A passenger lift is available for people with mobility difficulties. There are two communal lounges, a smoking lounge and separate dining room.

The registered manager worked at the home as a registered nurse and deputy manager before gaining promotion as the manager. They became the registered manager in June 2015. 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 present throughout the inspection.

The registered manager was passionate about good quality care and ensuring improvement. They had a clear action plan and during their time as registered manager, had worked with staff to implement various management systems, develop the culture of the home and improve care practice. The registered manager told us a clear, staggered programme would be in place for all new admissions to the home. They said this would enable improvements already made, to be sustained.

As there were nine people using the service, the numbers of staff on duty were sufficient. Staff answered call bells in a timely manner and other than on one occasion, people did not have to wait for assistance. The registered manager was aware that further staff would be required, once occupancy increased. They were in the process of recruiting additional staff for this purpose.

Improvements had been made to the information held about people. All care plans had been rewritten and were detailed and person centred. There were care charts and a brief summary of each person’s support and preferences in their bedroom. All charts were fully completed. However, not all demonstrated additional fluids were given to those people with a low fluid intake. Wound care was not clearly evidenced and the assistance one person received to change their position was not accurately recorded.

Staff were aware of their responsibility to raise a suspicion or allegation of abuse. Staff felt well supported and had received formal one to one supervision sessions to discuss their role. All staff had undertaken a high level of training in relation to core subjects. This included topics such as moving people safely and keeping people safe. Further training to enhance the clinical skills of staff was also being investigated.

Records did not evidence a robust recruitment procedure. This did not ensure new staff were suitable nor had the appropriate skills to undertake their role effectively. Staff told us the induction process of new staff had improved although a robust system was not demonstrated within personnel records. The registered manager confirmed they would look into these areas.

There were many positive interactions between people and staff. Staff spoke to people in a caring, friendly and respectful manner. They involved people in interactions such as using the hoist and encouraged decision making. Staff were attentive whilst supporting people with their mobility and whilst giving assistance to eat. However, many interactions were task orientated and happened because of a reason. During the inspection, other than an old film, there was little social activity people could participate in. Some people received little stimulation. The registered manager told us social activity was an area they wanted to develop.

There were complimentary comments about the registered manager and the effect they had had on the service since their appointment. Organised management systems had been developed. This included clear auditing and regular analysis of incidents and accidents. This information had been used to change practices and enhance people’s wellbeing. People, their relatives and staff had been asked to give their views about the service provided. This was informally through discussion and more formally by completing questionnaires. Whilst an overview of the findings from the questionnaires was not in place, issues raised had been considered and acted upon.

People looked well supported and were relaxed in their environment. Relatives told us they were happy with the care provided and their family members were safe. They were aware of how to raise concerns and were positive that any issues would be quickly addressed.

People were supported to eat a balanced diet and received snacks between meals. People were offered a choice of food with regular drinks throughout the day. Photographs of food were being taken to enable people to make their choice more easily. Those people at risk of malnutrition were regularly monitored and had supplement drinks to enhance calorie intake.

People received their medicines in a safe and unrushed manner. Records showed that people had taken their medicines as prescribed. People received intervention from a range of health care professionals to meet their health care needs.

You can see what action we told the provider to take at the back of the full version of the report.