The inspection took place on 22 and 23 January 2019 and the first day was unannounced. At the last inspection in June 2018, we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to the safe management of medicines and good governance.

At this inspection in January 2019, while some improvements had been made we found on-going breaches of the regulations relating to the safe management of medicines and good governance. These concerns had been identified at the previous four inspections carried out in May 2015, January 2017, September 2017 and June 2018.

The overall rating for this service is ‘Requires improvement’ and the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 92 people living at the home, across eight units or households (the term used by people living there and staff). The ground floor households were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor, Dove Meadow and Park Acre and on the second floor, Etchells, Clover Field and Stoney Knowll, the latter provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. Stoney Knowll was a partnership arrangement between the provider and Manchester University NHS Trust (formerly the University Hospital of South Manchester).

The home is situated in a quiet residential area of Wythenshawe in south Manchester and set within its own grounds which include an accessible garden area and onsite parking. Bedrooms had en-suite facilities and there were communal bathrooms and toilets on each floor. Each household had its own lounge and dining area and a small kitchen.

The service had a manager who was registered with the Care Quality Commission (CQC) in January 2019. 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 Regula

The inspection took place on 6 and 7 June 2018 and the first day was unannounced. At the last inspection in September 2017, we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to person centred care, need for consent, safe management of medicines, training and professional support, governance systems and safe recruitment processes. We took enforcement action and served two warning notices in relation to Regulation 11 (need for consent) and Regulation 17 (good governance). In April 2018, we invited the provider to attend a meeting to discuss the action that would be taken to improve the service offered. We discussed their action plans for how these concerns would be addressed.

At this inspection in June 2018, we checked and found improvements had been made in the following areas: person centred care, need for consent, training and professional support and recruitment processes. However we found on-going breaches of the regulation relating to the safe management of medicines and good governance which had been identified at the previous three inspections carried out in May 2015, January 2017 and September 2017.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 96 people living at the home, across eight units or households (the term used by people living there and staff). The ground floor households were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor – Dove Meadow and Park Acre and on the second floor, Etchells, Clover Field and Stoney Knowll, the latter provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. Stoney Knowll was a partnership arrangement between the provider and Manchester University NHS Trust (formerly the University Hospital of South Manchester).

The home is situated in a quiet residential area of Wythenshawe in south Manchester and set within its own grounds which include an accessible

The inspection took place on 5, 7 and 8 September 2017 and the first day was unannounced. This meant the service did not know we were coming. At the last inspection carried out in January 2017, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to person centred care, need for consent, staffing which included training and supervision, governance systems and failure to display the current inspection rating. The service had not submitted an action plan to us (CQC) demonstrating how these concerns would be addressed. At this inspection in September 2017, we checked and found improvements had been made to remedy two of the breaches, namely, person centred care and display of current inspection rating. However we found ongoing breaches in governance, the need for consent and staffing which had been identified at the previous two inspections carried out in May 2015 and January 2017. In addition at the inspection in September 2017, we identified additional breaches of the regulations in relation to providing safe care and treatment and fit and proper persons.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

The Peele is a purpose built care home that is registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 69 people living at the home. Only six of the nine units or households (the term used by people living there and staff) were occupied. Households on the ground floor were Rushey Hey, Hollin Croft and Brinkshaw; on the first floor – Dove Meadow and Park Acre and on the second floor, Stoney Knowll – which provided intermediate care to people requiring short term rehabilitation usually following a hospital stay. The intermediate care household was a partnership arrangement between the provider and the University Hospital of South Manchester. The registered manager told us the partnership agreement had expired and there were discussions taking place regarding the future of this collaboration.

People’s bedrooms had en-suite facilities but there were communal bathrooms

The Peele is a purpose built home registered to provide care and accommodation for up to 108 older people. Accommodation is provided on three floors. At the date of this inspection seven of the nine units were in use, accommodating 66 people. One of those units was specialising in caring for people living with advanced dementia. The unit on the third floor was an Intermediate Care Unit (ICU) where people were receiving short term rehabilitation care. The Peele is in a residential area of Wythenshawe in south Manchester.

The inspection took place on 18 and 19 January 2017. The first day was unannounced, which meant the service did not know we were coming.

At the previous inspection in September 2015 we found two breaches of the regulation relating to safe care and treatment. An action plan was submitted on 21 March 2016. At this inspection we checked and saw that action had been taken to remedy the two breaches. However, we found four breaches of regulations at this 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. The Peele had a registered manager who had been in post since May 2016, but was absent on long term leave at the date of this inspection. There was an interim service manager who had been in post since 9 November 2016, who is referred to in this report as the interim manager.

People living in The Peele told us they felt safe and that there were always enough staff on hand to assist them. Each unit had enough staff and there were team leaders who moved between units. There were high levels of agency staff, although many of the agency staff were regularly at The Peele and knew the people well. There had recently been a recruitment drive with a view to reducing the number of agency staff.

There was a new system which enabled people who were at risk of falls to have both call buttons and pressure mats to alert staff if people got out of bed. This was an improvement on the previous inspection.

Proper procedures were carried out when recruiting staff. Staff were trained in safeguarding although some staff needed to update their training. There had been two significant safeguarding investigations during 2016 when the findings included criticism of the service in relation to agency staff and their lack of induction. Measures had been introduced to prevent a recurrence.

We found that careful records were kept of the management and administration of medicines. The Peele was using a new system in conjunction with a new pharmacy, which was working well. The building was well cleaned and smelled fresh.

Since the last inspection The Peele had created personal evacuation plans for use in an emergency and a file of these was kept at the front desk. The fire detection and prevention systems were regularly serviced and the security of the building was maintained.

Mental capacity assessments were not carried out to determine if people lacked capacity to make their own decisions. This meant the service was not adhering to the principles of the Mental Capacity Act 2005. This was a breach of the regulation relating to consent.

The Peele had made a high number of applications for Deprivation of Liberty Safeguards (DoLS) authorisations. We learnt that five applications had been granted although they had not yet been notified to us. The service was awaiting paperwork from Manchester City Council.

New staff completed the Care Certificate. Existing staff received training in core areas, but the uptake of this low. There had been a lack of supervision during 2016, although the interim manager intended to resume supervision during 2017. The low rates of training and the absence of supervision meant that staff were not being adequately sup

Two inspectors and an expert by experience carried out this inspection. Part of the purpose was to follow up an inspection in February 2014. That was a 'dementia themed' inspection which meant it focussed specifically on the provision and care for people living with dementia. On that occasion we found the service was not meeting two standards and we required the service to tell us how they were going to put them right. On this inspection we looked to see whether these standards were now being met.

We also looked at other standards, and followed up some information we had received from relatives.

At the date of our visit there were 103 people living at The Peele. We spoke with 19 people in different units, three relatives, two visiting professionals and seven members of staff. The registered manager showed us round the building and discussed issues with us. We looked at care plans and other documents.

We considered all the evidence we had gathered and used it to answer five key questions:

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. The evidence supporting these findings can be found under our judgements for each standard.

Is the service safe?

On the two Intermediate Care units people were being encouraged to regain their mobility and their independence so that they could return home or to their previous environment. This meant they were undertaking physical exercises. We observed that there were plenty of trained staff around to ensure these exercises were done safely. We saw one person being encouraged to walk up a staircase, and staff stayed behind him to make sure he would not fall. We spoke with one person on the Intermediate Care Unit who said: "Yes, I do feel safe here."

On the residential units people were looked after in a safe environment. One person told us that they "definitely feel safe".

Staff knew about safeguarding procedures and told us they would have no hesitation in reporting the matter if they had any concerns about a person's safety or felt they were being abused in any way. We saw from our own records that the manager reported safeguarding incidents appropriately.

The CQC monitors the operation in care homes of the Deprivation of Liberty Safeguards (DoLS). At The Peele there was one person for whom a DoLS authorisation had been applied for at the time of our visit. We read the paperwork relating to this and saw that the correct processes had been followed.

Is the service effective?

We spoke with staff who were knowledgeable about people's care and support needs. We looked at a sample of people’s care plans and saw evidence which showed, where possible, people had been involved in developing their care plans. This meant they received care and treatment in a way they preferred. The service had developed training for staff working with people living with dementia.

Is the service caring?

One relative had written: "The quality of care given to all the residents never ceases to amaze me, and that is the point: the care, kindness, compassion, warmth and patience to all." Another relative had recorded: "I only have the highest praise for the staff of The Peele. Their selfless effort to care for my father I will always remember."

Is the service responsive?

The manager had responded positively to a number of criticisms in our last report. We saw that changes had been implemented. We saw evidence that the service responded to the needs of individuals. When a person had not been well settled, the manager had recently moved them to a different unit.

A visiting professional told us: "The home is very responsive to meeting people’s needs. The staff keep me informed of how people are and will request a review if they feel a person’s needs have changed."

Is the service well led?

The registered manager had made a number of significant changes since arriving fifteen months earlier. We saw that there was a good system of delegating responsibility to team leaders, who each managed a group of carers. We spoke to several team leaders who had a good understanding of their role.

The manager had acted decisively in relation to two incidents involving staff behaving inappropriately.

One member of staff told us: "We have very good management – you can go and speak with them at any time. You get very good support and it is a well led service."

We visited The Peele on 11 February 2014. Three inspectors, one "specialist dementia adviser" and one "expert by experience" supported the inspection. At the time of our visit there were 97 people living at The Peele. We were informed that although there was a specialist dementia unit (Littlewood unit) many of the people living at the home had some form of dementia.

We saw staff being supportive, patient and kind to people living with dementia. We observed staff treat people with respect and maintain their dignity. In particular staff were seen to speak with people respectfully, pleasantly and to preserve their dignity when providing personal care and support.

We found that people were supported by other health care professionals such as psychiatry teams, occupational therapists and speech and language therapists and that both management and staff had good relationships with these health care providers.

We found that many of the records relating to people living with dementia required more 'dementia specific' information recording for example, assessments and personal background information.

We found that staff did not always have time to interact with people on a one to one basis with little cognitive stimulation taking place for people living with dementia.

Sufficient monitoring was not in place to ensure people living with dementia received a quality service.

We found the service was not effectively meeting the full range of needs of people living with a dementia.

This inspection took place on 2 and 3 September 2015. The first day was unannounced which meant the service did not know we were coming that day. The second day was by arrangement.

At the previous inspection on 18 June 2014 we had found the service to be compliant with the regulations we looked at.

The Peele is a purpose built home registered to provide care and accommodation for up to 108 older people. At the time of this inspection there were 103 people in residence. Accommodation is provided on three floors, in nine units. There are three units per floor. Seven of the units provide residential accommodation. Two of those units are intended for people living with dementia. Two units on the second floor are Intermediate Care Units (ICUs) where people receive short term rehabilitation care. These units are part of The Peele but some of the staff are employed by the NHS. The Peele is in a residential area of Wythenshawe in south Manchester. It is set in its own grounds and has a car park.

Since our previous inspection The Peele had acquired a new registered manager who had been in post since January 2015. 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 2008 and associated Regulations about how the service is run.

Following a safeguarding investigation earlier in the year, about 60 pressure mats were in use, which would alert staff if someone got out of bed. Because of the wiring call bells and pressure mats could not be used together in the same bedroom. This meant that someone who needed assistance might be prevented from calling for help. This was a breach of the regulation about providing safe care and treatment.

There had been concerns about the security of the building. We found that access was not always monitored. Recommendations made in a report by the police had not been implemented. We recommended that the provider review the security of the premises.

We saw that fire prevention and detection equipment was maintained. However, there were no Personal Emergency Evacuation Plans (PEEPs) to assist the emergency services in the event of an evacuation. This was a breach of the regulation about providing safe care and treatment.

In relation to the breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, you can see what action we have told the provider to take at the end of the full version of the report.

There had historically been a high number of medication errors. Steps had been taken to reduce those. We looked closely at the process of administering medicines. We noticed that some further improvement was needed, but considered that given the size of The Peele the errors did not mean the regulation about the safe management of medicines was being breached.

We found evidence that in the recent past medicines may have been administered covertly without proper authorisation. But this was not happening currently.

We were satisfied that staffing levels were adequate. There had been a high usage of agency staff especially nurses on the ICUs, but this had reduced. Methods were used to ensure that suitable staff were employed. Staff were trained in safeguarding. The registered manager had reported safeguarding incidents and had dealt with disciplinary incidents robustly.

Records were kept of accidents and incidents and steps were taken to improve safety.

Some staff had been trained in the Mental Capacity Act 2005 and in the Deprivation of Liberty Safeguards (DoLS). Applications for DoLS authorisations had been made.

There was a comprehensive programme of training. Some gaps had been identified, especially in moving and positioning, and staff were booked onto training courses. Supervision and appraisals were taking place.

Food was prepared by a commercial catering company within the building. People needed to choose from the menu the day before. This meant that some people were unhappy when their food arrived. In some of the units no drinks were provided with lunch. We found no problem with the nutritional value of the food being served. However, we recommended that the dining experience could be improved.

There was good access to health professionals. We recommended that the building environment, especially for people living with dementia, should be improved.

People were mostly very satisfied with the quality of care received. We heard one complaint about laundry getting lost but the registered manager explained how the problem was being addressed.

Staff behaved respectfully towards people and we witnessed an example of excellent practice in defusing tension between two residents. Measures were taken to maintain people’s independence as far as possible.

The Peele was signed up to a programme to enhance end of life care. We saw a tribute paid to staff for their care and compassion when one resident had died.

Care plans were thorough and individualised to people’s needs. Most care plans were reviewed regularly although we came across examples where those reviews had not taken place. Care notes on the ICUs were of a high standard.

Detailed daily notes were made to record people’s health and wellbeing.

Activities were offered to those who were able to and wanted to take part. One of the activities organisers also ensured that toiletries were available to everybody. Residents’ meetings took place so that people could be involved in decisions about the home.

There was a system for recording and responding to complaints. There had been fewer complaints during 2015 than the previous year.

Most people were satisfied with the management of the home. The registered manager had been in post since January 2015 and was due to move on in January 2016.

The team leaders were in responsible positions and people spoke highly of their abilities.

The provider had a vision for developing the service which the registered manager had shared with staff. There were staff meetings every three months.

Regular detailed audits were undertaken both by the registered manager and by staff from the provider’s head office. We saw that action plans were implemented.

The registered manager had reported incidents to the CQC and had co-operated with safeguarding investigations led by the local authority.