This inspection took place on 7 and 8 August 2018 and was unannounced.

Troutbeck Nursing Home 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 care home can accommodate up to 54 older people and older people living with dementia in one adapted building. Accommodation is provided over two floors. At the time of our inspection, 29 people lived at the service.

At this inspection we found some improvements had been made to the administration, recording and storage of medicines. This meant the service was no longer in breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. However, further improvements were needed to the documentation of prescribed creams.

The registered manager had recently left the service and a new manager had been in position for three weeks at the time of our inspection. They were planning to register with the 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 2008 and associated Regulations about how the service is run.

Staff were being recruited safely and there were generally enough staff to take care of people. However, we have recommended that the manager reviews staffing levels and deployment of staff. Staff were receiving appropriate training and they told us the training was good and relevant to their role. Staff were supported by the manager and were receiving formal supervision where they could discuss their ongoing development needs.

People who used the service and their relatives told us staff were helpful, attentive and caring. We saw people were treated with respect and compassion.

Care plans were generally up to date and detailed what care and support people wanted and needed. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified. People felt safe at the home and appropriate referrals were being made to the safeguarding team when this had been necessary.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare needs were being met and medicines were mostly being stored and managed safely.

Staff knew about people’s dietary needs and preferences. People told us there was a good choice of meals and said the food was very good. There were plenty of drinks and snacks available for people in between meals. The completion of food and fluid charts needed to be improved.

Activities were on offer to keep people occupied both on a group and individual basis. Visitors were made to feel welcome and could have refreshments at the home if they wished.

The home was spacious, well decorated, generally clean and tidy. All of the bedrooms were single occupancy with en-suite toilets.

The complaints procedure was displayed. Records showed most complaints received had been dealt with appropriately.

Everyone spoke highly of the manager and said they were approachable and supportive. The provider had systems in place to monitor the quality of care provided. However, these needed to be more effective to ensure where issues were identified, actions to make improvements were done within a reasonable time frame..

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance and have made one recommendation in relation to deployment of staff. You can see what action we told the provider to take at the back of the full version of the report.

Our inspection of Troutbeck Care Home took place on 4 October 2017 and was unannounced. At our last inspection in February 2017, we found breaches of legal requirements relating to person centred care, safe care and treatment and good governance and the service was rated 'Requires Improvement.' At this inspection we found sufficient improvements had been made in regards person centred care and good governance so that the service was no longer in breach of legal requirements. However, we found a repeated breach in relation to safe care and treatment, relating to the proper and safe management of medicines

Troutbeck Care Home is situated in Ilkley, West Yorkshire and provides nursing or residential care for up to 54 people. At the time of our inspection there were 28 people living at the home. A registered manager was 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.

Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions of 'is the service safe, effective, caring, responsive and well led' to at least 'good'. At this inspection, we saw steps had been taken to address these questions although the service was still on an improvement pathway and had not yet reached the standards of a 'good' service.

People told us they felt safe living at the service. Staff understood how to keep people safe and had received training in how to recognise and report signs of abuse. Appropriate safeguarding referrals had been as well as incidents and accidents recorded. Risk assessments were in place and plans of care formulated to mitigate risks to their safety.

Staff who administered medicines had received training in the safe administration of medicines and their competency checked. We found some shortfalls in the safe administration, recording and storage of medicines. For example, the room which contained boxed medicines was left open on a number of occasions with the medicines cupboard unlocked.

We looked round the premises and found it reasonably well maintained with equipment serviced and in working order.

Staff were safely recruited and there were sufficient staff deployed to offer safe care. The registered manager told us they would increase the staffing levels as the service's occupancy rose. Training was up to date or booked and regular supervisions took place. The registered manager had not yet commenced appraisals but had plans in place to do so.

The service was acting within the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) although a more robust system for recording some best interest decisions such as for covert medicines needed to be put in place and consent forms were not always signed.

People were generally complimentary about the food and a healthy and nutritious diet was provided. People at nutritional risk were referred to the GP or dietician although people's fluid amounts did not always reach the level requested by the GP.

Most staff appeared caring and supportive and there was a positive atmosphere, with people treated with dignity and respect. However, some staff appeared disinterested when interacting or providing support to people. People were supported to maintain independence where possible.

Some people's care records contained good information although improvements were required in others, such as detailing information about how to support some people's moving and handling and medication needs and updating plans with the most relevant information.

Complaints were treated seriously and investigated, with outcomes communicated to all relevant parties. Th

Our inspection of Troutbeck Care Home took place on 24 February 2017 and was unannounced.

At our last inspection in July 2016 the service was found to have made some improvements from the previous inspection. We rated it 'Requires Improvement' overall, with identified breaches regarding dignity and respect, good governance and staffing. The service was deemed to have made sufficient improvements for it to be taken out of 'special measures'.

This inspection took place in response to a number of safeguarding issues raised and concerns from relatives of people living at the service about care and support. We found these concerns were now beginning to be addressed through the increased management support and the actions of the acting manager.

Troutbeck Care Home is situated in Ilkley, West Yorkshire, and provides nursing or residential care for up to 54 people. At the time of our inspection there were 29 people living at the service. Of these, 22 people required nursing care and 7 people required residential care.

The service should have a registered manager in place. 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 had recently left the service and there was an acting manager in place who was intending to apply for the post of registered manager. The home was also being supported by the provider's Clinical Skills Development Manager, Senior Operations Manager, Quality Assurance Manager and Regional Director.

Staff were suitably trained in the safe administration of medicines. However, we found some shortfalls with staff administering medicines safely and providing an accurate record of their actions.

People told us they felt safe at the service, staff understood how to recognise and report signs of abuse and appropriate safeguarding referrals had been made. Incidents and accidents were documented, people's needs were assessed and plans put in place to mitigate risks to their safety.

The premises was reasonably well maintained although we saw some areas required some refreshing. Equipment was regularly serviced although two pieces of equipment to assist with the safe moving of people were out of service and awaiting parts.

There were sufficient staff deployed to offer people safe care and support although we were concerned about plans to reduce these numbers. A robust recruitment process was in place and staff training was up to date or booked, with all staff currently undergoing a refresher induction training programme. We saw the acting manager had a plan for staff supervision and appraisal.

The service was acting within the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However we found staff had limited knowledge of this.

People were largely supported to consume a nutritious and varied diet although some food was served when it was not warm.

Plans of care were developed from initial needs assessments and these were reviewed regularly. However, these needed to be more person centred and care did not always follow these plans. Some charts relating to people's care were not always completed. Although care records were reviewed regularly, we saw little evidence of people or their relatives being involved in these.

We saw consent sought for care wherever possible, such as signed consent forms for care and support in people's care records and staff asking for people's consent before providing care. People's preferences were respected, such as where they wanted to spend their time, where they wanted to sit and what they wanted to eat or drink.

People's health care needs were largely met although there were some concerns from relatives about communication o

Troutbeck Care Home is located in the Wharfe Valley on the edge of Ilkey Moor and only a short distance from the town centre. The service provides accommodation for up to 54 people who require either residential or nursing care. However, at the time of inspection the second floor of the home was closed therefore the maximum occupancy had been reduced to 45. Of the 42 people using the service on the day of inspection 9 required residential care and 33 required nursing care.

The inspection took place on 28 July 2016 and was unannounced. The last inspection was in December 2015. At that time we found the provider was in breach of four regulations and the home was placed in special measures. The breaches of regulation were in regard to safe care and treatment, privacy and dignity, person centred care and good governance. Following the inspection we received an action plan from the provider detailing how improvements would be made including timescales. At this inspection we found the provider had made sufficient improvement to take the home out of special measures.

The home had 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 home had a safeguarding policy in place which made staff aware of their roles and responsibilities. We found staff knew and understood how to protect people from abuse and harm and what might constitute abuse.

We found the service was meeting the requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).This legislation is used to protect people who might not be able to make informed decisions on their own.

We saw staff were caring courteous toward the people they supported and received appropriate levels of training and supervision to carry out their roles effectively. However, we had concerns there were at times insufficient staff on duty to meet people’s needs and staff needed to be more vigilant and attentive when assisting people with their personal care.

We saw arrangements were in place that made sure people's health needs were met. For example, people had access to the full range of NHS services. This included GPs, hospital consultants, community health nurses, opticians, chiropodists and dentists.

We found the nursing staff responsible for administering medication received appropriate training and people received their medicines safely. However, poorly completed documentation meant we could not be certain creams/lotions were being applied as prescribed.

We found people’s needs were assessed and care plans had been put in place to meet their assessed needs although they did not always reflect the care and treatment people actually received. The majority of people we spoke with told us they were involved in planning their own care and treatment however this was not always evidenced in the care plans and supporting documentation we looked at.

We saw there was a complaints procedure available which enabled people to raise any concerns or complaints about the care, support or treatment they received.

We found although some improvements had been made to the quality assurance monitoring systems further improvements were required. The audit systems were not robust and had not identified the shortfalls in the service highlighted above and in the body of this report.

We identified three 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 the report.

Troutbeck Care Home is located in the Wharfe Valley on the edge of Ilkley Moor and only a short distance from the town centre. The service provides accommodation for up to 54 people who require either residential or nursing care. There were 43 people living at Troutbeck Care Home on the day of inspection. The registered manager confirmed that of the 43 people who used the service 16 required residential care and 27 required nursing care.

There was a registered manager in post at the time of 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.

We inspected Troutbeck Care Home on the 11 December 2014 and the visit was unannounced. Our last inspection took place in June 2014 and at that time we found the home was not meeting two of the regulations we looked at. These related to record keeping and assessing and monitoring the quality of service provision. We asked the provider to make improvements and following the inspection they sent us an action plan outlining the work to be completed including timescales.

During this inspection we found improvements had been made to the records and reports completed by staff in relations to people’s care and treatment and they now provided accurate and up to date information. We also found shortfalls in the service had been identified through the quality assurance monitoring systems in place.

We saw that arrangements were in place that made sure people's health needs were met. For example, people had access to the full range of NHS services. This included GP’s, hospital consultants, opticians, chiropodists and dentists.

Although medication policies and procedures were in place we found the nursing staff had not always followed the correct procedures which had led to 11 medication errors being recorded in the last seven months. This potentially placed vulnerable people at risk of unsafe care.

The organisation’s staff recruitment and selection procedures were robust which helped to ensure people were cared for by staff suitable to work in the caring profession. In addition, all the staff we spoke with were aware of signs and symptoms which may indicate people were possibly being abused and the action they needed to take.

The staff had access to a range of training courses relevant to their roles and responsibilities and were supported to carry out their roles effectively though a planned programme of training and supervision.

People’s care plans and risk assessments were person centred and the staff we spoke with were able to tell us how individuals preferred their care and support to be delivered. Care plans and risk assessments were reviewed on a regular basis to make sure they provided accurate and up to date information and were fit for purpose.

Staff received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards and were able to demonstrate a good understanding of when Best Interest Decisions need to be made to safeguard people. However, we found the provider was not meeting the requirements of the Deprivation of Liberty Safeguards. This legislation is used to protect people who might not be able to make informed decisions on their own. The registered manager was advised of this and confirmed that this matter would be addressed.

The home had a warm and homely atmosphere. We saw staff were kind, caring and compassionate and people were encouraged to participate in a range of appropriate social and leisure activities both within the service and the wider community.

There was a complaints procedure available which enabled people to raise any concerns or complaints about the care or treatment they received. However, we found the complaints procedure was not always being followed which might lead to people being reluctant to make a formal complaint.

We found three breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

There was no manager in post at the time of the inspection therefore information in this report was provided by the senior operations manager. The senior operations manager will manage the service until a new manager is appointed.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key 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?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

Is the service safe-

Each person's care file had risk assessments which covered areas of potential risk such as pressure ulcers, falls and nutrition. When people were identified as being at risk, their plans showed the actions required to manage these risks.

We found appropriate arrangements were in place for obtaining medicines and discontinued medicines were disposed of appropriately and stored safely. This helped to prevent mishandling and misuse.

We spoke with six people who used the service and they told us they were pleased with the standard of care and facilities provided by the service. One person said “"I enjoy living at Troutbeck and although the home has had a few problems I have always been well cared for." Another person said "I chose to live at Troutbeck and have never regretted my decision."

.

The operations manager told us they were familiar with the requirements of the Mental Capacity Act 2005 (MCA) and was aware of the recent Supreme Court judgment on the Deprivation of Liberty Safeguards.

Effective -

People had an individual care plan which set out their care needs. We saw wherever possible people had been involved in the assessment of their health and care needs and had contributed to developing their care plan.

The home had a good working relationship with other health care professionals and followed their guidance and advice. The input of other health care professionals involved in people's care and treatment was clearly recorded in their care plan.

Caring –

People who used the service and their relatives told us they were happy with the care and facilities provided at Troutbeck Care Home. One relative said "The home had hit rock bottom but is now moving in the right direction.” Another relative told us the standards at the home had fallen but over recent months they had seen signs of improvements being made. They put this down to the interim management arrangements put in place by the provider.

We found the staff we spoke with demonstrated a good knowledge of people’s needs and were able to explain how individuals preferred their care and support to be delivered. They felt confident the service provided to people who lived at the home was good. They told us they encouraged people to remain as independence as possible within a risk management framework.

We found the atmosphere within the home was friendly and welcoming. We saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Responsive –

People’s needs were assessed and care and support was planned and delivered in line with their care plan. Care records contained good information about how care and support should be delivered.

Wherever possible people who used the service and/or their relatives were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

People knew how to make a complaint if they were unhappy and were confident if they made a complaint it would be investigated thoroughly and action taken if appropriate. There was evidence that learning from incidents/investigations took place and appropriate changes were implemented.

Well led –

The staff we spoke with confirmed they were well supported by the operations manager and said they could contact them at any time if they had concerns. They also told us communication between management and staff had improved in recent months. This ensured the needs of people who used the service were met in line with their agreed support plan.

However, we found that although the service had a quality assurance monitoring system in place it was not used effectively to ensure compliance with the essential standards of quality and safety. We were also concerned records and reports relating to people's care and welfare did not always provide accurate and up to date information.

We have asked the provider to tell us what action they intend to take to address these shortfalls in the service.

The manager was on leave at the time of the inspection therefore information about the service was provided by the senior operations manager and quality assurance manager employed by the organisation.

When we inspected the service in November 2013 we were concerned care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. In addition, we were not confident people who used the service were protected from the risk of inadequate nutrition and dehydration or that there were sufficient staff on duty to meet people's assessed needs.

On this inspection we found the provider had taken steps to ensure people's dietary needs were met and there were sufficient staff on duty to meet people's needs. However, we were still concerned care and treatment was not planned and delivered in a way that ensured people's safety and welfare or there were suitable systems in place for the storage and administration of medicines.

We spoke with the relatives of three people who used the service and they told us they had been concerned about the standards of care but had found the care and treatment people had received had improved recently. However two relatives told us the care and attention people received was inconsistent and depended upon which floor of the building their bedrooms were located on.

The registered manager named at the front of our report was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

The new manager who was appointed in July 2013 was on leave at the time of the inspection and therefore information about the service was provided by the deputy manager and the quality assurance manager employed by the organisation.

We used a number of different methods to help us understand the experiences of people who used the service. This was because some of the people who used the service had complex needs which meant they were not able to tell us their experiences. For example, we observed care practices and talked to people's relatives and staff. People who were able to tell us of their experience of living at Troutbeck told us they were generally happy living at the home.

However, we were concerned care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. In addition, we were not confident everyone who used the service were protected from the risk of inadequate nutrition and dehydration and there was sufficient staff on duty to meet people's needs during peak periods of activity, which included mealtimes.

People that use the service or have a link to the service told us that they found the home to be working well, friendly and a good place to live. Other comments made on the day that we inspected the home included “It’s a posh home”, “The home has a great standing”, “We are all looked after well”, “Friendly”, “Excellent”, “Settled and happy” and “I’d recommend this home to anyone”. People were happy with the relatively new management team and had good communication with them.

Troutbeck Care Home is located in the Wharfe Valley on the edge of Ilkey Moor and only a short distance from the town centre. The service provides accommodation for up to 54 people who require either residential or nursing care. Of the 47 people using the service on the day of inspection 10 required residential care and 37 required nursing care.

This inspection took place on 4 and 8 December 2015 and was unannounced. At the last inspection on 11 December 2014 we found three breaches in regulations. These related to the management of medicines, consent to care and treatment and complaints. The overall rating for the service was “Requires Improvement.” Following the inspection we received an action plan from the provider detailing how improvements would be made including timescales. During this inspection we checked to see if the required improvements had been made.

A registered manager had been appointed since the last 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 home had a safeguarding policy in place which made staff aware of their roles and responsibilities. We found staff knew and understood how to protect people from abuse and harm and what might constitute abuse. The required checks were done before new staff started work and this helped to protect people from the risk of being cared for by staff unsuitable to work in a care setting.

We found the service was not meeting the requirements of the Mental Capacity 2005 and the Deprivation of Liberty Safeguards (DoLS).This legislation is used to protect people who might not be able to make informed decisions on their own. This had been a breach of regulation at the last inspection in December 2014 and should have been addressed and monitored by the service through the quality assurance systems in place.

In addition, we found the service had employed 39 staff including qualified nurses, care assistants and auxiliary staff since the last inspection. We found this had been done without proper consideration of the how this would impact on people who used the service.

We saw arrangements were in place that made sure people's health needs were met. For example, people had access to the full range of NHS services. This included GPs, hospital consultants, community health nurses, opticians, chiropodists and dentists.

We found the care plans and risk assessments in place were person centred but staff did not always use them as working documents. This meant people were at risk of receiving inappropriate care and treatment. We found that care and support was not always delivered in line with people’s agreed care plan. This was a breach of regulation because there was a risk people would not receive care and treatment which was appropriate, met their needs and took account of their preferences.

We also found that relatives were not always involved in specific aspects of people’s care and treatment including end of life care and staff did not always respect people’s right to confidentiality.

We found that although medication policies and procedures were in place medicines were not always available or administered as prescribed. This had been identified a breach of regulation at the last inspection in December 2014. Therefore, this was a continued breach of regulation because the provider was not making sure people’s medicines were managed safety and properly.

We found some records relating to people’s nutrition and hydration had not been completed correctly or could not be found. This was a breach of regulation because providers are required to keep complete and up to date records about people’s care and treatment.

We saw staff were patient and caring toward people in their care. People who were able told us they were happy living at the home and were complimentary about the staff. There was a complaints procedure available which enabled people to raise any concerns or complaints about the care or treatment they received.

We found the quality assurance monitoring systems in place were not robust as not all shortfalls in the service highlighted in the body of this report had not been identified through the internal audits system. This was a breach of regulation because we could not be assured the service was managed effectively and in people’s best interest.

We found four 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.

The overall rating for this service is ‘Inadequate’ and the service is 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