About the service:

Wellburn House is a residential care home that provides accommodation and personal care for up to 90 older people and people living with dementia, at the time of the inspection there were 31 people using the service.

People’s experience of using this service:

Improvements had been made since the last inspection in June 2018. People and relatives told us that the changes had improved the service.

A new manager had been appointed and they had worked to recruit, coach and develop the staff team. This led to a motivated group of staff who were committed in providing care that was person centred.

Medicines were now managed safely. The manager and staff team worked together to support people to be safe. Checks of safety and quality were made to ensure people were protected. Work to continuously improve was noted and the manager was keen to make changes that would impact positively on people’s lives.

Staff were well trained and skilled and used this training to effectively support people to promote independence and choice. The dining experience had improved, and people were happy with the food provided.

The values of the organisation of offering choice and respect were embedded.

Care plans were person centred, reviewed and contained up to date information. Activities were taking place all day, and these were either group activities or one to one activities. Complaints were now fully investigated with an outcome provided to the complainant and lessons learned to improve the service.

The management team now had an effective system of audits in place which identified and addressed any concerns that were found.

Rating at last inspection:

The rating at the last inspection was requires improvement and inadequate in well led. The report was published 9 October 2018.

Why we inspected:

This inspection was a scheduled inspection based on the previous rating.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

The inspection took place on 4 and 5 June 2018 and the first day of the inspection was unannounced.

We last inspected the service in October 2017. Following this inspection the service was rated 'requires improvement' and we identified breaches in two of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we had concerns about the safe management of medicines and the lack of effective auditing.

Following the inspection in October 2017 we served a warning notice against the registered provider in respect of the breach in regulation 12, safe care and treatment. This was because of concerns we had regarding the safe management of medicines. The warning notice stated that they must take necessary action to comply with this regulation by 31 January 2018.

We also issued a requirement notice in respect of the breach in regulation 17, good governance. This was because the provider did not have an effective system of audits in place and they were not identifying the issues we found during the inspection. The registered provider sent us an action plan detailing how and when they would take action in order to meet this requirement notice. The action plan stated that all of the work necessary to become compliant with this regulation would be completed by the end of November 2017.

During this inspection we found some improvements had been made but there were still areas of concern and the service remained in breach of these regulations.

Wellburn House 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.

Wellburn House can accommodate up to 90 people across three separate areas in a two storey building. One area, Laurel, provides residential care and the other two areas, Lilac and Fern, provide care to people living with dementia. Lilac is on the ground floor whilst Fern is on the first floor and provides care for people who have higher level care needs due to the advanced stage of their dementia. At the time of our inspection there were 45 people living at the service.

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.

This is the fifth time the service has been rated Requires Improvement since September 2015. In June 2016 the service was rated Inadequate.

There was still no robust system of audits in place. Those audits that were taking place were not effective as they did not identify all of the issues we found during the inspection. When audits were completed action was not always taken to make the necessary improvements. Quality assurance surveys were conducted but there was no clear action plan produced as a result of feedback.

Records were not always up to date, accurate or complete.

Medicines were not always managed safely for people. Improvements still need to be made in guidance and records for ‘when required medicines’ and topical medicines.

Risks assessment tools were not always used correctly. Some people did not have risk assessments in place to provide staff with information on how to manage and minimise all identified risks.

The provider had calculated the number of staff needed to safely meet the needs of the people using the service. We saw that the staffing levels were in line with these calculations however we received feedback from staff and relatives that people sometimes had to wait for assistance. We have made a recommendation about this.

Checks were carried out around the service to ensure the premises and equipment were safe to use. Staff had not

This inspection took place on 3 October 2017. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

The service was last inspected in October 2016 and rated 'requires improvement.' We found breaches of Regulations. This was because improvements were needed in medicines and audits failed to highlight issues and concerns regarding medicines. Following our last inspection the provider sent us information, in the form of an action plan, which detailed the action they would take to make improvements at the home.

Since receiving that action plan the registered manager left the service. A new manager was appointed who came to post in July 2017. The new manager was starting to make improvements but had only been in post two months, therefore a lot of the improvements had just been implemented.

At this inspection we found that medicines were still not being administered safely. Audits had started to take place and highlighted some of the concerns we raised but not all had been acted upon.

Wellburn House is a 90 bedded purpose built two storey care home. It has two units; the ground floor unit for people with personal care needs and the first floor unit for people living with dementia. All bedrooms have en-suite facilities and there is a large courtyard garden. At the time of inspection there were 44 people using the service.

There was a manager in place who was in the process of being registered with the Care Quality Commission since 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.

Risks to people arising from their health and support needs and the premises were assessed, and plans were in place to minimise them. Risk assessments were regularly reviewed to ensure they met people’s current needs. A number of checks were carried out around the service to ensure that the premises and equipment were safe to use.

There were enough staff to meet people's needs. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. Staff were now given effective supervision and a yearly appraisal.

Staff understood safeguarding issues and were aware of the whistleblowing policy [telling someone] if they had concerns.

Staff were in the process of receiving training to ensure that they could appropriately support people, and the service used the Care Certificate as the framework for its training. Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) training and clearly understood the requirements of the Act. Best interest decisions were made appropriately with the person and family were fully involved. This meant they were working within the law to support people who may have lacked capacity to make their own decisions. The manager understood their responsibilities in relation to DoLS.

People were supported to maintain a healthy diet, and people’s dietary needs and preferences were catered for. People told us they had a choice of food and everyone enjoyed what was on offer.

We saw evidence in care plans to show the service worked with external healthcare professionals to maintain people’s health.

We found the interactions between people and staff were kind and respectful and people were offered choice throughout the day.

Procedures were in place to support people to access advocacy services should the need arise. At the time of inspection no one was using an advocate.

Complaints were acted on using the guidance of the services complaints policy. However the outcome to show the complainant was happy was not recorded.

Staff had a clear understanding of people's needs and how t

We carried out this inspection on the 5 October 2016. The inspection was unannounced which meant the staff and registered provider did not know we would be visiting.

At an inspection in July 2015 we found a shortfall in relation to safe care and treatment, medicines were not managed safely and people were at risk on receiving incorrect nutritional intake; premises and equipment; staffing; consent to care or treatment; safeguarding and good governance. We also made a recommendation that the registered provider looks at the dining experience for people who used the service, care plans to become more person centred and to ensure people are involved in the care plan development and review where they are able.

The registered provider told us they would be compliant with the regulations by December 2015 in light of safeguarding concerns we completed an inspection in November 2015 and we found no improvement.

At the last inspection in March 2016 and April 2016 we found that the registered provider had not made required improvements and identified more shortfalls so we rated the service as inadequate. The service was place in special measures and we have been following our enforcement policies.

The shortfalls we identified were in relation to:

• Safe management of medicines, risk assessments provided limited or no information. Not everyone had a personal emergency evacuation plan (PEEP), staff could not tell us how many were at the service and the list in the emergency evacuation pack did not match who lived at the service.

• We found the registered provider was not following up and reporting safeguarding concerns.

• We found the registered provider was not employing sufficient staff, inductions were not effective and staff did not have the knowledge and skills to support people who used the service.

• We found the registered provider was not obtaining consent from people who used the service.

• We found bathrooms and shower rooms out of use.

• We found the registered provider was not completing audits effectively.

• We found the registered provider was not involving people in their plan of care, the care records were confusing and not person centred.

• We found the registered provider was not documenting reasons for gaps in employment or following up on problems with references.

• We found the registered provider was not providing a dignified dining experience.

• Also the registered provider was not notifying the Care Quality Commission of significant events.

We completed this inspection to review the action the registered provider had taken in response to the shortfalls we identified at the last inspection.

Wellburn House is a 90 bedded purpose built two storey care home. It has three units and at the time of the inspection two of the units were operational; the ground floor unit for people with personal care needs and the first floor unit for people living with dementia. All bedrooms have ensuite facilities and there is the availability of a large courtyard garden. At the time of inspection there were 45 people living at the service.

Since our last inspection the manager and the area manager had left Akari Care. A new manager had started at Wellburn House in May 2016 and became registered with the Care Quality Commission in August 2016. 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. A new area manager had taken over this service in April 2016.

At this inspection we looked at how medicines were handled and found that although improvements had been made the arrangements were not always safe.

People were protected from the risks of harm or abuse because there were effective systems in place to manage any safeguarding concer

We carried out this inspection on the 10 March 2016 and 7 April 2016. The inspection was unannounced which meant the staff and registered provider did not know we would be visiting

Wellburn House is a 90 bedded purpose built two storey care home. It has two units; the ground floor unit for people with personal care needs and the first floor unit for people living with dementia. All bedrooms have ensuite facilities and there is the availability of a large courtyard garden.

On the first day of our inspection the service had a manager who was planning on registering with the Care Quality Commission. We were informed before the second day of inspection that this manager no longer worked at Wellburn House. 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.

At our last full inspection of the home in July 2015 we found six breaches. These were in relation to safe care and treatment. We found medicines were not managed safely and people were at risk on receiving incorrect nutritional intake. There was also a breach in relation to Premises and equipment. The cleanliness and condition of the service was not maintained. Staff did not receive support through supervision. Staff were not seeking consent before any care or treatment was provided. The service was not safeguarding service users from abuse and improper treatment. People were being deprived of their liberty without lawful authority. Audits were not taking place and people’s views were not sought. We also made a recommendation that the registered provider looks at the dining experience for people who used the service, care plans to become more person centred and to ensure people are involved in the care plan development and review where they are able.

Following concerns being raised we also completed a focused inspection in November 2015. This inspection concentrated on looking at whether the service was ‘safe’. We found that action was needed to ensure fire procedures were effective; people received appropriate care and treatment; recruitment procedures were safe; and staffing levels met the needs of the people who used the service.

During this inspection we found measures to improve the service had not taken place.

Medicines were not always managed safely for people and records had not been completed correctly. People did not receive their medicines at the times they needed them and in a safe way. Medicines were not administered and recorded properly.

Although the manager had knowledge of the Mental Capacity Act [MCA] 2005 and Deprivation of Liberty Safeguards [DoLS], records made it difficult to understand who was subject to a DoLS authorisation. We checked this on the second day of inspection but due to records the area manager could not establish who had a DoLS authorisation or where a request had been put in.

Risks to people’s health or well-being had not always been assessed and plans were not always put in place to protect people. One person who had grade four pressure sores was placed on two hourly turns and 30 minute observations. There was no record of two hourly turns or 30 minute observations taking place.

Accidents and incidents were not monitored each month to see if any trends or patterns were identified.

We found people were cared for by insufficient numbers of staff. People were left sitting alone in wheelchairs due to needing two members of staff for support and two members of staff not being available. Recruitment and selection procedures were in place but appropriate checks had not been undertaken before staff began work. Staff did not receive support through supervision or did not receive relevant training.

Staff we spoke with understood the principles and pro

We carried out an unannounced comprehensive inspection on 15 July 2015 and found the service to be overall Requires Improvement. We received an action plan which stated that the service would be fully compliant by 31 December 2015. After that inspection we received concerns in relation to people who used the service being woken up at five in the morning, being short staffed and one night only three staff members on duty, insulin not being administered, staff not using correct moving and handling techniques, falls not being documented and safe recruitment procedures not being adhered to.These safeguarding concerns have been reported to the local authority. The local authority will manage safeguarding concerns raised in line with their lead role and safeguarding procedures. We undertook a focused inspection to look into concerns raised. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Wellburn House) on our website at www.cqc.org.uk. During this inspection we did not check whether the service were meeting these regulations as the registered provider’s timescales were not yet reached. But evidence showed reg 12 (1) needed further work to be completed in order for this to be met.

Wellburn House is a 90 bedded purpose built two storey care home. It has two units; the ground floor unit for people with personal care needs and the first floor unit for people with dementia. All bedrooms have ensuite facilities and there is the availability of a large courtyard garden. One section of the building was not currently in use by people using the service with none of the bedrooms occupied or bathrooms used. At the time of this inspection there were 61 people living at Wellburn House.

The home had a manager who had only been at Wellburn House for four weeks. The manager was in the process of completing their application to apply to be registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We arrived at the service at five thirty am. On arrival it was difficult to gain how many people were living at the service. The senior carer working downstairs did not know how many people were living upstairs and vice versa. Staff we spoke with were not able to tell us fully about the emergency evacuation procedures or where this information was kept. Personal Emergency Evacuation Plans (PEEPs) did not reflect the current information on who lived at the service and what room they occupied.

We did see some people were up and dressed at five thirty am but staff could provide good explanations of why each person was up. The people we spoke with confirmed that it had been their choice to get up. We also saw that the majority of people were still in bed asleep. Therefore we could not evidence that people were being awoken at five am.

We found that once people were up and out of their room, their room would be locked. Staff we spoke with said this was on request of families to stop other people entering their rooms. We saw no documented evidence of this. We were told that people could lock their rooms themselves from the inside and staff had a master key if they needed to enter in an emergency. The night shift staff only had one master key for the whole service and if an emergency did take place this meant they would have to search for the person who was holding that key. We were also told this master key was the same key for the treatment room where medicines were stored.

We looked at the records for insulin administration. Insulin is not administered by care staff in the service but by the district nurse and this was documented.

At the time of our inspection there were enough staff on duty. However staff we spoke with said that they had been short staffed on a number of occasions. We looked at the night when we were told by the person raising the concern there were only three staff on duty. We found that there was six staff on duty that night. We found this information on the staff rotas, staff signing in sheets and payroll information. We did see evidence that on some days they were working with two staff down. The manager said they were aware of this and a recruitment drive was taking place and they were awaiting Disclosure and Barring Service (DBS) returns for some people who had been offered positions. DBS carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults, to help employers make safer recruiting decisions and also to minimise the risk of unsuitable people from working with children and vulnerable adults.

A concern was raised regarding the recruitment of staff. We were told that one person had worked before the return of the DBS and staff were not shadowing experienced staff and were working alone. We looked at the recruitment files for five staff who had been recently recruited. One of these was for the person who had worked a shift before the return of the DBS. We saw that the DBS was returned on the 11 November 2015 and this person worked on the 16 November 2015..

Concerns were raised about falls not being documented especially one particular fall. We saw evidence that falls were documented and the particular fall had been recorded correctly with follow up actions taken.

We did note that staff were applying dressings without checking with the community matron or GP that this was the correct one needed for a particular sore or injury. This meant that staff were dressing wounds without any oversight or authority to do so. The residential staff were not trained to determine how best to deliver wound care. This meant that the role of the district nurse was being undertaken by residential staff and this could put people at risk of inappropriate treatment. Also we found that staff continued to store dressings prescribed by the community nurses in people’s bedrooms long after their involvement with this service had ceased. We found that some of the items stored were out of date.

Concerns were also raised about moving and handling techniques. We observed people being hoisted and using stand aids. We saw that this was all carried out correctly.

At the July 2015 inspection we found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of that report.

The inspection visit took place on the 15 July 2015 and was unannounced which meant the staff and provider did not know we were visiting.

We last inspected the service on 21 February 2014 and found the service was compliant with regulations at that time.

There was an acting manager who had worked at the service for several years as a carer and had been acting manager since April 2015, they had not applied to CQC to become the registered manager . The home has now been operating without a registered manager for at least six months. 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. Not having a registered manager is a breach of the provider’s conditions of registration and we will be dealing with this matter outside of the inspection process.

We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

People told us they felt safe at the service and staff were aware of safeguarding procedures and told us what they would do to report a concern. We saw staffing numbers at the service was not always provided at the level of their own dependency tool, although people did not raise any concerns over staffing levels and staff provided prompt attention to people on the day of our visit.

There were issues with cleanliness and maintenance of the service in certain areas mainly toilets and bathrooms.

There were concerns around how staff managed the medicines. The service used a multi dose system where the pharmacy provided a photograph of each medicine in the blister pot. Some photographs did not match which medicines were dispensed into the blister pot. Some quantities were incorrect and did not match what had been carried over and administered. Medicines were not always administered correctly in line with the manufacturer’s guidelines.

Staff did not have an understanding of the Mental Capacity Act 2005 and Deprivations of Liberties (DoLS) and were unsure of their responsibilities. People who had capacity had been put forward for authorisations incorrectly. Staff adopted restrictive practices for people irrespective of whether the person had capacity to make choice and even when DoLS had not been authorised still prevented people from leaving the home. Staff were not adhering to the requirements of the Mental Capacity Act 2005 code of practice. They presumed people lacked capacity and failed to complete capacity assessments prior to making decisions on behalf of people. There was also no evidence to show that when people did lack capacity decisions were made via the ‘best interest’ process.

There was not a regular programme of staff supervision or appraisal although the management team said these had now begun to take place. However the manager was not taking appropriate action to ensure staff received adequate supervision and when concerns arose such as complaints that staff were sleeping on duty or staff behaviour was not in line with expected practice this was not investigated. Staff training was in place and there was a matrix to monitor when mandatory training was due.

Care plans were slightly confusing in terms of format as the service was transitioning to a new format. People’s basic needs and information about them were recorded but people’s involvements in their reviews were not apparent. We found that risks were not always appropriately assessed and action was not taken to reduce the impact of potential risks.

We saw people being given choices and encouraged to take part in all aspects of day to day life at the service. The service encouraged people to maintain their independence and provided a variety of activities and people told us they were treated with dignity and respect.

We observed a lunchtime and teatime meal. People were not well supported to have their nutritional needs met and mealtimes were not always well supported. Several people said the food was only warm not hot.

Accidents and incidents were not adequately monitored by the service to ensure any trends were identified. We saw patterns of incidents at night time that had not been addressed.

We saw safety checks and certificates that were all within the last twelve months for items that had been serviced and checked such as fire equipment and electrical safety.

The registered provider had no effective quality assurance system in place.

We recommended that the registered provider looks into the dining experience for people who used the service. We recommended action is taken to make care plans more person centred and to ensure people are involved in their development and review where they are able.

We found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

At our last inspection of Wellburn House 2013 we identified some concerns with the way the service provided care to people, which did not take account of people’s own lifestyle preferences. We also had concerns about staffing within the service and to some of the record keeping.

At this inspection we found that improvements had been made. We found that life for people living at Wellburn House was much more flexible and reflected their individual choices and preferences.

We saw that there was sufficient care staff available to meet people’s needs. However, more analysis was needed in relation to the different roles and skill mix within the service to determine the needs across all departments.

We saw that a range of records had improved. Records relating to fire evacuation were up to date and in place. Care records were in the main up to date and reflective of people’s needs. We found that work had commenced on other records such as accident analysis and the duty rota, however there was still further work to do.

Relatives said, “The staff are very good. They do work very hard and are always very busy but I find they are always friendly and caring”, “We are happy with the care and find the staff are fantastic.”

There was one area that relatives were unhappy with and that was the lack of refurbishment. We requested that the provider send us information about the refurbishment programme and timescales.

We spoke with eight people who live at Wellburn House, as well as two relatives of people. They said they thought they received the care they needed. One person said, "They always give you information and help you in anyway they can." Another person said, "I cannot fault the treatment and care here. If I am not feeling too good they will get the doctor, they have done so three times in the last six weeks."

We spent time on both units, observing the interaction between people living there and staff. We found staff were respectful when working with people and were seen to give good explanations and reassurances. We observed a very relaxed atmosphere throughout the home.

We observed staff using a hoist when transferring people from armchairs to wheelchairs thus maintaining people’s safety. Staff explained to people what they were doing at each stage of the transfer to reassure people.

We observed a member of staff escorting a lady to her room. The staff member talked to the lady as they were walking, they did not rush her and reassured her there was no need to rush.

We observed three people that used the service sat in a small separate lounge. There was not a lot of interaction with them from staff and the door between this lounge and the main lounge was closed. We discussed this with the deputy manager at the time of the inspection as people may become isolated.

We decided to visit the home at 7pm to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region.

We spoke with six people who lived at Wellburn House. They said that they found staff attended to their care needs in a timely manner. All the people spoken with were very positive about the staff and how they were treated. People said, “The staff try their best”, “The staff are very good and are very kind” and “I’m not sure why I need to be here but the staff are good."

We also spoke with ten staff and the manager of the service.

We found that whilst people had up to date care records and assessment, these did not wholly reflect people's needs. We found that people's lifestyle preferences, choices and decision making had not been fully considered.

We found that there was limited understanding about people's capacity and the legal frameworks that supported people's rights.

We found that the way in which staff were deployed within the home did not provide for person centred care.

We found that some of the records were not up to date or accurate.