About the service: Wordsworth House is a residential care home and is registered to provide accommodation and personal care for up to 40 older people and people living with dementia. At the time of our inspection, 27 people were using the service.

People’s experience of using this service: We found improvements had been made since our last inspection.

People told us they felt safe at the service. There were enough staff available to provide care and support; staffing arrangements were kept under review. The provider followed safe processes were in place to make sure appropriate checks were carried out before staff started working at the service.

Staff followed some good processes to manage people's medicines safely. Some improvements were made during our visit and the registered manager agreed to ensure checking systems were developed.

The provider had arrangements in place to promote the safety of the premises, this included maintenance, servicing and checking systems. People were protected by the prevention and control of infection.

Staff were aware of the signs and indicators of abuse and they knew what to do if they had any concerns. Staff had received training on safeguarding and protection matters.

People's needs were being assessed, planned for and reviewed. Each person had a care plan which was designed to ensure their needs and choices were met. People were supported with their healthcare needs. Changes in people's health and well-being were monitored and responded to. Where necessary, people received appropriate medical attention.

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 at the service supported this practice.

People made positive comments about the caring attitude of staff. They said their privacy and dignity was respected. We observed staff interacting with people in a kind, pleasant and friendly manner. Staff were respectful of people's choices and opinions.

There were opportunities for people to engage in a wide range of group and individual activities. Visiting arrangements were flexible, relatives and friends were made welcome at the service.

There was a suitable standard of décor and furnishings to provide for people's comfort and well-being.

People said they were satisfied with the variety and quality of the meals provided at the service. Their individual needs and preferences were catered for. People were supported to enjoy the mealtime experience.

People had an awareness of the service's complaints procedure and processes. They indicated they would be confident in raising concerns. Some complaints records were unclear and lacked detail. We have made a recommendation about complaints management.

Arrangements were in place to encourage people to express their views and be consulted about Wordsworth House. They had opportunities to give feedback on their experience of the service and suggest improvements.

Improvements had been made with checks on quality. A variety of systems and processes were in place, to regularly monitor and improve the service. There were management and leadership arrangements in place to support the effective day to day running of the service.

Rating at last inspection: Requires Improvement. (6 March 2018) At this inspection the overall rating has improved to Good.

Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up: We will plan a follow up inspection as per our inspection programme. We will continue to monitor the service and if we receive any concerning information we may bring the inspection forward.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 30 and 31 January 2018. The first day was unannounced.

Wordsworth House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates 40 people across two separate units, each of which has separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of the visit there were 32 people who received support with personal care. There is no nursing care at this service.

At the time of our inspection there was no registered manager in post. The registered manager had recently left. A new manager had been appointed and was in the process of completing an application to become the registered manager. 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 regulations about how the service is run.

At the last inspection in December 2016, we found shortfalls in the safe management of people’s medicines. This was breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the provider sent us an action plan, which set out what actions they intended to take, what they would do and by when to improve the key question, ‘Is the service safe?, to at least good.

During this inspection we reviewed actions the provider told us they had taken to gain compliance against the breach in regulations identified in December 2016. We found necessary improvements had not been made in relation to the safe management medicines. We also found improvements were required in relation to the control and prevention of infection and good governance at the service.

During this inspection we found breaches of regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had not ensured the safe management of people’s medicines and there was a failure to establish effective measures for the prevention and control of infections. You can see what action we told the registered provider to take at the back of the full version of the report.

This is the second consecutive time this service has been rated Requires Improvement.

There was mixed feedback from people and their relatives regarding the quality of care at the home. Visiting professionals we spoke with also gave us mixed feedback about the service. People who lived at the home told us that they felt safe. There was mixed feedback about the staffing levels in the home. There had been a high staff turnover. We found in majority of the cases, cover had been provided using agency staff. However, there were times when adequate cover had not been provided. The manager was in the process of recruiting new staff in order to address this matter.

We found there was a negative culture and low morale within some of the staff team. This had impacted on the quality of care provided and necessary improvement needed in the home had not been achieved. Risk assessments had been developed to minimise the potential risk of harm to people who lived at the home. However improvements were required to the risk management procedures.

Staff had received safeguarding training and knew how to report concerns to safeguarding professionals. Accident and incidents had been recorded. However, unwitnessed falls that involved head injuries had not always been referred to medical professionals. There were improvements in the safe recruitment of staff and checks were carried out to ensure suitable people were employed to work at the home.

The staff who worked

The inspection took place on 12 and 14 December 2016. The first day was unannounced.

Wordsworth house is a residential care home registered to provide care for up to 40 people. Facilities were provided over two floors. The first floor was a unit that cared for people who were living with a dementia. All of the bedrooms were single occupancy and benefited from ensuite facilities. People who used the service had access to outside gardens with raised planters and seating.

The service had a registered manager in post. 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.

At the last inspection on 19, 20 April and 20 May 2016, we identified 11 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safeguarding, safe administration of medicines, managing risk, staffing, infection control, premises and equipment, staff skills, nutrition, Deprivation of Liberty, consent, person centred care, dignity and respect, complaints, records, good governance and failure to notify the Commission. We asked the provider to take action to make improvements and to send us an action plan. The provider complied with our request. During this inspection we found the required improvements had been made.

During this inspection we found one continuing breach of the Health and Social Care Act 2008 (regulated Activities) Regulation 2014 in relation to medicines. You can see what action we told the provider to take at the back of the full version of the report.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Whilst improvements had been made in the safe administration and handling of medicines since our last inspection on this occasion we identified some concerns relating to the recording and administration of medications.

There was a new computerised system in place to record and monitor medicine administration. Whilst this would ensure regular checks of stock and administration could be easily monitored we saw one person had not received their medication in a timely manner and another person’s medication had not been administered according to the directions for use.

People who used the service and relatives told us they felt people were safe in the home. There were policies and procedures in place to guide staff in the event of a concern. Staff demonstrated their understanding of the signs and types of abuse and what actions they would take if abuse was suspected.

We saw risk assessments had been completed since our last inspection. These included individual risk assessments as well as environmental risk assessments.

There was an emergency contingency plan and personal evacuation plans were in place and up to date. This would ensure the emergency service had access to information about the needs of people in the event of an emergency. Essential environmental checks such as water temperatures, radiators and room checks had been completed.

Staff had undertaken the training required to enable them to meet the needs of people who used the service.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. Staff we spoke with demonstrated an understanding of MCA and DoLS and the impacts on people who used the service. Records

We under took a comprehensive inspection on 19, 20 April and 10 May 2016. The 19 April and 10 May 2016 was unannounced which meant they did not know we were coming.

Wordsworth House is registered to provide care for up to 40 people. The home is registered with the Commission to provide accommodation for persons who require nursing in a care home without nursing for older people, people with a mental health diagnosis, younger adults or people living with a dementia related condition. At the time of our inspection there were 38 people in receipt of care from the provider.

The registration requirements for the provider stated the home should have a registered manager in place. There is no registered manager for this service. The home manager told us they had started the application process for registered managers 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.

Systems to monitor and review concerns were inadequate. During our inspection we identified a number of concerns relating to allegations of abuse that had not been reported in a safe and appropriate way. We asked the home manager to refer the concerns that had been identified during our inspection to the Local Authority safeguarding team.

The system to record, investigate and monitor allegations of abuse was inadequate. The home manager showed us a safeguarding file. However this contained only a cover sheet and no record of the any current or previous investigations.

There was a risk assessment file which indicated a general risk assessment had taken place recently. Areas included; kitchen equipment, housekeeping and maintenance. However we identified some concerns relating to individual risk assessments for people living in the home.

Observation of medicines administration identified concerns relating to the length of time it took to administer all the medicines. Some medicines that were required before breakfast were not given as directed. We noted gaps in Medicines Administration Records (MAR) and the coding system lacked clarity on why medicines were not given.

Monitoring of room and fridge temperatures did not take place in line with guidance to ensure safe storage of medication. We saw on two occasions that the medicines trolley was left in the lounge on one of the floors and it had not been secured to the wall.

We looked at the training matrix and saw evidence of training taking place. However there was also some gaps in training.

Some staff we spoke with raised concerns about the staffing numbers in the home. Examples of comments received were, “We are falling behind. We keep having to do medicines on both floors if there is sickness.” Another said, “Staff morale is low”. However one person said it was a, “Good staff team”. Senior management and the home manager told us they were in process of recruiting senior staff for the home.

We asked about how people were assessed when a Deprivation of Liberty Safeguards (DoLS) was required. We saw DoLS applications that did not reflect people’s individual and current needs. Evidence of training for DoLS and Mental Capacity Act (MCA) identified that not all staff had completed the required training.

Systems to protect people from the risks of infection were ineffective. We saw evidence of an outbreak of diahorrea and vomiting that had not been referred to the relevant authority. We observed staff entering the kitchen without using appropriate personal protective equipment. We saw a sling in a bathroom that was stained and dirty.

We identified some concerns relating to maintenance checks in the home. For example the monthly room checks had not been completed since February 2016 and had identified are

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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 a summary of what we found:

Is the service safe?

There was evidence of enough skilled staff in place to care for people living in the home. We were told regular assessments of people’s needs were carried out to ensure the staffing numbers reflected people's care and support needs

The manager told us there had been no application for a deprivation of liberty safeguard. We were told the home was in the process of implementing new paper work to ensure all people living in the home received appropriate assessments in relation to mental capacity. Some of the staff spoken with were able to discuss appropriate procedures to take if there were concerns about a person’s mental capacity. (The Mental Capacity Act provides a legal framework to protect people who need to be deprived of their liberty for their own safety).

We saw evidence of comprehensive and appropriate care planning in place to ensure people living in the home received safe and effective care.

Is the service caring?

We spoke with people living in the home who told us staff were caring and kind. We observed positive interactions between staff and people living in the home and we saw staff sat chatting in a kind and respectful way in the public areas of the home with people who used the service.

We saw there were ongoing upgrades in people’s bedrooms and the public area. All the bedrooms we looked at were decorated with personal items and mementoes. We observed reminiscence items and textured objects for example hats and coats on the dementia unit. Public areas, toilets and bathroom had pictures to help people living in the home to identify them. Evidence of activities equipment for example books were available for people in the lounges.

The four care files we looked at contained all the relevant information to enable staff to care for people living in the home safely and effectively.

Staff had received training to meet the needs of people who used the service including, mental capacity and safeguarding. We were told there was an ongoing training programme in place and we saw evidence of plans for future updates.

Is the service responsive?

We saw evidence of completed questionnaires by people living in the home. The manager told us people who used the service received questionnaires on different topics for them to complete for example cleanliness.

We looked at the complaints and incident file and saw that no complaints had been recorded since the last inspection. All the staff we spoke with were able to tell us the appropriate procedure to take if a complaint was received. People living in the home and their families all told us they were happy with their care and had no complaints.

Is the service effective?

There was evidence in people’s care files that their care needs were being met and reviewed regularly. There was evidence of people being involved in the care files and people we spoke with confirmed they had discussed their care with the staff.

We saw evidence of people’s health being monitored and appropriate intervention by professionals such as the district nurse or the GP. A visiting professional we spoke with confirmed staff requested visits from them appropriately.

There was a comprehensive activity programme for people living in the home. We observed activities taking place on the day of our inspection. We saw evidence of activities recorded in people’s care files and people living in the home confirmed they took part in the activities.

Is the service well led?

The manager is registered with the Care Quality Commission. The staff we spoke with were positive about the manager and told us they received more support from him since our last inspection. However we received some comments from staff that the manager did not respond to their concerns. We received positive feedback about the manager from people who used the service and relatives that we spoke with.

There were systems in place to regularly assess and monitor how the home was managed and to monitor the quality of the service. We saw evidence of regular and recent audits taking place for example, medication, care plans, accident and weights. There were notes on actions seen.

There was evidence of supervision taking place with evidence of notes and feedback from staff seen.

During our last inspection we found non-compliance on assessing and monitoring the quality of service provision. We visited the home on 9 December 2013 and asked the manager to tell us about how they addressed the concerns raised.

We saw the manager had recently introduced care file audits each month and we saw completed copies of these with notes and actions seen. The manager told us each month a quality audit was completed and within this care files were also reviewed.

We spoke with two people who used the service who were complementary about the manager and staff at the home. One person told us, “X (the manager) is good I have no complaints”. Another said, “He is always around if you want to ask him questions he is there for you. I am looked after properly the staff check me in the night. It is like a home from home”.

We used a Short Observational Framework (SOFI) for two people living at Wordsworth House which helped us to evidence the quality of the care provided. We saw that care delivered was person led and delivered privately which ensured that care and personal support was consistent and met people’s changing needs.

We spoke with four people living in the home who told us they were happy with the care and support they received. Comments included, “It's a lovely place; I'm very comfortable" and “They look after us so well”.

We looked at the records of six people who used the service and saw there were procedures in place to ensure their consent was gained in relation to the care provided.

Most of the care staff had achieved a recognised qualification in care, which would help them to look after people properly. We saw staff interacting with people in a pleasant and friendly manner and being respectful of people's choices and opinions.

People told us there were sufficient staff to look after them and made positive comments about the staff team such as, “The staff love us and we love them” and “I’m very well looked after”. A relative spoken with told us, “The staff are wonderful here. I can’t fault them at all”.

We found some auditing systems in need of improvement which meant the systems to monitor the outcomes for people who use the service were not effective and did not help to identify non compliance with the regulations.

We wanted to review the service for people who had conditions that meant they could not reliably give their verbal opinion on the service they received. Therefore we used a Short Observational Framework (SOFI) for two of the people living at Wordsworth House. This framework helped us to evidence the quality of the care provided.

We spoke with two people who used the service. They told us they were happy with the care and support they received and commented that they were treated well by the staff. Comments included, "They're very good to me" and "The staff are lovely". People told us they were able to express their views and opinions and could influence the way their care was delivered.

During our visit we looked at three care plans that belonged to people who used the service to ensure their needs were fully met and their rights were protected. People spoken with told us they could raise any concerns with the manager or the staff and were confident they would be listened to.

People living in the home who were able to tell us how they were treated said, the staff treated them very well and they were happy. The staff were generally polite and considerate and they felt able to raise any issue of concern they may have.

A visitor to the home told us they had never witnessed anything untoward that gave them concern. People were spoken to with respect, and staff “did a marvelous job”.

There were arrangements in place to safeguard people, but people who had challenging behaviour needs were not always managed adequately. As a result people presenting challenging behaviour and staff dealing with them were not always protected. Some staff supporting people with challenging behaviour and dementia care needs had not had training.

Some people living in the home were unable to keep their door locked because staff did not have a master key to gain access in an emergency. There had been some improvements in assessing people at risk.

People were cared for by staff who were carefully recruited. People living in the home told us the staff team were very good. There was always someone around to help them.