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Inspection carried out on 16 August 2017

During a routine inspection

Anley Hall is registered to provide nursing care for up to 54 people, some of who may suffer from memory impairment, dementia, a physical disability or be terminally ill. The service is divided into two separate units; one is specifically used for people who are living with dementia. The service is a stone built country house, previously a private dwelling and is situated in a rural setting on the outskirts of the market town of Settle in the Yorkshire Dales. There are communal areas for dining and relaxation. Car parking is available in the grounds. On the day of our inspection 46 people were living in the service.

This comprehensive inspection took place on 16 August 2017 and was unannounced. At the last comprehensive inspection in May 2015, the service was rated Good. At this inspection we found the service remained Good.

The service was safe. Care staff had received training to ensure they knew how to recognise and report potential abuse. Risks to people were identified and these were monitored to enable trends to be identified and plans developed to help manage these from reoccurring. There were sufficient numbers of care staff available to meet people’s needs. Medicines were managed in a safe way and checks were carried out to ensure care staff were competent to administer people’s medication.

The service was effective. Care staff were provided with a range of training, and development opportunities to enable them to effectively support people's needs. Whilst staff had not always received regular professional supervision, plans were in place to address this in the future. People were assisted to have maximum choice and control of their lives and care staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. A variety of food and drinks were provided to enable people to have choices about their meals to ensure their nutritional needs were appropriately supported and maintained. People's medical needs were supported with input from relevant health care professionals when this was required.

The service was caring. People were treated with dignity and respect by care staff who provided their support in a caring, kind and compassionate manner. People and their relatives were included in decisions about the way their support was provided. People were able to live their lives how they chose, although some relatives wished care staff would spend more time engaging with people.

The service was responsive. People received their support in an individualised way, which was personalised to meet their needs. A variety of opportunities were provided for people to enable them to have meaningful social interaction and reduce potential risks of social isolation. People’s care plans were evaluated and reviewed to ensure they accurately reflected their wishes and preferences. People were happy with the service delivered and were able to raise their concerns and have these investigated and where possible resolved.

The service was well-led. The service had an open and inclusive culture and people, their relatives and staff were positive about the way it was managed. People’s opinions and views about the service were valued and considered to enable the service to learn and develop. A range of systems were available to enable the quality of service people received to be assessed and monitored to help the service to continually improve.

Inspection carried out on 4 May 2016

During an inspection to make sure that the improvements required had been made

This focused inspection was unannounced and took place on 4 May 2016. The last inspection at Anley Hall Nursing Home took place on 14 May 2015 and the service was meeting all of the regulations we assessed at that time and was given a quality rating of ‘Good.’

This inspection was carried out to follow up on concerns which had been raised with CQC. The person raising the concerns wished to remain anonymous. They made the following allegations:

• People were being left in a soiled condition,

• People not being bathed,

• Peoples health risks not being dealt with,

• Lack of staff training,

• Staff starting work without the relevant pre-employment checks,

• Falsification of medicine records,

• Medicines not being stored correctly,

• Medicines not being given as prescribed,

• People not being supported with dietary or hydration needs,

• People being moved around the service without just cause, and

• A spike in deaths during March 2016.

This report only covers our findings in relation to the above topics and focuses on whether the service was ‘safe, effective and responsive.’ You can read the report from the inspection in May 2015 which was a comprehensive inspection, by selecting the ‘all reports’ link for ‘Anley Hall Nursing Home’ on our website at www.cqc.org.uk

At this inspection we found that the registered provider was meeting the requirements, apart from some minor improvements needed with regard to specific care records which were discussed with the registered manager at the end of the inspection. The registered manager agreed to deal with these matters as a priority.

Anley Hall is registered to provide nursing care for up to 54 people, some of who may suffer from memory impairment, dementia, a physical disability or be terminally ill. The home is divided into two separate units; one is specifically used for people who are living with dementia. The home is a stone built country house, previously a private dwelling, and is situated in a rural setting on the outskirts of the market town of Settle, in the Yorkshire Dales. There are communal areas for dining and relaxation. Car parking is available in the grounds. On the day of our inspection 45 people were living in the home.

Anley Hall had a registered manager. 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.

People told us the service was kept clean and we saw this was the case when we carried out a tour of the building. Equipment, including wheelchairs and soft furnishings were also clean.

People told us they received a good standard of care. We saw detailed information in care records which showed that people were receiving care and treatment which was planned or based on their current needs. Information was up to date and relevant.

The registered manager had made statutory notifications which are required by law. Statutory notifications are matters such as safeguarding incidents, serious injury, expected and unexpected deaths.

People told us they were safe and well cared for and this view was shared by the staff and relatives we spoke with. The service had sufficient staff to meet people’s needs and staff had the time to ensure people were provided with a good standard of care.

Medicines were managed safely and people received their medicines at the correct time and as prescribed by their doctor. Staff giving medicines were well trained and competent. The service had safe systems to store, administer, order and dispose of medicines.

People told us the food was well prepared, good and tasty. People were given choices at each meal and had a varied menu. Staff, including the chef and catering staff, knew people’s individual likes and dislikes. Care staff understood the importance of people having enough to eat and drink and we saw people being regularly encouraged to eat and drink throughout our visit.

The service was working within the principles of the Mental Capacity Act 2005 and staff routinely sought consent from people and supported them to make their own choices.

People had access to routine health care professionals and where they needed more specialised support, this was sought as appropriate.

All of the staff we spoke with told us they enjoyed supporting people and this was clear in their interactions with people, which were patient, kind and warm. Staff told us about their commitment to make sure people were well supported, comfortable and happy.

Staff we spoke with told us they felt well supported by the registered manager and provider and had access to regular training and supervision. Staff morale was described as good by those we spoke with and there was clear evidence of staff working as a team for the benefit of people living at Anley Hall.

Inspection carried out on 14 May 2015

During a routine inspection

This inspection took place on 14 May 2015 and was unannounced. We last inspected this service on 3 November 2014 where we found breaches relating to care and welfare; quality assurance; infection control; nutrition and hydration; premises maintenance and staff training and support. We used our enforcement powers and issued a notice to the provider. We also asked the provider to take action to make improvements to the shortfalls identified in November 2014. The provider sent us an action plan telling us about the actions to be taken and that the improvements would be completed by 28 February 2015.

Anley Hall is registered to provide nursing care for up to 54 people, some of who may suffer from memory impairment, dementia, a physical disability or be terminally ill. The home is divided into two separate units; one is specifically used for people who are living with dementia. The home is a stone built country house, previously a private dwelling, and is situated in a rural setting on the outskirts of the market town of Settle, in the Yorkshire Dales. There are communal areas for dining and relaxation. Car parking is available in the grounds. On the day of our inspection 35 people were living in the home.

There was no registered manager at this service but there was a manager in post who had started the process of applying to be a registered manager with the Care Quality Commission (CQC). 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 this inspection we found the service had made major improvements in all the key areas we looked at. For example, staff understood what it meant to keep people safe and we saw that they had been trained in safeguarding adults. Handover information had improved between shift changes which provided clear information to ensure people’s care needs were more effectively communicated. Staff had been recruited safely.

Care records had been improved to ensure more detailed and accurate information for staff to be able to support people’s needs safely.

The risk of infection was minimised for people who used the service because staff were using appropriate measures to monitor and clean the service.

Staff administered medicines safely and in line with the prescribers instructions.

The service had carried out maintenance and redecoration around the premises to improve the overall environment.

Staff knew the people they cared for and were well trained in areas relating to the people living at Anley Hall. Strong teamwork with a more stable staff team enabled staff to work together to support people’s needs. People gave positive feedback about the service and how it had improved over recent months. Staff worked within the principles of the Mental Capacity Act 2005.

The service was caring. From our observations during the day we saw that staff knew people well. We noted staff approached and spoke with people in a kind and respectful way. People’s dignity and rights were promoted and staff empowered people to maintain their independence, be involved in their own care and contribute to the running of the home. Staff were at times task orientated, but the majority of interactions we witnessed were friendly, supportive and compassionate.

People were offered the opportunities to join in with activities throughout the day and staff were proactive in their efforts to minimise the risk of social isolation for some people who chose to spend time in their bedrooms or were being looked after in bed.

There was a new quality assurance system in place which used audits in each area of the service so that there was a consistent approach to maintain and improvement standards in the home.

There was an improvement in staff morale and staff reported a more cohesive way of working to help drive improvement. They also felt positive about the future of Anley Hall and paid tribute to how the new manager had embraced the leadership and guidance role and worked with staff to make sure the service was meeting peoples needs.

Inspection carried out on 3 November 2014

During a routine inspection

We inspected the home on the 3 November 2014. The visit was unannounced.

Our last inspection took place on 25 June 2014 and at that time the service was not meeting the requirements in relation to:

  • the care and welfare of people using the service;
  • meeting peoples nutritional needs;
  • staffing arrangements;
  • assessing and monitoring the quality of the service, and
  • record keeping.

For example, care and treatment was not always planned and delivered in a way that was intended to ensure people’s safety and welfare. In addition to this people were not protected from the risks of inadequate nutrition and dehydration because some people, who required assistance to eat and drink, were not supported appropriately. We also found, at the inspection in June, that there were not always enough qualified, skilled and experienced staff on duty to meet people’s needs; there was no effective system to assess and monitor the quality of the service and that accurate and appropriate records were not being completed.

Following our June inspection, we sent a report to the provider. An action plan was provided on 19 August 2014, from the provider, telling us what action they were taking to address the shortfalls and they would be complaint by 5 September 2013.

We found, during this visit, that the provider had not made sufficient improvements to address these matters and continued to be in breach of the regulations.

Anley Hall is registered to provide nursing care for up to 54 people, some of who may suffer from memory impairment, dementia, a physical disability or be terminally ill. The home is divided into two separate units; one is specifically used for people who are living with dementia. The home is a stone built country house, previously a private dwelling, and is situated in a rural setting on the outskirts of the market town of Settle, in the Yorkshire Dales. There are communal areas for dining and relaxation. Car parking is available in the grounds. On the day of our inspection 35 people were living in the home.

During this visit, we spoke with 17 people living at the home, four visitors, eight members of staff, and a visiting doctor. We carried out our observations in the communal areas.

The home has a manager, who at the time of our visit was absent from work and who has not yet completed a formal registration application to be registered with the commission. The provider had employed the assistance of a management company to oversee the running of the service in the manager’s absence. The management company includes an operations manager and two assistants. They were present in the service from Monday to Friday and available for support and advice on the telephone during other times.

Some people living in the home had complex needs and had difficulties with verbal communication. The staff had developed different communication methods in accordance with people’s needs and preferences. This approach reduced people’s levels of anxiety and stress.

Although people told us they felt safe in the home we found the service was not providing consistent safe care. We found there was a reliance on agency staff to cover staff absence and staff vacancies, that care records lacked detail, were inaccurate at times and that peoples nutritional and hydration needs were not consistently being met. Despite some positive comments from the people we spoke with we found the service was not effective. People had been found to be losing weight and in some examples we saw, no action had been taken to address this, people were not regularly supported when they were at risk of developing pressure ulcers and not everyone was being supported to eat and drink despite there being a clear need for this.

We also found the home was in need of some maintenance and there were malodours in some areas of the home.

People had not been routinely involved in planning their care, some people we met during the visit were dishevelled and attention was not given to people who had food spills on clothing or around their mouths after meals.

There were no clear lines of accountability and the home did not have an effective quality assurance system in place and there was no audit schedule. We found this put people at risk of potentially unsafe or inappropriate care. This meant people were not benefiting from a service that was continually looking at how it could provide a better service for people. This contradicted the view of the staff we spoke with who told us they were keen to improve the service.

We were unable to confirm what training staff had been given as the training records were not available during or subsequent to the inspection visit. Staff we spoke with talked about the training they had received but some of this was a considerable time ago or was due for updating.

Medicines were appropriately stored and administered overall.

Inspection carried out on 25 June 2014

During a routine inspection

One inspector carried out this inspection. During the inspection, the inspector focussed on answering five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we looked at records for four people who used the service. We spoke with the manager, five people who lived in the home and three relatives and two nursing and care staff. We reviewed records relating to the management of the home.

Below is a summary of what we found. The summary describes what people who used the service and staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found there were some issues with staffing levels and high use of agency staff within the home. Although staffing levels were now being monitored to ensure they remained safe, this was with a large percentage of the nursing and care staff being from agencies. There was no consistent use of the same agency staff so was often staff who had never worked in the home before. This meant they didn’t know people well and didn’t have a chance to read care plans before supporting them. This could have resulted in inappropriate care.

There were not sufficient arrangements in place in relation to organisation of staff during meal times which meant some people were not getting the support they needed to eat in a timely manner. This was putting people at risk of malnutrition and dehydration.

A programme of auditing and monitoring in order to maintain safety within the environment and with documentation as well as care was not being used sufficiently to ensure people were safe. There had been a large amount of injuries such as falls and there were ongoing safeguarding investigations being undertaken at the time of our visit.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safety within the service.

Is the service effective?

People had an individual care plan file which contained a number of care plans. We saw care plans contained information about people’s needs. The care plans we looked at didn’t always contain sufficient information and some were out of date or no longer relevant to the person’s current needs. There were risk assessments in some of the records which were sufficient to identify and minimise risks.

We spoke with people who used the service and they felt the support they received was meeting basic needs. People told us “Staff don’t have time to check whether we are okay or just to have a chat”, “The staff have helped me to improve and they always help you out”. A relative told us “My relative is always clean, appropriately dressed and has never complained about being hungry or thirsty. They have access to a call bell in their room”. When we spoke with staff they felt it was difficult to provide fully effective care due to staffing issues.

Food and drink provided was sufficient to ensure people had enough to eat and drink available and individual dietary needs were catered for well. However, lack of staffing at meal times meant some people were waiting a long time to be supported to eat. It was not clear if people were getting the support needed to eat sufficient amounts of food provided.

People we spoke with acknowledged there was a lack of appropriate stimulation and activities. We observed during our visit there were long periods where people were sat silently in communal areas or their rooms without any stimulation or interaction. One person said “Most people are bored – some people just go from their room to a chair and then back to their room again. That’s not living”.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to effective care within the service.

Is the service caring?

All the staff we spoke with were enthusiastic about providing caring and effective support. We observed during our visit that staff were friendly and caring with people when supporting them although most staff we observed seemed rushed and only had time to deliver basic care.

We spoke with people who used the service and they were reasonably complimentary about the support provided by staff. There was a general recognition from people who used the service and relatives that staff did their best in difficult circumstances. One person told us “I am assertive so I make choices. There are some carers who tell you where to sit”. Interactions we observed throughout our visit were reasonable. Staff spoke with people in a friendly and clear manner although it was clear some staff did not know people well and were unsure how to interact or support them appropriately. One relative told us “The staffing fluctuates. Sometimes there aren’t many staff around. The communication can be variable as staff need to get to know my relative to be able to understand them”. We saw numerous examples of people’s dignity and privacy not being respected including people in a state of undress in their rooms with the door open, people requiring personal care and this not being picked up by staff and people in inappropriate dress in communal areas.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to care within the service.

Is the service responsive?

There were audit systems in place regarding the environment, delivery of care, medication, documentation and people’s satisfaction with the service they received. This was designed to allow management to monitor the quality of service. However, these systems were not used appropriately and there was a lack of knowledge about issues in some areas. The new manager indicated that some areas highlighted during the inspection had already been identified and work had commenced to make improvements in these areas. The systems in place for highlighting issues and learning from accidents, incidents, surveys and resident meetings, staff feedback and complaints were not being used effectively at the time of our visit.

We spoke with people who used the service about the ways they fed back and how this information was used. Comments made to us included “I have raised concerns before and they listened but I am unsure if they did anything”, “There isn’t any point in raising things as they don’t do anything about it”. Relatives we spoke with were positive about raising concerns. One told us “I would raise things with the manager and they are always happy to take suggestions”. There was not any way to formally gather feedback from people who used the service in order to ensure improvements were in line with their wishes.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the responsiveness of the service.

Is the service well-led?

There was an inconsistent permanent staff team and a large amount of vacancies. Many permanent staff that worked in the service had done so for some time and knew people well. However there was very high usage of agency staff. This was not consistent agency staff but different people in a lot of cases. There was a reasonably high level of sickness, absence and vacancies within the staff team.

The manager had been in post for three months at the time of our inspection. We discussed the future of the service and the areas of priority. The manager had some clear ideas about how the service could improve and the ways this was being actioned. The manager identified some areas for improvement at the start of the inspection. However, the manager had initially spent time sorting out very basic issues such as staffing levels and had not yet been able to make improvements in other areas.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to how the service is led.

Inspection carried out on 21 June 2013

During an inspection in response to concerns

This inspection was carried out during the early morning after we received information of concern. We were told that people were being got up at 5am, not being dressed or washed properly, that the home was too short staffed to meet people's needs and staff had not been trained in moving and handling. We also received details of two safeguarding matters. One of these was historical and had been dealt with appropriately. The other was new information and we have referred the matter to the safeguarding local authority in accordance with our own procedures.

We used a number of different methods to help us to understand the experiences of people, including observing the delivery of care. We spoke with four people who used the service and all of the staff on duty. Everyone told us they were satisfied with the care they received. We saw records that showed what people preferred during their daily routines and evidence of person centred care plans.

We saw how staff supported people to make sure they were comfortable. People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People experienced care, treatment and support that met their needs and protected their rights.

Staff talked enthusiastically about their work, specifically referring to the recent improvements in team work. There were enough staff on duty to meet people’s needs. Staff were receiving training and this was being monitored by the manager.

Inspection carried out on 3 April 2013

During a routine inspection

Some people were not able to tell us about their experiences. We therefore used a number of different methods to help us to understand the experiences of people, including observing the delivery of care. We spoke with nine people who used the service and twelve visitors. Everyone told us they were extremely satisfied with the care they or their relative received. We saw records that showed people were involved in developing their care plans and that relatives or their representatives had been involved, if the person was unable to give their consent. We saw how staff supported people, at their own pace, to make sure they knew how best to meet a person's need.

The records we reviewed were generally accurate and up to date. However, some records were in need of some adjustment and amendment.

People were protected from the risk of infection because appropriate guidance had been followed.

We found staff were supported in their work and there had been recent improvements in the staff supervision and training programme. Staff talked enthusiastically about their work and said they were proud of the service they provided.

People looked well cared for and relatives told us they thought people were treated well and that their experiences in the home were positive.

The provider had a system in place to identify, assess and manage risks to the health, safety and welfare of people using the service. However, the record keeping in this area needs to be formalised.

Inspection carried out on 7 July 2012

During an inspection in response to concerns

We spoke with eight people and two relatives. Two people said they thought the staff were very 'caring' and that their relative was 'well looked after.' One person said their relative had settled in quickly because the staff were so good and that they were able to maintain involvement in their relative's care, which was important to them both.

Two people said they thought the home was clean, smelt nice and was kept tidy. One person went on to say that their relative’s room was kept 'nice and clean.'

Three people gave us examples of when there had been a delay in staff answering their nurse call system. One person recalled having to wait for up to half an hour on some occasions and that they had noticed a shortage of staff at evening times. One person told us that staff answered the nurse call system 'when it suited them,' therefore causing a delay. Three people said they had noted a reduction in staffing levels during the weekend.

Inspection carried out on 11 April 2012

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service, because some of the people using the service had complex needs, which meant they were not able to give us their views. We spoke to the relatives of two people. One of the relatives told us; "The food and service here is excellent. They are responsive to everything." The second relatives said; "It is absolutely excellent in everyway. They act on issues straight away."

A small number of the people we met during our visit were able to tell us what they thought about the service. Two people said they were 'very happy' at Anley Hall Nursing Home. One person said "It's great, it's a nice place to live." Four people said they were involved in their care, with their preferences being sought and taken into consideration. This included being enabled and supported to live their lives as independently as they wished. One person said they were able to express their views freely and that they aqfelt able to talk to any member of the staff team if they felt they needed clarification or something was worrying them.

People who were able to comment told us that they were happy with the care and treatment they were receiving. One person said "I am quite happy here. We get looked after very well" and another person said, "It's a good place. They look after you pretty well here."

Those people who were able to express their views said they 'felt safe' at Anley Hall Nursing Home. One person said "You feel safe in here" and two other people told us they thought staff 'protected' them.

Inspection carried out on 29 March 2011

During an inspection in response to concerns

People told us that they were well looked after, that the home was kept clean and that the food continued to be very good. People told us that staff are kind to them. People's general comments about their care were, 'If you need to be in a nursing home Anley Hall is the place to be. It is fabulous. Very well cared for here.' Another person said, ' The home is very nice I have settled quite well. We go out on trips and there are always activities.'

Everyone spoken to said that the food was very good and suitable for their needs. One person said 'I enjoy the food although I can be quite picky.' another said, 'The food is excellent. If you yearn for something they try to provide it.' and another commented, 'Food here is good they give you plenty.'

Visitors to the home made comments such as 'the home is very good and both I and my daughter are very pleased with the care here'.

When we spoke to staff they told us that they were able to attend various training they made comments such as, 'the training here is very good, the opportunities you get here are very good. You are not just a number you are a person.'

Reports under our old system of regulation (including those from before CQC was created)