All inspections: Lifestyle (Abbey Care) Limited Archery - Bower

We inspected Lifestyle (Abbey Care) Limited Archery-Bower on 26 July and 18 August 2017. The first day of the inspection was unannounced and we told the provider we would be visiting on day two.

At the last inspection in October 2016 we found the provider had breached 10 regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, person centred care, equipment and premises, dignity and respect, consent, safeguarding, staffing, recruitment, dealing with complaints and overall oversight of the home. Also Regulation 18 of the Care Quality Commission (CQC) (Registration) Regulations 2009 requirement to notify CQC of significant events.

We imposed a condition on the registered provider’s registration to prevent people moving into the service. This meant 15 people remained living in the service following our last inspection in October 2016 who required nursing and personal care. At this inspection we saw the provider had not continued to breach any regulations and therefore this condition will be lifted and new admissions will be able to happen.

We also imposed 10 conditions to require the provider to make improvements. The improvements needed related to recruitment to ensure suitable people were employed and that a review of each person’s care plan and risk assessments were carried out. The provider complied with these conditions and CQC removed them in June 2017 once we were satisfied they had been met.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months of the publication of the previous report. We expect services to make significant improvements within this timeframe. During this inspection the provider demonstrated to us that improvements had 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.

Lifestyle (Abbey Care) Limited Archery-Bower is a large purpose built property. The service can provide nursing and personal care for up to 60 older people some of whom maybe living with dementia. At the time of our visit 15 people lived at the service.

A registered manager was in post who had registered with us 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 registered manager is referred to as ‘manager’ throughout this report.

On day one of our inspection we saw issues were still evident with the recruitment of agency workers, medicines systems and management of complaints. The provider’s quality assurance system had not recognised these issues. We asked the provider to make improvements; this included a request that an independent and qualified representative of the provider complete an audit of the service. When we returned on day two we found improvements had been made and we no longer felt there were any breaches in regulations.

We discussed with the director how they must adapt their approach to quality assurance to ensure the service sustained quality and safety and that as the director they were alerted to when quality or safety was deteriorating. The director re-designed the system and implemented the changes following our inspection. We will continue to work with the local authority to monitor that such systems are effective. CQC need to see ongoing and sustained improvement to enable us to assess the service to be rated good overall in the future.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Risk assessments had been personalised to each individual and covered areas such as moving and handling, health and behaviour that challenged the service. This enabled staff to have the guidance they needed to help people to remain safe.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

We saw staff had received appropriate training and supervision on a regular basis. This included supporting nurses to ensure their fitness to practice was maintained. People told us there were enough staff on duty to meet people’s needs. The director had a plan in place to increase staffing as new people moved into the service and more resources were required, this included the recruitment of their own staff to reduce reliance on agency workers.

Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

There were positive interactions between people and staff. We saw staff treated people with dignity and respect. Staff showed they knew the people very well and could anticipate their needs. People told us they were happy and felt very well cared for. This included high satisfaction with the food and snacks available.

People had their health monitored well including nutrition. We saw people had access to healthcare professionals when required.

People’s care plans were very person centred and written in a way to describe their care, and support needs. These were regularly evaluated, reviewed and updated. We saw evidence to demonstrate people were involved in all aspects of their care plans.

People’s independence was encouraged and their hobbies and leisure interests were individually assessed. We saw there was a good supply of activities which were tailored to meet people’s preferences. People told us they enjoyed the activities on offer.

We carried out this inspection on the 25 October, 2 and 28 November 2016. The inspection was unannounced, which meant the staff and registered provider did not know we would be visiting.

Lifestyle (Abbey Care) Limited Archery – Bower had three inspections since the introduction of ratings in 2014. Initially in July 2014 the home was rated as inadequate. The home was in breach of seven regulations and we issued two warning notices. At a follow up inspection in February 2015 the home continued to be rated as inadequate. However, it was found that action had been completed to achieve compliance with breaches of regulation but continuing action was still needed in relation to staffing, governance and the need to obtain people's consent. A further inspection was conducted in September 2015 and we found although some improvements had been made the home still needed to take further action. We made recommendation to improve the administration of covert [hiding] medicines and quality assurance systems had not been in long enough to demonstrate an overall improvement and ensure it was sustained. We rated the home as requires improvement.

Lifestyle (Abbey Care) Limited Archery - Bower is a nursing home, providing care for people with nursing needs, some of whom were living with dementia. The home is part of the Abbey Care Village, located in the North Yorkshire village of Scorton. The home is a purpose built, two storey building, providing bedrooms with en-suite bathrooms. There is also parking and private grounds. Local pubs, a coffee shop and village shop are located within walking distance. The home can accommodate up to 60 people. On the first day of inspection we were told by staff that 27 people used the service.

The service has not had a registered manager since January 2014 and the nominated individual was acting as the 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. It is condition of registration that a registered manager is in place at the home.

We have written to the registered provider about their failure to meet this condition of their registration. To date no application to register a manager has been submitted. We are taking action outside of the inspection to deal with this matter.

We identified significant concerns during the visit and discussed these at length with the nominated individual and on 28 October 2016 we wrote to the registered provider to outline our serious concerns about the health, safety and wellbeing of people who used the service. On 1 November 2016 the registered provider agreed at the request of the commission to accept no more admissions to the home, until improvements had been made.

On 2 November 2016 we returned to Lifestyle (Abbey Care) Limited Archery – Bower to continue the inspection. We found that since our first visit five people had been admitted with one of these people being admitted on 1 November 2016. We found one person had passed away since our last visit and there were 31 people using the service. The acting manager who is also the nominated individual was unaware that a person had been admitted on 1 November 2016.

We found there were multiple breaches of regulations of The Health and Social Care Act (Regulated Activities) Regulations. The breaches were in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, receiving and acting upon complaints, good governance, staffing and fit and proper persons employed. But more seriously, there was a significant risk being posed to service user’s life, health and wellbeing. We found the impact of seriousness to people who used the service was risk rated as extreme or high

The nominated individual and registered provider were made aware of the risks posed to service users during our visit on 25 and 28 October 2016 followed up with a letter. No action had been taken between then and 2 November 2016 to mitigate these risks and people continued to be admitted into the home. In light of this we used our enforcement powers to prevent any more people being admitted to the home.

Following our visit on 2 November 2016, we continued to have serious concerns about the competency of the staff working at the home and their ability to ensure the safety of people who used the service. Therefore, we asked the registered provider to produce an action plan detailing how they would be reducing risks posed to people. They sent us an action plan we found was inadequate, with insufficient detail about how they intended to reduce the risks posed to people and who would be responsible to make sure risks would be reduced, so asked for this to be revised. On 14 November 2016 we received the revised action plan, again this failed to give sufficient detail about how the proposed measures that would reduce risks posed to the people who used the service.

In light of continued concerns we used our urgent powers and served a notice that required the registered provider to submit, on a weekly basis, information to confirm that sufficient staff were on duty at the home and that they obtained robust information from agencies about the staff they were supplying.

The notice required that the registered provider reviewed all of the people’s care plans and risk assessment to ensure these followed best practice guidance. Also that they reviewed medication practices at the home to ensure all service users received medication appropriately.

The registered provider was required to supply us with all of the information confirming that these actions had been taken, which they did.

During our inspection we found that the registered provider had not displayed the rating for the home either on site or on their website. This is a legal requirement that the CQC rating is displayed. The information about the home was now shown on their website but was not on display in the home. This was being dealt with outside the inspection process.

The registered provider had not sent notifications about incidents and DoLS authorisations, which are required under the Care Quality Commission (Registration) regulations 2009. We wrote to the registered provider about this failure and are dealing with this matter outside the inspection process.

During this inspection we found risks to people’s health or well-being had not always been assessed and plans were not always put in place to protect people.

Medicine practices were unsafe and medicines were not handled safely

Care plans and instructions from external healthcare professionals were not followed.

Action was not taken to reduce the risk of malnutrition. We found staff had not completed the MUST tool correctly and where people had lost weight a recording was made to say there was no weight loss. Where people required their weight to be recorded weekly or monthly, we could not find evidence that this was taking place consistently. This meant that people were at risk of becoming seriously ill.

Accidents and incidents were not monitored each month to see if any trends or patterns were identified. The form staff completed following an incident or accident was unclear and this meant it was very difficult to identify any patterns and therefore take action to reduce the risk.

We found people were cared for by insufficient numbers of suitably qualified and experienced staff. The nominated individual did not know which staff were on site at what time or which agency staff came to the home. This meant that if an emergency was to take place they could not account for who was in the home at that time. No names were recorded of which agency staff worked at the home, the rota just named them as agency.

Appropriate recruitment checks had not been undertaken before staff began work. The registered provider used agency staff to cover both nurse and care worker shifts. There was no information to confirm which agency staff member had been on duty at what time. No prior checks were done to ensure agency staff were suitable to work at the service. This meant that they could not be assured that staff had been working at the home or that unauthorised people were in the building.

People’s privacy and dignity was not always respected. For example staff compromised people’s dignity by telling them to soil in continence aids rather than taking them to the toilet and people were not bathed on a regular basis.

Appropriate recruitment checks had not been undertaken before staff began work. The registered provider used agency staff to cover both nurse and care worker shifts. There was no information to confirm which agency staff member had been on duty at what time. No prior checks were done to ensure agency staff were suitable to work at the service.

A nurse was employed at the home had an interim order from the Nursing and Midwifery Council (NMC) which set out conditions they needed to meet in order to practice. An interim order is a restriction or suspension of a registrant's registration with the NMC. In this case the nurse had restrictions in place. We found the nominated individual had not ensured these conditions were met. On 16 November 2016 the NMC suspended this nurse from practice because they had failed to adhere to the conditions that had been imposed.

Staff were working excessively long hours and although the nurse signed out of the building at 8am the

This inspection took place on 28 September 2015 and was unannounced. We last inspected this service on 4 and 10 February 2015 we found breaches relating to:

Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to staff failing to carry out person centred care.

Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2014, which related to the arrangements in place to ensure that staff were appropriately trained and supervised to deliver safe care and support to people

Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2014 which related to obtaining and acting in accordance with the consent of service users in relation to the care and treatment provided for them in accordance with the Mental Capacity Act 2005 and the Deprivation of Liberty safeguards.

Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2014 a failure to have effective systems in place to monitor the quality of the service delivery.

We found continued breaches in Regulation 12 (f) and (g) HSCA 2008 (Regulated Activities) Regulations 2014 relating to safe administration of medication and Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2014 which relates to appropriate and safe person centred care.

We used our enforcement powers and served warning notices to the provider in respect of Regulation 12 (f) and (g) and Regulation 9.

We also asked the provider to take action to make improvements to the shortfalls identified. The provider sent us an action plan telling us about the actions to be taken and that the improvements would be completed by 1 July 2015.

During this inspection we found the provider was no longer in breach of regulations and had made significant improvement to the service and the care people received. However some areas continued to require further improvement and we identified concerns about how these improvements are to be maintained in the longer term

Lifestyle (Abbey Care) Limited Archery – Bower provides nursing care and accommodation for up to 60 older people which included a dementia care service. The home has four areas, though only two were operational at the time of the visit and two units were closed. Each unit has a lounge and dining room. All accommodation has en-suite facilities. During our inspection there were 20 people living at the home.

Since the previous inspection the previous acting manager had left the service. The service was being run by the general manager who had responsibility for the oversight of three registered services. There is now a newly appointed acting manager in place 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.

This inspection was carried out to look at the five questions, is the service safe, effective, caring, responsive and well-led and to follow up on whether action had been taken to deal with the breaches. At this inspection we found the service had made improvements in all the key areas we looked at.

People told us they felt safe. Staff knew the correct procedures to follow if they considered someone was at risk of harm or abuse. They received appropriate safeguarding training and there were policies and procedures to support them in their role.

Risk assessments were completed so that risks to people could be minimised whilst still supporting people to remain independent. The service had systems in place for recording and analysing incidents and accidents so that action could be taken to reduce risk to people’s safety. However these systems are at an early stage and their ongoing impact on maintaining safety and quality needs to be monitored over time.

Medication was managed safely and people received their prescribed medication on time. Staff had information about how to support people with their medicines. We have made one recommendation with regard to improved systems to ensure people receiving covert medicines were receiving them safely.

Staff recruitment practices helped ensure that people were protected from unsafe care. There were enough qualified and skilled staff at the service and staff received ongoing training and management support. Staff had a range of training specific to the needs of people they supported.

Staff had received further guidance and training with regard to current good practice for supporting people living with dementia. They were able to speak more confidently about the issues and how this had impacted on their practice and improved the well-being for people they cared for. Our observations indicated that there was a better balance between tasks staff needed to complete and supporting people with their choices about how they were occupied and choose to spend their day.

People had their nutritional needs met. People were offered a varied diet and were provided with sufficient drinks and snacks. People who required special diets were catered for.

People were offered choices and staff knew how to communicate effectively with people according to their needs. People were relaxed and comfortable in the company of staff. People were provided with a range of activities in and outside the service which met their individual needs and interests. Individuals were also supported to maintain relationships with their relatives and friends.

Staff were patient, attentive and caring; they took time to listen and to respond in a way that the person they engaged with understood. They respected people’s privacy and upheld their dignity when providing care and support.

People’s rights were protected because the provider acted in accordance with the Mental Capacity Act 2005. This is legislation that protects people who are not able to consent to care and support, and ensures people are not unlawfully restricted of their freedom or liberty. The manager and staff understood the requirements and took appropriate action where a person may be deprived of their liberty.

People’s needs were regularly assessed, monitored and reviewed to make sure the care met people’s individual needs. Care plans we looked at were person centred, descriptive, and contained specific information about how staff should support people.

People knew how to make a complaint if they were unhappy and all the people we spoke with told us that they felt that they could talk with any of the staff if they had a concern or were worried about anything.

Staff spoke positively about the general manager who had taken a “hands on” approach to the day to day management of this service in order to address the areas of concern. Staff told us the general manager was supportive and encouraged an open and inclusive atmosphere. The staff we spoke with were aware of their roles and responsibilities and they told us that the general manager was a positive role model in providing a high standard of care. However the running of the service was now being handed over to an acting manager for this service who needs to register with CQC. This posed a risk that improvements made so far would not be maintained or that quality would not continue to be driven forward within the service.

The provider completed a range of audits in order to monitor and improve service delivery. Where improvements were needed or lessons learnt, action was taken. However these systems are at an early stage and their ongoing impact on maintaining safety and quality needs to be monitored over time.

We carried out an unannounced comprehensive inspection of this service on 22 July 2014 which was undertaken during the testing phase of our new approach to regulating adult social care services. During this inspection we found a breach of legal requirements. We undertook a comprehensive inspection on 4 and 10 February 2015 to follow up on whether action had been taken to deal with the breaches.

Lifestyle (Abbey Care) Limited Archery – Bower provides nursing care and accommodation for up to 60 older people which included a dementia care service. The home has four areas three were operational at the time of the visit and one unit was closed. Each unit has a lounge and dining room. All accommodation has en-suite facilities. During our inspection there were 25 people living at the home.

After our inspection of 22 July 2014 we asked the provider, that is, the legal entity that provides a regulated adult social care or healthcare service to members of the public, to write to us to tell us what they were going to do to meet legal requirements in relation to breaches of regulations identified at that inspection. The breaches were of Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of people who use services, Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service providers; Regulation 13 HSCA 2008 (Regulated Activates) Regulations 2010. Management of medicines; Regulation 14 HSCA 2008 (Regulated Activates) Regulations 2010. Meeting nutritional needs; Regulation 18 HSCA 2008 (Regulated Activates) Regulations 2010. Consent to care and treatment; Regulation 20 HSCA 2008 (Regulated Activates) Regulations 2010.Records; Regulation 23 HSCA 2008 (Regulated Activates) Regulations 2010. Supporting workers. The provider did not provide an action plan detailing what they were going to do to meet these legal requirements.

This inspection was carried out to look at the five questions, is the service safe, effective, caring, responsive and well-led and to follow up on whether action had been taken to deal with the breaches. At this inspection we found further breaches in regulations. You can see what action we told the provider to take at the back of the full version of the report.

People told us they felt safe. The acting manager and staff had undergone refresher training with regard to safeguarding adults from abuse. Staff were able to tell us what they would do if they suspected abuse had taken place.

Action had been taken to improve the safety and maintenance of the building and equipment used to support people. There was an action plan in place to ensure this continued.

Accidents and incidents were not analysed effectively. Risk assessments did not contain sufficiently detail and were not reviewed. This had a direct impact on some people’s health and wellbeing.

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.

Appropriate checks were completed to help reduce the risk of employing unsuitable staff. There were enough staff on duty and while there were plans to make sure staff had the right skills and knowledge to meet people’s needs this was not yet the case for all staff.

Some staff had received training with regard to the Mental Capacity Act (2005) and Deprivation of Liberty safeguards. However we found some practice still did not take into account people’s mental capacity and best interests.

We found improvements to the food and drink provided and people we spoke with told us they were happy with the improvements. The new chef provided nutritious and appetising looking meals.

We found people’s needs were still not being assessed sufficiently and inaccurate, conflicting information recorded in care plans resulted in some people not having their needs met.

The provider responded to complaints in a timely manner and people felt confident any concerns would be listened to and acted upon.

Although a new general manager had recently started in post, quality and monitoring of the service had not been previously been taking place. This meant improvements to the service had not been made in a timely manner.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection carried out on 22 July 2014.

Since May 2013 the provider had breached one or more regulations associated with the Health and Social Care Act 2008. At an inspection in August 2013 we found the provider did not have an effective system to assess and monitor the quality of service that people received. At the last inspection in March 2014 we found the provider still did not have an effective system to assess and monitor the quality of service that people received and they did not have appropriate arrangements in place for managing medicines. We told the provider they needed to take action and asked them to send us a report by 29 April 2014, setting out the action they would take to meet the standards. We did not receive a report of these actions. At this inspection we found improvements had not been made with regard to these breaches. We also found additional areas of concern.

Lifestyle (Abbey Care) Limited Archery – Bower provides nursing care and accommodation for up to 60 older people which includes a dementia care service. There were 26 people staying at the home when we visited. The home has four areas three were operational at the time of the visit and one unit was closed. Each unit has a lounge and dining room. All accommodation has en-suite facilities.

Although an acting manager had been in post for the last eight months, the provider had not ensured this person applied to be the registered manager. This is a breach of their conditions of registration and we are taking action separate to this process. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We saw that people received appropriate assistance to eat and drink, and enjoyed their lunchtime meal. However, we found the provider’s catering budget did not afford the opportunity to provide adequate fresh fruit and vegetables or for additional high calorific food to be made for people at risk of losing weight. Staff were not always identifying when people were losing weight. People’s nutritional needs were not being met.

People’s safety was compromised in a number of areas. During this inspection we found that people’s needs were not always fully assessed and at times staff failed to identify when people who used the service were at risk, for example of losing weight. Care planning was not always personalised so we could not be sure care was centred on people’s needs and preferences.

When we visited the home, people who used the service and their relatives told us they were happy with the service they received. People told us they were well cared for. We observed staff supporting people throughout the day and saw staff were caring, attentive and chatted to people when they provided assistance. Staff communicated with people in a respectful way.

People did not receive their medicines at the times they needed them and in a safe way. Medicines were not administered and recorded properly.

Staff were unclear about their roles and responsibilities in relation to safeguarding people. The management team had identified through recent safeguarding cases that staff did not understand safeguarding vulnerable adults procedures; Mental Capacity Act and Deprivation of Liberty Safeguards. Staff had not had the training necessary to deliver treatment to an appropriate standard.

Staff were not meeting the requirements of the Mental Capacity Act 2005, which meant people who lacked capacity were not being supported to ensure they received appropriate care. The provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards even though people’s liberty may have been restricted.

Although the acting manager was trying to make improvements in the systems for monitoring the service, the overall leadership and management of the home was poor. The provider did not have a system in place to effectively monitor the quality of the service or drive forward improvements. Staff we spoke with said the provider had not checked how the home was operating or spoken to them about the service. People had asked the provider to go to their last two ‘resident and relative’ meetings but they had failed to attend. Annual surveys were not completed. The provider had not completed any records to show they had completed quality and monitoring visits.

We found a number of 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.

Overall we found that the service was meeting people's health and welfare needs. The people who used the service and relatives we spoke with were generally positive about the standard of care provided. Comments made to us included 'The personal care of my relative is faultless. They always look well cared for' and 'I think the home has greatly improved over the last few months.' However, some relatives said that they were not kept sufficiently informed or involved in their relative's care and some felt that consistency of care between different staff and shifts could improve.

People's general nutritional needs were being met by the service. Comments made by people's relatives included 'I don't feel meals are rushed, staff treat people respectfully' and 'The food is good, good portion size and (relative) is eating very well and their weight remains steady.'

The home was clean and staff were aware of their roles and responsibilities in maintaining cleanliness and infection control. Suitable arrangements for supplying equipment, such as gloves, were in place.

We found that medication was not always being managed in a safe and effective way. This meant that people didn't always get their medication in the way that it had been prescribed.

Staffing levels were safe and suitable for the needs of the people living at the home at the time of our visit. However, the acting manager was at times being counted as the nurse for the downstairs unit, meaning that they were not supernumerary and unlikely to be able to fulfil both roles during those shifts.

We found that further improvements were needed to the way the provider monitored and assessed the quality of the service provided. Some improvements had been made, but these were in the early stages and there was still a lack of confidence in the provider's ability to make and sustain improvements among staff and relatives. For example, one of the comments we received was 'I have no faith in the change process and that it will result in the long term improvement of standards.'

Overall, we found that the home's records were of a reasonable standard and the difficulties we had identified during our previous visit had been resolved.

This was a follow up visit, to check that the required improvements had been made since our last visit.

Arrangements were in place to ensure that safety critical equipment was serviced and inspected regularly. However, the home still needed on-going maintenance to ensure that people had a pleasant place to live.

A suitable complaints process had been put in place. This included monitoring of complaints to ensure that they were being dealt with appropriately and to highlight any lessons learnt. Relatives and significant others were being encouraged to be involved in people's care and voice their opinions through regular meetings. However, there remains a long standing complaint that needs to be resolved and we will continue to monitor this.

We found that the service was now notifying CQC of appropriate events.

We carried out this visit because of concerns that had been raised with us regarding the provision of nursing staff during the weekend of 2nd to 4th August 2013.

We found that there had been a serious breach of regulation during the weekend in question. This had resulted in a lack of adequate nursing cover at the service, including a night shift when no suitably registered nurse had been on duty. Since this incident arrangements had been put in place to ensure nurses were on duty and prevent the risk of such an incident re-occurring. The provider has also provided ongoing assurances that appropriate nursing cover has been arranged.

We also found that the records relating to staffing during the weekend in question were not accurate or fit for purpose. They did not provide an accurate and reliable record of the staffing arrangements that had been in place.

We carried out this review because of concerns we had about the provider's ability to maintain on-going compliance with the regulations across their three services. Due to these concerns we carried out a focused review of the arrangements the provider had in place to assess and monitor the quality of service provision across their services. The review of this outcome included a visit by a professional advisor. Overall we found that the provider did not have an effective system in place to regularly assess and monitor the quality of service that people received. However, a new operations manager, with relevant experience in governance and quality monitoring, had recently been recruited to improve this.

We observed that people looked care for and that most staff were kind and well meaning. We saw staff responding to people and interacting with them well. However, we also saw that some staff had a better understanding of dementia care than others and this came across in the way they provided people's care. Relatives told us '(name of person) Is very much at home here' and 'They (staff) are very pleasant and thoughtful.'

People and staff told us that improvements should be made to the quality and choice of food provided. However, people's nutritional needs were being monitored by staff and people were having their basic nutritional needs met.

There were a number of maintenance issues that had not been dealt with promptly. Staff at the service told us that systems for getting maintenance work completed were not working well.

We found that the manager was often covering nursing shifts. This included working some very long hours, to ensure that there was a nurse on duty. New staff had been recruited to replace staff who had left, but agency staffing was not being used effectively to cover the shortfalls.

A number of people told us that they did not feel that their complaints had, or would be, dealt with properly. Records showed that the manager had dealt with complaints in accordance with their procedure. However, there was evidence that complaints brought to the attention of the provider for action had not always been resolved promptly.

We had received some information telling us that staff were having to cut up old towels and use them to wash people with, as there was not enough disposable wipes available for staff to use on the Archery unit of the home. When we visited the home we found evidence that this was happening. Although there were wipes in stock at the home they had not been made available for staff to use.

We were also told that there was no hot water in some areas of the Archery unit. We found some bedrooms where the hot water taps on the hand wash basin were not working, and the hot water tap in the kitchen/diner area of the unit was also not functioning. We asked the provider to get these fixed as soon as possible. We were told that the plumber would be on site the next day and that the taps would be a priority for them to repair.

We found that the service had made improvements. Comments made to the 'expert by experience' included, 'There is a great improvement and the puddings are lovely, that is something that has been changed for the better', 'I noticed how the food has altered, it has come on a lot', 'It is nice to have good and different food, you feel better inside', 'Food is lovely, beautiful, the teas have improved' and 'It's nice to now have a cooked breakfast, there is more choice at lunchtime and also at tea time.'

There had been changes to the menus, giving people the options of a cooked breakfast and two choices at each meal time. There was evidence that people's nutritional needs had been assessed and that other professionals had been involved where appropriate. People's care records highlighted their assessed nutritional needs and had been reviewed regularly. This included monitoring people's weight and recognising where people were at risk. Our observations showed that people were now being provided with meals, snacks and supplements that met their assessed needs.

However, we found some areas where minor improvements were still needed. Those areas were: Flexibility around the food that is provided if people do not want the main menu options. How people with dementia should be enabled to make choices about the food they want. Improvements to how care staff record people's fluid intake and their awareness of some people's specific needs.

We found that improvements had been made to the care people received, the way capacity and consent is considered, how staff use equipment, record keeping and how quality is monitored.

People told the Expert by Experience that they were looked after and generally happy with their care. Comments included 'the staff look after me very well, I would not want to be moved anywhere else'. Relatives we spoke to were either positive about the service, or told us that they had experienced problems but felt that things were now improving. One person commented on how their relative now appeared better looked after when they visited. Comments made to us included 'no concerns, we've never seen anybody roughly handled or spoken to inappropriately' and 'she's very happy here, quite settled'.

Our observations showed us that staff interacted nicely with people. We saw staff talking to people while they helped them and acting in caring ways. The Expert by Experience observed that 'the staff were very good with the residents, they spoke kindly to them and were respectful'.

However, we still have concerns that people's special dietary requirements are not being met. We observed that some meals and snacks did not meet people's assessed needs. People told the Expert by Experience that they would like more variety in the food that was provided. People didn't like the way they always got soup and sandwiches for tea and would like more than just a drink and biscuits for supper.

This was a focused responsive review, which was completed in response to whistle blowing concerns that had been brought to our attention. We completed this visit during the night and early morning, so most people were asleep for the majority of our visit. In addition to this the people using the service had complex needs which meant they were not able to tell us their experiences. However, we used a number of different methods to help us understand the experiences of people using the service, including observations, looking at care records and talking to staff.

We saw that staff carried out regular checks to make sure that people were safe and changed people who needed continence care during the night. Staff only started to get people up after 6am, if they were awake and appeared to want to get up. We could hear staff talking to people and explaining what they were doing while they provided people's care. We accompanied staff on their checks and observed that people did not appear to be wet, dirty or smell unpleasantly, as would be expected if insufficient night time care had been provided.

For this inspection we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed an inconsistent quality of interactions between staff and the people they were caring for. Some staff interacted well with people who use the service. However, at other times staff did not engage appropriately with the people using the service and we saw examples where people's privacy and dignity were not being maintained. For example, people wearing clothes that did not fit, people wearing other people's socks and people not getting baths as often as they should. We observed that the food provided did not meet everybody's needs. For example, we saw that snacks were not made available for people who needed a soft diet and the meal provided for one person with very special dietary requirements did not meet their needs. During our observations we also saw three examples of wheelchairs being used without footplates. This is bad practice and risks injury to the wheelchair user.

We spoke to health and social care professionals who had spent time at the home, working with people who use the service, their relatives and staff. They told us that some people's relatives had expressed satisfaction with the standard of care provided at the service and that they had observed good interactions between staff and the people they were looking after. However, they also told us that they had some concerns because staff were not consistently implementing best practice around mental capacity and best interest decision making.

We spoke to four care and nursing staff during our visit. The staff we spoke to told us that there had been some difficulties with staffing levels in the recent past, but also acknowledged that staffing had recently become more consistent, with comments including 'things now seem okay, I just hope it continues'. The temporary management told us how the staff rotas had been reviewed to make sure that adequate staffing was in place and that new staff were being recruited.

The provider and temporary management have acknowledged the improvements that are needed at this service and have started to take action. For example, a new manager and clinical lead have been recruited and are due to start work soon. They were also able to show us the checks, audits and management systems that were being put in place to improve care practice at the service. However, due to the concerns about this service we will be monitoring it closely and will carry out a follow up review to make sure that the provider has taken appropriate action to reach compliance.

This inspection was very focused and involved a specialist pharmacist inspector, who could look in depth at the way the service manages medication. We did not directly speak to people about their medication during our visits, but looked at people's experiences using observations, records and pathway tracking.

At this inspection we did not consult with people who used the service. Instead we spoke with the manager and staff at the home.

People told us they were very happy with the care and support they received at the home. They said the staff were kind and very caring.

On this occasion we did not speak to people who use the service. Instead we spoke to the manager and some staff who are employed a at the home and looked at some documentation associated with the recruitment and deployment of staff.

Many of the people who use this service could not tell us directly about their care due to a variety of complex needs.

We saw that people were relaxed with staff. They responded to staff and to us by making eye contact and smiling. Some people did shout out on occasion. Staff were patient with them and they settled again.

These are some of the comments staff made:

'(they are) well cared for'

Relatives of people living at the service told us:

'quite happy'

'(name of person) is quite settled'

'on the whole, well cared for'

'(name of staff member) brilliant, good at her job'

Archery unit was calm during the course of our visit and people seemed to be settled. We saw that staff were situated in the lounges, supervising people, on both units. One person who was being nursed in bed was given the care he needed, including drinks and snacks, for example this person had cake with cream and a cup of tea in the middle of the afternoon.

These are some of the comments staff made:

'slight improvement'

'still worried (about staffing)'

'work well as a team and do the best we can'

'none get missed out'

'quite stressful'

'a little bit behind (with records)'

Staff told us that they felt that the staffing levels were 'OK' currently but that it could still be quite difficult sometimes. One member of staff commented that the majority of people really needed two staff to see to them.

Staff told us that the provider expects records to be completed within the shift and sometimes this is hard with all the demands that are made during the shift. For example, the nurses have to help get people into bed and provide people with support at mealtimes.

We spoke with people who were visiting the service and these are some of their comments:

'(staff are) spread a bit thinly'

'never many people about'

'initial improvement, none since then'

People we spoke to had different views of the care and service provided at Lifestyle (Abbey Care) Limited Archery ' Bower. Some relatives told us that they were happy with the service that was provided, that staff were helpful and their relatives appeared to be well looked after. However, some people were less happy and gave examples of times when they felt that people's needs had not been met by staff.

A number of relatives and staff expressed concerns about the staffing levels on the upstairs unit. Relatives said that the individual staff were 'good', 'top class' and 'fantastic', but that they were also 'run ragged', 'overloaded' and 'do their best with the staff they have'. People felt that the upstairs unit now needed more than one nurse on duty to adequately meet people's needs.

Some of the relatives and other professionals who visit the home have expressed concern about the language skills and understanding of some of the service's staff whose first language is not English. We were told that some staff have good English language skills, but people also gave examples of times when they had experienced difficulty getting staff to understand them.

People also told us that they did not have confidence that they would be treated fairly and respectfully by staff if they raised a concern. For example, one person told us how staff had ignored them when they visited, after raising concerns with the home's management.

These older reports are from our old approaches to inspection, including those from before CQC was created.

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