Manton Heights Care Centre Also known as Ranc Care Homes Limited

Manton Heights Care Centre is a residential care home split in to two buildings providing accommodation and personal care for up to 91 people aged 65 and over some of whom were living with dementia. The main building consists of three units, two units are on the ground floor and a third unit is on the first floor. There is a shared dining room and lounge in each unit and one shared garden. At the time of our inspection one of the ground floor units was closed for refurbishment. The service was supporting 43 people in the main building and 12 people in the building which supports people living with an acquired brain injury.

People’s experience of using this service and what we found

There had been a lot of improvements put in place since our last inspection. People, relatives and the staff team were positive about their experiences at the service. One relative told us, ‘‘I would recommend Manton Heights to anyone. The staff are very caring.’’

At our last inspection we found the provider to be in breach of several regulations of the Health and Social Care Act (2008). Due to the improvements made since the last inspection the provider was no longer in breach of regulations.

People were safe living at the service. Staff knowledge about keeping people safe and safeguarding, was mostly good. Staffing levels were sufficient to keep people safe, although some further areas for improvement were identified at certain times of the day. Staff recruitment checks were thoroughly completed. Recruitment was also ongoing to ensure that a consistent staff team would be in place. People received safe support with their medicines, however some areas for further improvement were identified at this inspection.

Assessments were completed to ensure risk to people was minimised and staff had a good understanding of these.The service was kept clean and infection control measures were thorough, including with regards to COVID-19. When things went wrong an analysis took place to see where improvements could be made and acted upon.

Staff had the experience, skills and knowledge to do their job and the management team were supporting new staff to become core members of the staff team. People were well supported with food and drink according to their needs and preferences. Health professionals were consulted to support people to maintain their health and wellbeing. The service engaged and worked well with external partners.

The premises were suitable for people using the service and the management and staff team were focusing on people’s lived experiences of using the service. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People, relatives and staff were asked for feedback about the service.

The new manager and the provider were passionate about continuing to improve the service. They were aware of areas that still required attention, including those found during this inspection. Audits identified areas for improvement and the provider had an action plan which they were monitoring. There were still areas for improvement to be made and the manager and senior management team understood the feedback we and other professionals gave about these.

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

Rating at last inspection (and update)

The last rating for this service was inadequate (published 13 October 2020).

This service has been in Special Measures since 08 September 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service could respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced inspection of this service on 01 to 08 September 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve in the areas of Safe care and treatment, Safeguarding service users from abuse, Staffing, Good governance, Duty of Candour and failing to notify CQC of incidents the service is required to do by law.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manton Heights Care Centre on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Manton Heights Care Centre is a residential care home providing accommodation and personal care for up to 91 people aged 65 and over.

The service is split into two buildings on one site. One building supports people with an acquired brain injury and the main building supports people living with dementia. The main building consists of three units, two units are on the ground floor separated by a locked door and a third unit is on the first floor.

At the time of our inspection, the unit manager of the brain injury unit told us they were supporting 12 people. The manager of Manton Heights Care Centre told us there were also supporting 74 people in the main building. There is a shared dining room and lounge on each unit and a shared garden area.

People’s experience of using this service and what we found

We inspected the service to review outcomes of the actions the provider had told us they would implement after we identified numerous concerns to safe care and treatment of people at the previous inspection on 30 July 2020.

People were still a risk of unsafe care and treatment as systems had not yet been fully implemented to effectively monitor staff practices and understanding of the requirements of their roles.

Some people continued to experience alleged abuse and incidents resulting in injuries which were not always reported and acted upon appropriately by the provider and senior managers.

People were supported in the main by staff who were not yet sufficiently trained in areas of identifying abuse and who did not have the understanding of how to report it. Staff had not yet received the required training and supervision to develop their practice.

People’s medicines were still not always administered and recorded safely meaning they were at risk of over dosing or missing medicines.

The provider had systems in place to monitor care and incidents at the service and to investigate concerns raised. However, these have proven to be ineffective in identifying the concerns we found during the inspection process and when external complaints had been received.

Staffing levels for care staff had improved which meant people were less likely to wait for care or to be alone in their bedrooms and communal areas for long periods of time.

People and relatives gave mixed reviews of their experience but were mostly positive and agreed that the service culture and atmosphere had improved since the change of management. One person told us, “[Staff] attitude is always helpful and empathetic. I have only had to complain once about a staff member, it was their approach but we have now ironed out this misunderstanding.” Another person said they sometimes had to wait up to 10 minutes for support with using the toilet.

Relatives told us they had concerns previously about staffing levels and people not always receiving personal care. Relatives also said senior managers were not always responsive to complaints. However, they felt these had now been addressed since the new manager had been in post.

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

Rating at last inspection (and update)

The last rating for this service was inadequate (published 08 September 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations and the service remains in special measures.

Why we inspected

We undertook this targeted inspection to check whether the actions the provider had stated would be taken following the previous inspection on 30 July 2020 had been implemented. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified continued breaches in relation to reporting and acting on safeguarding concerns, medicines administration, staff training and development and poor provider and managerial oversight of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Manton Heights Care Centre (Manton Heights) is a residential care home providing accommodation and personal care for up to 91 people aged 65 and over at the time of the inspection. The service is split into two buildings on one site. One building supports people with an acquired brain injury and the main building supports people living with dementia. The main building consists of three units, two units are on the ground floor separated by a locked door and a third unit is on the first floor. At the time of our inspection, the main building was supporting 60 people. There is a shared dining room and lounge on each unit and a shared garden area.

People’s experience of using this service and what we found

The management did not ensure staff were sufficiently trained and supported to understand and fulfil the requirements of their roles and provide safe care. Most staff were not aware of what abuse looked like and how to report it. They were unclear about their duty of care responsibilities to seek appropriate medical support for people who needed it.

Staff told us they often worked below the required staffing levels in practice due to staff shortages and how tasks were deployed. This meant they did not have time to spend quality time with people and ensure people remained safe. As a result there have been a significant number of falls and safeguarding incidents at the service. One serious case is currently being investigated by the safeguarding team.

This also impacted on safe administration of medicines. Medicine rounds times took so long there was a risk that people who received medicine again at the next round could be overdosed due to insufficient time gaps between doses.

People and relatives gave mixed views about the care at Manton Heights. Some people told us they felt safe and although they said there was not enough staff, they were happy living at the service and that staff treated them well. People told us they would like staff to be able to sit and spend time with them. They felt the home was kept clean and the food was good. Some relatives agreed with this view.

However, other people told us the home had deteriorated over the last nine months with many staff leaving resulting in a shortage of staff and often having to wait longer periods when calling for assistance.

People told us staff did not have time to talk to them and they found that management was unhelpful and at times unprofessional in their attitude. Other relatives were very unhappy at the level of poor care and failure to seek appropriate medical support. They also felt there was a lack of responsiveness when raising complaints and poor communication generally.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The provider had systems in place to monitor care and incidents at the service and to investigate concerns raised. However, these have proven to be ineffective in identifying the concerns we found during the inspection process and when external complaints had been received.

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

Rating at last inspection:

The last rating for this service was requires improvement (published 03 June 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

The inspection was prompted in part due to concerns received about the management of people’s care needs and falls in the service. There had also been a specific incident of harm currently being investigated by the local councils safeguarding team, low staffing levels and the managers attitude and style of management was also a concern. A decision was made for us to inspect and examine those risks. We undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous focused and comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Following discussions with the provider about these concerns they have recognised improvements to their systems and management of the service needed to improve. They have started to implement plans for change but these were not yet fully in place at the time of the inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manton Heights Care Centre on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safe management and reporting of falls, failure to ensure staff are sufficiently trained and supported to fulfil their roles and safe and effective monitoring of the service at this inspection.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Manton Heights Care Centre (Manton Heights) is a residential care home providing accommodation and personal care to up to 91 people. The service comprises of two purpose-built buildings on one site. The main building provides care in three units including one specifically supporting people living with dementia. The second building supports people living with acquired brain injuries.

People’s experience of using this service and what we found

Risk assessments were not always sufficiently detailed and, in some instances, had not been completed at all. This, and a lack of incident reporting and analysis put people at risk of harm.

Staff felt overstretched. Not all incidents had been reported, and this may have had a negative impact on how staffing requirements were calculated. We have recommended the provider explores good practice guidance in relation to incident reporting and uses this to support the calculation of staffing numbers required to meet people’s needs.

Although pre admission assessments had been completed they lacked essential detail. Staff completing these did not understand how to use the system and consequently completed them incorrectly. It was established during the inspection that the provider had a new, simpler system in place now, but this had not been used by Manton Heights. Care plans and priority risk assessments were not developed in a timely manner following a person’s admission to the service. This meant people were put at risk because staff did not have the right information with which to support them well.

Medicines were managed safely, and people were supported to have their health care needs met. They had enough to eat and drink and were supported by staff to make choices about this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, where decisions had been made in people’s best interests, this was not always recorded and the rationale for any restrictions in place had not always been clearly identified.

Staff were checked as suitable before they started work, received an induction and training to support them to carry out their duties well. However, the induction for the new manager had not been completed in line with the provider’s policy. They had been left with insufficient support in the first weeks of their role. This, and the lack of a deputy manager meant team leaders and senior staff were under more pressure to carry out more leadership duties. Without time off the care rota for them to do this, the impact on people was team leaders had less time to ensure their needs were being effectively met.

Although the provider had quality monitoring systems in place, they had not been effective in identifying the issues we found at this inspection. However, the provider had recognised the need to make improvements and was in the process of rolling out a new governance system to all their services.

The service was clean, and staff were trained in infection control and followed robust processes in line with their training to reduce the risk of cross contamination. The provider had a robust and continuously updated strategy for protecting people from the risk of Covid 19 infection.

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

Rating at last inspection

The last rating for this service was Good (report published 8 March 2019)

Why we inspected

The inspection was prompted in part by information shared with us about two specific incidents. Following one of these incidents a person died. This incident was subject to a criminal investigation at the time of the inspection. This was discontinued on 12 May 2020. As a result, this inspection did not examine the circumstances of the incident. We looked into the other incident where interactions between two people using the service had put one person at potential risk of serious harm.

The information CQC received about these incidents indicated concerns about the management of admissions, falls and behaviours that may put the person or others at risk of harm. This inspection examined those risks. We undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

The manager and the provider were very responsive to our feedback about the improvements required at the service. On the second day of the inspection we found they had already taken steps to improve support to the service and to start making the necessary improvements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Manton Heights Care Centre on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

We found significant improvements had been made to the service since our last inspection. The registered manager, with the support of a new deputy manager, had worked very hard to address the issues identified at the last inspection. They had put measures in place to embed good practice within the culture of the service. A staffing restructure, including the appointment of several new staff had supported this process. The provider had started work with a leading dementia care expert to drive a new dementia care strategy across the whole organisation. This showed the provider was committed to developing the service in line with recognised good practice guidance.

At the last inspection, the unit for people living with an acquired brain injury was not running yet. At this inspection the unit was now running having opened in November 2018.

People told us they felt the care and support they received at Manton Heights was safe. Risks to people were identified and monitored. Clear guidance was in place for staff on how to support people with these risks.

Staff understood their responsibilities to safeguard people from harm and how to report their concerns internally and externally to local safeguarding authorities.

Staff treated people kindly. There was a significant improvement in the way staff spoke with people. People`s personal information was kept confidential and their dignity and privacy was promoted and respected by staff.

Care plans had been fully updated and significantly improved since the last inspection. They were detailed and personalised to give guidance to staff on how to support people effectively. Where people displayed behaviour that might be perceived as challenging, clear guidance was in place to support staff to work positively with the person.

Medicines, including ‘as required’ medicines. were managed safely and people worked with other healthcare professionals to meet people’s health related needs.

People were encouraged to eat a healthy balanced diet and to have enough to drink.

People and their relatives were involved in discussions about their care.

Staff encouraged people to maintain their interests and take part in activities, and most people felt they had enough to do.

There were enough staff to meet people`s needs. Staff had regular supervision and training in subjects considered essential by the provider to develop their skills and knowledge. Staff had additional training in relation to people’s specific support needs, such as dementia.

The provider`s governance systems and processes had improved and the registered manager had a clear plan in place to continue to develop these systems to support ongoing improvements.

Rating at last inspection:

At the last inspection in June 2018 the service was rated ‘Requires Improvement’ with one domain (caring) rated as inadequate. We found several breaches of regulations. Improvements were needed in the care of people living with dementia, particularly where people displayed behaviour perceived as challenging, the way staff treated people, the management of ‘as required’ medicines, the way incidents were managed, how staff training was embedded and the management oversight of the service. We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had made improvements and there were no breaches.

Why we inspected: This was a scheduled inspection based on the previous rating to assess improvements the provider had made.

Follow up: We will continue to monitor Manton Heights and will return to inspect in line with our methodology.

Manton Heights is a ‘care home without nursing’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Manton Heights accommodates up to 79 people in one purpose built premises across three separate units. There is a fourth unit which is currently not in use. One unit is primarily for people with needs related to living with dementia and the other two units support people with residential needs. At the time of the inspection there were 64 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had effective recruitment processes in place. Although we identified some gaps in the employment history for some staff, administrative staff were aware of this and work was underway to address this. There were sufficient numbers of staff to support people but some lacked the skills and knowledge to do this safely and effectively.

Staff understanding of their roles and responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) required improvement. Staff did not always gain people’s consent before they provided care or support to them.

Risk assessments were in place that gave guidance to staff on how risks to people could be minimised without compromising people’s independence. However, these lacked detail in some instances and were not always regularly reviewed.

Staff supervision was provided regularly. However, training to enable staff to support people well was not up to date and some staff lacked skills in relation to people’s specific needs.

Staff engagement with people was varied; some staff spoke kindly and were respectful to people whereas others were task orientated and were not respectful in all their communications with people.

Care plans took account of people’s individual needs, preferences, and choices but lacked sufficient detail to ensure staff were able to meet people’s needs well in all areas.

The provider’s values were not known or understood by all staff and the culture was task oriented and did not put people at the heart of the service. The registered manager aimed to promote a person-centred culture within the service but a clear strategy for how this would be achieved was required.

The provider had quality monitoring processes in place to ensure they were meeting the required standards of care, but although many of the issues identified at this inspection had been identified, action towards achieving the necessary improvements was not clearly in evidence.

People were supported to pursue their interests.

The provider had a formal process for handling complaints and concerns.

Medicines were administered safely and people were supported to access health and social care services when required.

Manton Heights Care Centre is a purpose built care home with accommodation provided from three units over two floors. The home currently provides residential care for older people and people with dementia care needs. On the day of our visit, they were providing care and support to 71 people.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that risks to people’s safety had been assessed, with plans in place to mitigate these, particularly in respect of falls. Staff had taken into account the risks to which people were exposed and had worked hard to ensure areas were free from obstacles and that equipment was well maintained. People had risk assessments which identified the hazards they may face and which provided guidance to staff on how to manage any risk of harm.

Accidents and incidents were recorded and the causes of these overviewed and analysed, so that preventative action could be taken to reduce the number of occurrences.

There were appropriate numbers of staff on duty, at day and night, to ensure that people’s needs were met in a safe and timely manner.

We re-inspected in August 2014 and found that the provider had achieved compliance in care and welfare, medicines management, infection control, nutrition and quality monitoring. In order to ensure that action had been taken to address the remaining outstanding non-compliance, that we did not check in August 2014, we inspected the service again in September 2014, to review the management of safeguarding and staffing at Manton Heights Care Centre.

The inspection was conducted by two inspectors. At the time of our inspection, there was no registered manager but the service had employed a new manager who was due to commence employment in October 2014. We spoke with the deputy manager, six care workers, two ancillary staff, two people who lived in the home and one relative. We looked at staff rotas, safeguarding records and policies and procedures.

During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer our key questions that were relevant to the outcomes we looked at; Is the service safe? Is the service effective? Is the service caring? Is the service responsive?

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

Is the service safe?

Care staff had been trained in the safeguarding of vulnerable adults and were aware of the processes they should follow should they have safeguarding concerns. We found that risk assessments had been undertaken for staff and people with particular needs and requirements to ensure they remained safe.

Emergencies measures were in place and the people who lived in the home had personal evacuation plans.

Is the service effective?

People and their relatives told us they were satisfied with the quality of care that had been delivered and had noticed an improvement over recent weeks.

Is the service caring?

We found that the people who lived at the home were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff provided encouragement, reassurance and practical help. Requests for assistance were responded to promptly.

Is the service responsive?

We found that the numbers of staff on duty enabled them to provide timely support for people and to meet people's needs effectively. Staff told us that the home was much calmer and that they now had time to spend with people and 'do everything we need to.'

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive to people's needs?

' Is the service well led?

This is a summary of what we found:

Is the service safe?

All of the people we spoke with told us they felt safe living at Manton Heights Care Centre. One person said, 'The staff have time for us now.' A visitor told us that the service was calmer and they felt more attention was given to their relative. We observed that plans of care included risk assessments to promote people's safety, such as assessments for malnutrition, the risk of falls and moving and handling assessments. We also observed staff used safe moving and handling techniques.

Staff understood infection control processes and demonstrated how they would reduce the spread of infection.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DOLs). We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. They had sought appropriate advice from the local authority following the recent changes in guidelines.

Is the service effective?

Steps were taken to involve people in making decisions about their care and support by involving them in their care planning. It was clear that people had stated their preferences, particularly in relation to their food likes and dislikes and their preferred name.

Staff we spoke with had a good understanding of people's needs and knew how they preferred to be supported. This meant people were supported appropriately in relation to their needs

Is the service caring?

Staff now spent time interacting with the people who used the service and were able to provide a range of activities to stimulate them. This was particularly noticeable in the area of the home where people lived with dementia.

We saw evidence that staff sought the support of care professionals, for example a G.P. correctly.

Is the service responsive?

The staff team had received updates of their training to ensure they had the experience and qualifications to meet people's needs. This had been achieved in part by moving people with high needs to more suitable accommodation, following the last inspection.

During our inspection we observed that call bells were answered in a timely fashion and any requests from people were responded to. This meant that there was minimal delay in people receiving the attention they needed.

Activities were planned to help stimulate people and people told us these were varied and catered for all interests. One person said, "I don't know what scrabble is and I can learn."

Is the service well- led?

The service did not have a registered manager. However, recently a new manager had been employed and was committed to remaining until a registered manager was in post.

Quality assurance procedures were in place, however, they had not been in place long enough to prove their effectiveness and will be tested during future inspections.

Below is a summary of what we found. The summary is based on our observations and conversations with people during the inspection. We spoke with three relatives, twelve people who lived in the home and nine members of staff.

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

During our inspection on 23 and 24 June 2014, we witnessed examples of inadequate standards of care within Carlton Unit (the Nursing Unit of Manton Heights Care Centre). For example, poor manual handling practices, a lack of support from staff to assist people with their lunch time meals and a lack of supervision and monitoring for another person who exhibited high levels of anxiety and was at risk of falling. We found these omissions had a significant impact upon people's health and safety and placed their care and welfare at risk.

We found that people were not kept safe as their assessments of need were not completed or reviewed on a regular basis. This meant that records were not reflective of people's needs and that staff were unable to accurately identify people's current needs so they could deliver safe and appropriate care.

We found that staffing levels were not conducive to enable staff to safely meet the needs of the people within Carlton Unit. Some residents, relatives and staff expressed their concern to us about this. One member of staff told us, 'The place is in a mess, it's unsafe and we shouldn't have nursing.' Another told us, "It's awful, there are not enough nurses to look after people."

The associated impact of the reduced staff numbers on people's care was that some had not received basic elements of required care, including pressure care and monitoring of nutritional intake. This increased their risk of developing further complications, for example, skin integrity issues and nutritional concerns.

We found information in one person's care records to suggest they had an infectious condition. However, we found no evidence to suggest that the correct infection prevention control measures were being used by staff. This placed the person, other service users, visitors and staff at risk and meant that the condition could be transmitted to other people, because effective infection control systems were not utilised.

We observed that staff did not consistently handle medicines in a safe way. We found some people had not been given prescribed medication for particular conditions which required specific doses, and some had failed to receive required pain control when this was needed. This meant that people were left without important medicines and at risk of uncontrolled pain or potential relapse in their condition.

Is the service effective?

Although we found that people had their needs assessed prior to admission, we saw that since March/ April 2014, some people's care plans and risk assessments had not been reviewed or evaluated. This meant they had failed to receive required care interventions which had led to deterioration within their condition, for example within skin integrity. The delay in records being updated meant staff did not have an accurate guide as to people's current care requirements.

Care plans did not provide sufficient detail for staff as to the care people required. For example, we found that care plans and risk assessments did not include details of the size of sling to be used during hoist transfers; the air flow settings that individual pressure mattresses should be on or the size of continence pad to be used for people. This meant that people were at risk of not being cared for safely and effectively.

Is the service caring?

We found that some staff interactions were not always respectful. For example, when we intervened on behalf of one person who was distressed, we were told, 'That's how [the person] always is. There is nothing we can do.' This demonstrated that staff did not always support people with their respect and dignity in mind.

We observed a lack of activities for people on Carlton Unit and found that people were not stimulated. People told us that staff did not engage with them about matters that were important to them. Some people's care plans indicated that they enjoyed particular activities, for example tennis and gardening but we found no evidence that this was acknowledged by staff.

Is the service responsive to people's needs?

We found that the medication systems in place within Carlton Unit were ineffective and that people's prescriptions were not always available when required. This meant there were delays in people receiving prescribed medication. One person, whose medicine had run out, required a visiting professional to write a short term prescription to enable the unit to access the medication quickly. This person had suffered as a result of the unit's failure to ensure effective systems were in place.

Since our last inspection in April 2014, the local authority and complex care teams had been providing regular support to the provider to address the issues of concern that had been identified. Despite these interventions, the service had failed to sustain the required improvements and was not being responsive to people's needs.

Is the service well- led?

The home did not have a registered manager in place. We found that the interim management of the service had not consistently demonstrated characteristics of strong leadership. It was evident that the home had suffered from a lack of stability within its management structure.

We found a lack of effective quality assurance and governance processes in place. The service was not therefore able to effectively identify whether care plans had been evaluated, recognise trends in relation to pressure wounds or to manage efficient infection prevention control systems. Some staff told us they felt unsupported and had not received supervision or had the opportunity to give their feedback about the service. This demonstrated that the service had failed to identify that care plans and risk assessments were not being updated or reviewed on a regular basis or to acknowledge that staff felt unsupported, through its own internal monitoring systems.

We shared our concerns with Bedford Borough Council (BBC) and the Complex Care Team who commenced reviews of all people who lived on the nursing unit, to ensure people were protected and no longer exposed to poor care practices. We will report further on all the action we took in due course.

The five questions we ask about services and a summary of what we found:

Is the service safe?

We found that Manton Heights did not consistently have enough staff to meet the needs of people who used the service. The impact on people's care was, that on occasions, they had to wait for long periods to receive required interventions. This meant that people did not receive care at the time they wanted or to suit their preferences. Some residents, relatives and staff told us that, particularly at weekends and meal times, there was not enough staff on duty to ensure that people were cared for safely. The records we found, and our observations confirmed this to be the case at times. We found that although the staffing ratio facilitated people to receive appropriate care, that the delivery of care was not always timely.

Individual care plans and associated risk assessments were updated regularly and generally contained sufficient detail to guide staff and ensure that people were protected from harm. We found that people were protected from potential abuse because the staff understood their role in safeguarding the people they supported. The home did not however have robust processes in place for the administration, ordering and recording of medicines. This meant that staff did not consistently handle medicines in a safe way.

Although there was a system in place to make sure that manager and staff learnt from events, such as accidents and incidents, complaints and concerns, this was not utilised effectively or consistently. We found that despite quality audits taking place, these were not analysed effectively and action plans were not completed to drive improvement. This increased the risk of harm to people and meant that lessons were not always learned from mistakes or areas of concern.

Is the service effective?

People had their needs assessed prior to admission and again on a regular basis. We found staff had a good understanding of what people's care needs were and when they had changed. We noted that people were involved in decisions about their own care and that relatives or representatives were included in the decision making process. Care plans provided sufficient detail to guide staff as to the basic care required and were updated regularly. Records showed the service engaged with other professionals to ensure that all aspects of people's care were appropriately attended to.

We observed staff talking with and assisting people; we found this was done with people's privacy and dignity in mind and reflected the support plans we viewed on the day. We found that staff had a good awareness of people's individual dietary needs and supported them to maintain a healthy dietary intake, whilst enabling them to make independent choices.

People's mobility and other support needs were taken into account in relation to signage and the layout of the premises, which enabled people to move around freely and safely. Within the dementia units, we found the corridors were long and wide, which gave people the freedom to move about with ease. We did however find that some of the signs in the dementia unit, although pictorial in nature, were similar, meaning that there was nothing to assist people to identify individual bedrooms.

Staff training and supervision was not up to date which meant staff did not consistently receive the support they required, in order to develop personally and professionally. The lack of current training potentially impacted upon people, who were at increased risk of not having their needs met appropriately, because of staff knowledge not being up to date. Some staff told us they did not always receive effective support within the home and that the recent departure of the registered manager had meant the home had not been as stable as it could have been.

Is the service caring?

We found that people were involved in planning their care and making decisions about their support and treatment. People were supported by kind and attentive staff. We saw that care workers showed patience and offered encouragement when supporting people. People told us staff were kind and caring and respectful of their wishes. We found personal preferences were detailed within the care plans so that staff could act in accordance with people's wishes.

People told us that staff generally asked them what they wanted prior to delivering care and we observed this to be the case in practice. However, some relatives expressed concerns that staff did not have time to deliver timely care, especially over the weekend period, because of staffing numbers. We observed that people were offered support at a level which assured their individual needs were met, although not always in a timely manner. The staff were friendly and courteous in their approach to people and interacted confidently with them.

We found that people were not encouraged to express their views about the quality of care in the home and were told that satisfaction questionnaires had not been given to people, although staff and relatives had been asked for feedback on the quality of care. We were informed that service users had not had a meeting since November 2013. People were therefore at risk of not having feedback and concerns properly taken into account.

Is the service responsive to people's needs?

We found that people received person- centred care and appropriate support from relevant people, when required. We noted that people's wishes were respected by care staff and taken into account when making best interest decisions and planning care and support. People's needs had been assessed before they moved into the home and records confirmed that people had been supported to maintain relationships with their friends and relatives.

We found that the medication systems in place were chaotic and that prescriptions were not always available when required. This meant there were delays in people receiving prescribed medication. At the time of this inspection, the local authority and complex care teams were providing support to the provider to strengthen the medication systems in place.

Is the service well- led?

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. We found that although the service had a short term, interim manager covering the role, the lack of consistent leadership meant the home did not have a positive ethos or the ability to drive and sustain ongoing improvement.

The service had a quality assurance system, records seen by us showed that not all of the shortfalls identified had been addressed. The system did not ensure that staff or people were able to provide feedback to their managers, so their knowledge and experience was not properly taken into account. Staff told us they were not always clear about their roles and responsibilities. They said the management had not previously consulted with them before implementing changes to the home and therefore their views had not consistently been taken into consideration.

At the time of our visit, 53 people were living in the home. We spoke with 11 people, and used a number of methods to help us understand the experiences of those people who could not talk to us, including observation and talking with people's relatives and care staff.

Two people's relatives said they were happy with the care provided. People who were able to speak with us told us they felt cared for and supported by staff. Two people said the care was "wonderful", and one person said, "I really like the staff here; they are so kind and caring.'

We noted there was a policy for the management of medication and saw staff had received training before administering medication.

Staff said they felt well supported at work and that the home manager was approachable. They also said they received some planned supervision and were supported with appropriate training and development to assist them in their roles.

We observed a robust quality assurance process. Both staff and people told us they would feel able to raise any concerns or issues that they had.

We observed evidence of effective record keeping and were given free access to all information we required as part of this inspection.

During this inspection we found a very different environment which was welcoming, relaxed and friendly. We observed positive engagement and interactions between staff and residents. The home had been divided into two units, one for people with residential needs, and one for people with dementia needs. Previously all people had been in one area and staff had not been able to meet their needs.

We spoke with eight of the 13 people using the service who told us they were happy with the care and support. One person said 'the staff are much more caring, and really understand our needs; it wasn't like that before'. Another person said 'they've made good improvements; I feel as if staff now like looking after us'.

We spoke with two people's relatives who said they had noticed improvements in the home. One person said 'It's such a relief to feel you can trust the care now given.'

We also spoke with all staff on duty, some of who had been employed recently, others who had worked in the home at the time of our last inspection. Staff told us they were happy working there, the atmosphere was relaxed and staff got on well together. Three staff independently told us they 'loved coming to work.'

We identified serious concerns related to poor staffing levels, poor record keeping, chaotic mealtimes with people missing meals, long delays in call bells being answered, and long delays in the administration of medicines.

On 23 September, we spoke with many of the residents and their family members, all who said they were unhappy with the level of care they were receiving, due to the lack of staff on duty. People also told us they were concerned about the lack of knowledge staff had about their needs. Residents and relatives told us the staff were 'kind and caring', but 'there was not enough of them'. People said that because many staff were agency staff and therefore not familiar with the home and residents, they did not have confidence in the staffs' knowledge about peoples' care needs being understood and met.

Relatives told us they felt it necessary to visit regularly throughout the day to ensure their family member was appropriately washed, dressed and received meals, by providing most care themselves: we observed this during our visits.