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Inspection carried out on 7 January 2019

During a routine inspection

Mr ‘C’s is a ‘care home’, operated by Woodland Healthcare Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Mr ‘C’s is currently registered to provide accommodation for people requiring both nursing and personal care. However, during 2018 the service began making changes and has ceased providing nursing care for a trial period. People who needed nursing care left the service and so the service no longer had registered nurses working at the service at the time of the inspection. Any nursing needs people may develop were met by the community nursing teams. At the time of the inspection 28 people were living at the service, some on a permanent basis, others were there for short stay respite care, or intermediate care between a period of hospital care and returning home.,

People living at Mr ‘C’s were mainly older people, most living with physical health conditions associated with older age, or mental ill health. Some people had limited care needs but were awaiting changes to their accommodation or needing support during the ill health of their carer. The service accommodates up to 40 people in one adapted building, set over four floors, but we were told they were not intending to take over 29 people at the present time.

At the last inspection in August 2017, Mr ‘C’s was rated as requires improvement overall and in the key questions of safe and well led. Key questions for effective, caring and responsive were rated as good.

On this inspection we have rated the service as good overall, but with requires improvement in the key question of safe. This was because we identified some areas of concern about the medicines systems in use and the management of urinary catheters. Between the inspection visits the service changed the way they managed medicines. We have recommended they arrange for an early audit of the new systems to ensure they meet safe standards and good practice. We also saw the service had taken immediate action in the meantime to reduce risks.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Since the last inspection the service’s management structure had been strengthened by the appointment of two managers at the service - one looking at the management of the environment and the other looking at people’s care. People living at the service and staff were clear about who was ‘in charge’, and told us they were approachable and supportive.

Systems were being operated to assess, monitor and improve the quality and safety of the services provided, and mitigate the risks to people from their care or the environment. Assessments including those provided through the trusted assessor scheme or intermediate care professionals identified risks to people and how they could be reduced. For example, from skin damage, long term health conditions or choking. Staff were aware of the principles of safeguarding people from abuse and how to report concerns about people’s well-being.

Mr ‘C’s was continuing to develop the services and care provided. Some people stayed at the service for only 24 hours, while others were there for longer periods of intermediate care following a hospital admission. Advice on good practice was sought and visiting professionals including those from the intermediate care team told us the service communicated with them well, and followed their advice to support people’s needs. We heard examples of where people had improved and returned home following a supported stay at the service.

People were supporte

Inspection carried out on 3 August 2017

During a routine inspection

Mr C’s is a nursing home in the centre of Torquay. It is registered to provide accommodation and personal care for up to 40 people, who may be older or have nursing needs. On the first day of inspection there were 23 people living at the service and on the second day there were 22 people living there. The provider has made a decision not to admit people who are living with high dementia care needs. The statement of purpose for the service indicates that while people living with dementia can be accommodated they will only be admitted where their physical needs are predominant. There is a registered nurse on duty at the service each day from 8am to 8pm. From 8pm to 8am one registered nurse covers three services in the area which are also owned by the provider.

There was a registered manager employed at the service. 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 service was last inspected in November 2016 when it was rated overall as Inadequate. This was because we found improvements were needed in all the key questions. Improvements were needed to the way the quality of the service provided was monitored, the maintenance of the environment, staffing levels, risk assessments and staff recruitment. Improvements were also needed to ensure people received person-centred care and were treated with dignity. As the service was rated as Inadequate at the inspection in November 2016 it was placed in ‘Special Measures’. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection in August 2017 the service 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. The overall rating for the service is now ‘Requires improvement’.

However, the quality assurance systems had failed to identify the issues in relation to the recording of some care provided, the disruptive noise of the call bell panel and the temperature some medicines were stored at.

There were details of some activities available to people on the noticeboard in the hallway. These included crafts, bingo and outside entertainment. Pet therapy also visited the service with animals for people to hold and people told us they enjoyed these visits. An activities organiser was employed by the service, but were on leave during the inspection. The registered manager told us care staff provided activities while the activities organiser was away. There were some activities detailed on people’s daily notes and these included spending time with people in their rooms.

People’s care plans contained details of how their personal care needs were to be met and were reviewed regularly. However, they did not always record the safe care and treatment given. People’s medicines were managed safely. However, the provider could not be assured some medicines were stored at a safe temperature.

People’s needs were met in a safe and timely way, because there were enough staff on duty to ensure this. Since the inspection in November 2016 an extra staff member had been employed to cover the periods of breakfast and supper. This enabled care staff more time to meet people’s needs during these busy times. Previous issues with call bells not being answered quickly had been addressed and there had been no further issues raised with the registered manager or CQC. There was a daily check of the call bells to ensure they were working correctly. However, we heard the noise from the main call bell panel was intrusive and loud and interrupted conversation at meal time

Inspection carried out on 16 November 2016

During a routine inspection

Mr ‘C’s is a nursing home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. It is registered to provide accommodation and personal care to up to 40 people who may have needs related to dementia. The home also provides nursing care. There is a nurse on duty during the day, and at night one nurse covers three homes owned by this provider.

This inspection took place on 16, 17 and 21 November 2016 and was unannounced. During the first two days of the inspection there were 19 people living at the home and on the third day of the inspection there were 18 people living at the home. The home is spread over five floors with the dining room, kitchen and lounges on the ground floor and people’s bedrooms on the first to fourth floors. People with the highest level of nursing care needs had bedrooms on the first floor, where the nurse’s base was situated. People who were more independent, with residential care needs were furthest away, on the fourth floor. At the time of the inspection, there were eight people requiring nursing care and eleven people requiring residential care living at the service. Twelve people needed the help of two care staff to assist with their mobility. Two people were living with dementia type illnesses.

The service was first inspected in August 2014, when we identified the provider was not meeting the regulations in respect of records. We carried out a ratings inspection in August 2015 when the home was rated as Requires Improvement. The provider was not meeting the regulations in respect of ensuring people received safe care and treatment, staffing levels and record keeping. The provider sent us an action plan that confirmed improvements would be completed by December 2015. At this inspection we found sufficient action had not been taken in relation to the concerns identified at the previous inspection. We also identified new areas of concern.

We have found people were not always receiving a safe, effective, caring, responsive or well-led service.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was responsible for two nursing homes owned by the company and had a quality monitoring function for a third home, one day per week. This meant they only spent two days a week at Mr ‘C’s, sometimes split into half days. The lack of a consistent manager presence had impacted on the safety and quality of care and led to people and their relatives losing confidence in the overall management approach.

The layout of the building presented challenges for staffing. There were not always enough staff on duty at all times to ensure people received the care, support and observation they needed. At night there were two care staff on duty to cover the home. A registered nurse covered Mr ‘C’s and two other nursing homes in the group overnight. They were not always present at Mr ‘C’s. Although the registered manager told us they had assessed staffing levels, the consistency of concerns raised indicated people did not always receive assistance at the times they needed it.

Staffing levels meant staff were not always able to provide care in a way that ensured people’s dignity was protected. For example, on the second day of our inspection when we arrived we found one person downstairs walking by the reception area who was naked from the waist down. There were no care staff on the ground floor at this time.

Complaints about some aspects of care were repeatedly raised by people living at the service and their relatives. These included the varying availability of hot water in parts of the home and call bells not be

Inspection carried out on 19 and 25 August 2015

During a routine inspection

Mr ‘C’s is registered to provide nursing care and support to 40 people who may have dementia care needs.

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

This inspection took place on 19 and 25 August 2015 and was unannounced. There were 24 people living in the home at the time of the inspection. People had a range of needs with fourteen people requiring residential care and ten people requiring nursing care. Some people were independent, other people were being nursed in bed, and five people were living with dementia.

The service was last inspected on 20 August 2014 where we identified the provider was not meeting the regulations in relation to records. The provider sent us an action plan and confirmed in July 2015 they had completed the required actions to meet the regulations. At this inspection, we found sufficient action had not been taken in relation to the concerns identified at the previous inspection.

Prior to this inspection, we received safeguarding concerns from the local authority. Concerns included a lack of monitoring of blood sugar levels for people with diabetes, weight loss, skin care, records in place for monitoring people’s health and wellbeing not being completed, and referrals to healthcare professionals not being made in a timely way.

Shortfalls in the assessment, planning and delivery of care and treatment meant people may not always be kept safe. There was no system for ensuring that people at risk had been checked on regularly. People’s fluid intake was not recorded in a way that ensured people were having enough to drink and could place people at risk of dehydration. Weights were not being monitored and recorded in a way that addressed the risk of people losing weight. Where people were at risk of pressure sores, there were no records to evidence they were repositioned in line with their care plan. Records relating to pressure sores were unclear. One person’s diabetes was not well managed. We have made safeguarding alerts to the local authority about these concerns.

Prior to the inspection, a visiting healthcare professional raised concerns about staffing levels. The building layout is over four floors with long corridors. When a staff member needed assistance they said it could take some time to find another staff member, which meant people had to wait. People, relatives, healthcare professionals, and staff told us there were not enough staff at times. One person said the staff did not always assist them to the toilet in time. We observed staff were very busy during our inspection. Although the registered manager had carried out an assessment of staffing in April 2015, there had been some changes and they said this needed to be reviewed.

People’s needs had been assessed and care plans were reviewed monthly and updated when their needs changed. Where updates had been added, these were not always clear and dated which meant it was difficult to follow. This meant people’s care plans did not always accurately reflect people’s needs. The registered manager told us they had recently introduced a new care plan format.

People’s social and emotional needs had not been fully assessed and care plans had not been developed to ensure people’s needs were met. Some people spent most or all of the day in their bedroom. There was no evidence that activities or engagement had been designed to address issues such as preventing isolation. One person said “I have tried going downstairs but I found it depressing as they all seem to go to sleep or outside to smoke”. People living with dementia did not benefit from individual activity plans to ensure they had meaningful activities to promote their wellbeing. Staff told us the activities co-ordinator was in the home and provided activities every Saturday from 1.00pm to 5.00pm. The Provider Information Return said the provider was looking to link care planning and the activities provided.

People spoke highly of the care they received. They said “Everything is good here… the staff are lovely and so patient” and “I love it and if I didn’t I’d go somewhere else.’ Staff talked about the people in their care affectionately. They demonstrated they knew the people they supported. People were clean, looked well cared for and well dressed. People were supported to make choices about the clothes they wore. One relative told us staff always made sure their husband’s clothes were colour co-ordinated which was important to them.

People enjoyed the food in the home. One person said “There’s a very good chef…we get two choices daily…I’ve enjoyed all the meals here…he’s very nice to talk to, he comes and has a chat with me”. The chef had been trained to cater for people with specific dietary needs.

There were systems in place to assess, monitor, and improve the quality and safety of care. The director visited the service every two to three weeks. The registered manager had identified records were still not being completed accurately and was taking action to make improvements.

There was an open and supportive culture. People were comfortable when speaking with the registered manager and smiled at them. One person commented “They are so efficient”. A visiting healthcare professional said they found the registered manager acted professionally, was genuine, listened to them, and cared about people. Staff found the registered manager to be very approachable. Comments included “They’re brilliant, a good manager” and “I can approach the manager whenever I want to”. However, two relatives told us they were not happy with the registered manager’s attitude and response to their comments and concerns. We discussed this with the registered manager who was disappointed to hear that people felt this way. They told us they would follow this up by speaking with everyone involved in the home.

You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 20 August 2014

During a routine inspection

One adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

We had received some concerns prior to our inspection relating to the care of people living at Mr C’s. We found no evidence to support this concern.

Is the service safe?

Records showed that people's needs and risks had been identified and planned for. A range of risk assessments had been completed including those for pressure areas, nutrition and moving and handling. We saw that some good directions had been given to staff on how people's needs should be met. For example, we saw clear instructions on how one person should be assisted to eat.

However, we saw that some of the information contained in records was contradictory and could leave people at risk of receiving inappropriate care. For example, we saw that a support plan relating to pressure area care stated the person should have the dressing changed weekly, but records showed the dressing being changed every three days. A compliance action has been set for this and the provider must tell us how they plan to improve.

We saw that people were protected from the risk of abuse because reasonable steps had been taken to identify the possibility of abuse and to prevent abuse. For example, there were policies and procedures in place for staff to follow if they suspected abuse had occurred. People appeared relaxed and comfortable in their interactions with staff. When we asked people if they felt safe at the home they told us “Yes”.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us “Staff are very good, they look after me very well” Staff had received training to meet the needs of the people living at the home.

There were arrangements in place to deal with foreseeable emergencies. For example, the files we looked at contained Personal Emergency Evacuation Plans (PEEPS). This meant that staff had access to the information they would need if an evacuation of the premises was needed.

Is the service caring?

People were supported by kind and attentive staff. We saw and heard positive interactions between staff and people who lived at the home. Any directions that were given to people were done so in a sensitive and discreet manner. During our visit we heard staff speaking with people in a respectful and caring way. We saw staff interacting with the people they supported and providing opportunities for people to talk with them. We also saw that staff were friendly and patient in their approach.

Is the service responsive?

People living at the home and their representatives had been asked for their views on the quality of care provided. Responses included “Impressed with your attitude and dedication", and “Couldn’t ask for better care for X”. One questionnaire had asked for name badges for staff. We saw that some had been purchased, but the manager did not like them and had ordered a different type.

Is the service well-led?

Prior to this inspection we found that the Registered Manager had been de-registered. They had applied to de-register from another home, but had also been de-registered from Mr C’s. They were unaware of this and we are looking to rectify the matter.

The home was registered in October 2013, but did not start to admit people until June 2014. All the staff working at the home had been employed since June 2014 and had received an induction prior to people being admitted. They told us they felt the manager supported them well. One staff member told us that they felt the manager had taken care to ensure all staff worked well together and “complemented each other”.