1 Sewardstone Close is a ‘care home’. 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. The service provides accommodation, personal care and nursing care for up to 29 people who have a neurological condition which has been acquired through a life changing event or diagnosis.

The inspection was completed on 6 November 2018 and was unannounced. At the time of this inspection there were 21 people receiving a service.

A registered manager was 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.

Although suitable arrangements were in place to assess and monitor the quality of the service provided, information relating to the actions to be taken to address identified shortfalls were not routinely completed. Improvements were required to ensure medication practices were improved and staff employed at the service received regular formal supervision and an annual appraisal of their overall performance.

Suitable arrangements were in place to keep people safe. Policies and procedures were followed by staff to safeguard people and staff understood these measures. Risks to people were identified and managed to prevent people from receiving unsafe care and support. The service was appropriately staffed to meet the needs of the people using the service. Recruitment procedures were followed to ensure the right staff were employed. People were protected by the providers arrangements for the prevention and control of infection and suitable arrangements were in place for learning when things went wrong.

Staff had a thorough induction to carry out their role and responsibilities effectively. Staff had the right competencies and skills to meet people’s needs and received regular training opportunities. People’s nutritional and hydration needs were met, including having their cultural requirements and preferences met. People received appropriate healthcare support as and when needed from a variety of professional services. The service worked together with other organisations to ensure people received coordinated care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were treated with care, kindness, dignity and respect. People received a good level of care and support that met their needs and preferences. Staff had a good knowledge and understanding of people’s specific care and support needs and how they wished to be cared for.

Care plans were in place to reflect how people would like to receive their care and support, and covered all aspects of a person's individual circumstances. Social activities were available for people to enjoy and experience both ‘in house’ and within the local community. Information about how to make a complaint was available and people’s representatives told us they were confident to raise issues or concerns.

There was a positive culture within the service that was person-centred, open and inclusive. The service sought people’s and others views about the quality of the service provided.

Recommendations were made relating to medicines management and the service's quality assurance arrangements.

Further information is in the detailed findings below.

The inspection was completed on 19 February 2016 and 29 February 2016 and there were 20 people living at the service when we inspected.

1 Sewardstone Close offers residential, nursing and intermediate care for up to 20 people with complex needs, as well as acquired brain injury and neurological conditions following an accident or other life threatening trauma.

A registered manager was 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.

Although staff were supported improvements were required to ensure that they received regular formal supervision and where actions were highlighted, these were followed up and addressed.

People told us the service was a safe place to live and that there were sufficient staff available to meet their needs. Appropriate arrangements were in place to recruit staff safely so as to ensure they were the right people. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure their and others’ safety.

Medicines were safely stored, recorded and administered in line with current guidance to ensure people received their prescribed medicines to meet their needs. This meant that people received their prescribed medicines as they should and in a safe way.

Staff understood the risks and signs of potential abuse and the relevant safeguarding processes to follow. Risks to people’s health and wellbeing were appropriately assessed, managed and reviewed.

Staff received opportunities for training and this ensured that staff employed at the service had the right skills to meet people’s needs. Staff demonstrated a good understanding and awareness of how to treat people with respect and dignity.

The dining experience for people was positive and people were complimentary about the quality of meals provided.

Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been made in their best interests. The manager was up-to-date with recent changes to the law regarding the Deprivation of Liberty Safeguards (DoLS) and at the time of the inspection they were working with the local authority to make sure people’s legal rights were being protected. People who used the service and their relatives were involved in making decisions about their care and support.

Care plans accurately reflected people’s care and support needs. People received appropriate support to have their social care needs met. People told us that their healthcare needs were well managed and they received suitable therapies.

Staff were friendly, kind and caring towards the people they supported and care provided met people’s individual care and support needs.

People and their relatives told us that if they had any concern they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns were listened to, taken seriously and acted upon.

There was an effective system in place to regularly assess and monitor the quality of the service provided. The manager was able to demonstrate how they measured and analysed the care provided to people, and how this ensured that the service was operating safely and was continually improving to meet people’s needs.

As part of our inspection on 2 May 2014, we looked at the care records of three of the 20 people living at 1 Sewardstone Close. We spoke with four people who used the service and with two visiting relatives. We also spoke with a professional who was working at the service on the day of our inspection and four staff members.

We looked at people’s care records, health and safety checks, resident meeting minutes and records of the checks the manager and the provider’s representative completed to monitor the quality of the service.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

Records showed that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

People were protected from the risk of infection because appropriate guidance had been followed. Staff were provided with the information, support and equipment needed to enable them to promote good infection control practice.

Quality monitoring systems were in place to assess and manage risks and assure the health, welfare and safety of people who received care at the service and the staff who supported them. We saw records which showed that health and safety in the service was regularly checked.

Is the service effective?

Full assessments of each person were undertaken prior to their admission to the service to make sure that the service could meet the person’s needs effectively.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The care records were regularly reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met safely and effectively.

We saw there was involvement of a range of professionals in the care of each person to ensure care was effective and specialist input obtained where necessary.

We saw in care records and from looking at, and listening to, the daily activities of life that people were encouraged to be as independent as they wanted, or were able, to be.

Arrangements were in place to manage medicines so as to ensure people consistently received their medicines as prescribed to promote their well-being.

Is the service caring?

People told us that staff were kind and caring. One person said I am very well cared for, I cannot complain at all. The staff are nice, they help me, but also let me do things for myself too, that is why I am here".

We saw that people were relaxed in the company of each other and that staff were attentive to people's needs. Staff we spoke with were able to demonstrate they knew people well. We saw staff treating people with dignity and respect.

We observed that staff were kind to people they supported and interacted with people in a caring and professional way. One person told us that the staff were polite and friendly. A visitor told us they found staff to be caring and approachable and said, “I am so happy with the care here. I cannot believe the improvement in [person] in the short time they have been here”.

Is the service responsive?

People using the service were provided with the opportunity to participate in meetings and to express their views and plan activities that interested them. We saw that the chef attended meetings with people who used the service to hear their comments and that the menu had been changed in response to people’s views.

People's choices were taken in to account and listened to. One person said, “I can do things I like. I like to spend time in my room and listen to my music and that is no problem." Another person told us that staff responded to their preferences, such as to rest on their bed at any time they felt the need for this.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. We saw for example that one person did not eat specific foods for religious reasons. Both care and kitchen staff were aware of this and ensured that this was respected. We also saw that the service had respected a person’s request to be supported only by female staff.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service well-led?

A new and experienced manager had been registered since our last inspection in October 2013. We saw that the improvements identified as required at our last inspection in relation to management of medicines had been put into place.

Staff told us that a system was in place to inform staff of the tasks and support that needed to be completed each shift. A brief meeting was held at the start of each day to identify, for example, where people who used the service had hospital appointments or needed blood tests. This was to ensure that people’s care was well organised and managed.

Overall, the provider had procedures in place to support the manager and to ensure that systems were in place to check the quality of the service. This was used to manage risks and to assure the health, welfare and safety of people who received care at the service. Systems were being put into place to ask the views of staff and people who used the service to help the provider to continuously improve.

During our inspection on 8 October 2013 we spoke with five people who lived at the home and received information from the relative of another person. We also spoke with five staff and observed care being provided.

Concerns about the quality of the care, whether people’s nutritional needs were met and whether there were sufficient staff to meet people’s needs were raised anonymously in June 2013. The local authority and provider investigated these and the provider told us how they would make improvements in these areas. Also in June 2013 the provider informed us that they had identified shortfalls in the process for ordering medicines. They told us improvements had been made.

During our inspection on 8 October 2013 we found people’s privacy, dignity and independence were respected. One person told us they felt the change in management had had a positive effect on the service. Staff echoed this view and said how much staff morale had improved.

People experienced care and support that met their needs and protected their rights. The majority of people we spoke with said that they felt their needs were met by staff at the home. We found people were protected from the risks of inadequate nutrition and dehydration.

We found there were enough qualified, skilled and experienced staff to meet people’s needs. Record keeping had also improved and we found records were up to date, accurate and fit for purpose.

However, we found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines and ensure people consistently received their medicines as prescribed.

The people we spoke with during our inspection who lived at the home told us that their needs were met and they liked the staff. One person told us, “The staff are nice, [they are] very good. They know me well and know how to support me with my rehab.” Discussion with staff demonstrated that they clearly knew the people living at the home well and were familiar with how to meet their needs.

The majority of staff interactions with people who used the service were positive. However, during a meal time we saw that people’s dignity was not maintained in that staff did not provide people with napkins to wipe their hands and clean up spills.

Before people received any care or treatment they were asked for their consent and staff acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

People who used the service were protected from the risk of abuse, because the staff had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found there was an effective complaints system available. Comments and complaints people made were responded to appropriately.

However, we found omissions and inaccuracies in records which meant there was a risk that people were not receiving the right care and treatment. This was because staff did not always have the correct information available to them to refer to.

When we visited the home on 06 September 2012 we spoke with six people. They all told us that they were involved in decisions about their care and treatment. One person said that they had made decisions about their therapy and about how they took their medication. They said that the staff supported them in their decisions. Another person communicated with us using a communication aid, supported by staff. They said, “I am much happier and less frustrated now that I can communicate with other people.”

We saw evidence that the provider carried out regular surveys of people’s views, and had acted on the concerns raised in the last survey. These actions included people choosing their own keyworkers and the Registered Manager holding regular open meetings for people in the home and for their relatives so that they could raise any concerns more easily.

Everyone we spoke with said that they felt that they received treatment and support that met their needs and the staff supported them with their goals. One person said, “Everyone is very good, very caring. They try so hard. I need to get myself together in health and strength, and everyone here helps me. I feel much better now.” Care plans had been rewritten since our last inspection. They contained clear information on meeting people's personal and health care needs and made reference to appropriate risk assessments, to guide staff to the information that they needed to support each person appropriately.

We used a number of different methods to help us understand the experiences of people using the service. This was because people had complex needs, which meant not everyone was able to tell us about their experiences. We observed that there was a calm atmosphere with staff interacting at a suitable pace for the person concerned. People were encouraged to engage with their surroundings and the activities taking place. One person told us that the number and variety of activities offered had improved recently. We observed that staff were on hand to respond to people’s needs. People confirmed they had good relationships with the staff who support them. One person told us the staff were ‘very good’, ‘like one big family’. Another person was able to confirm that staff were gentle and respectful when they were providing their personal care.

People we spoke with said they were happy with the way that the home manages their medicines on their behalf. One person said that staff were "usually" on time with their medicines.

People told us that they were treated well by care staff and that their privacy and dignity were respected. They also told us that they liked living at 1 Sewardstone Close and that they found the staff to be nice and caring, however care provided could be variable depending on the staff on duty. Three people spoken with told us that they had not been involved with their care plan or seen the information recorded. None of the people spoken with were aware of a specialist rehabilitation programme in place for them. They told us that there were limited opportunities provided for them to participate in meaningful activities of their choice, both ‘in house’ and externally. People told us that if they had any concerns or worries, they would discuss them with their relative or a member of staff. However not all felt confident that any concerns or complaints would be listened to, taken seriously and/or acted upon.

A ‘family meeting’ was held at the home in December 2011 and attended by four relatives of people who use the service. The majority of comments recorded within the ‘family meeting’ minutes were viewed as negative. Not all relatives felt that their member of family received good care and/or had their care needs met. Two relatives spoken with told us that they were not happy with some elements of care provided for their member of family. They told us that they had discussed these with staff but did not feel listened to. Comments recorded included “…..always get excuses when we ask why things are not done”, “Relative does not feel that their member of family is looked after well-feels weak points are communication and continuity of care and feels totally let down” and “Relative feels that Sewardstone Close used to be Marks and Spencer’s but now it has turned into Woolworth’s. ” Some relatives voiced that they did not have confidence in the management of the home.

One person who uses the service told us that they had not received their pain relief medication at the time they needed them and did not have this medication administered for a further one hour and 40 minutes. The rationale provided to the person who uses the service was that the qualified nurse had “been too busy.” As a result of this and following discussion with the management team of the home a safeguarding alert was raised. Another person who uses the service told us on some occasions they had to remind staff to provide them with their prescribed medication. They told us that the reason for this was that they could not be assured that this would be provided without prompts.

Relatives spoken with told us they did not always feel confident or assured that their member of family received their medication at the time they should. They told us that when discussed with staff the rationale provided was “we’re short of staff.” They told us that where they had raised concerns and/or queries with staff about medication issues, they did not feel confident that accurate information had always been given to the clinical professional team. They also told us that they had requested confirmation from the management team of the home as to the outcome of their relative’s medication review. They confirmed that this had yet to be provided.

Not all people who use the service felt there were sufficient numbers of staff available at all times. People told us that permanent staff working at the home were very nice and caring but that they found it difficult when agency staff were deployed to the home as they did not know their individual care needs and they were not familiar with their routines of daily living.