The inspection was carried out on 10 May 2017. The inspection was unannounced and carried out by one adult social care inspector.

Adamstan House Nursing Home accommodates up to 34 people who require nursing care. The service is situated in a residential area with easy access to St. Helens town centre and local amenities. Accommodation is over two floors. There were 31 people using the service at the time of our inspection.

The service 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 last inspection of the service was carried out in March 2016 and we found that the service was not meeting all the regulations of the Health and Social Care Act 2008 and associated Regulations. The registered provider sent us an action plan following the last inspection detailing how and when they intended to make the improvements. During this inspection we found that the required improvements had been made.

Improvements had been made in relation to the recruitment of new staff. Appropriate checks which were required to ensure the suitability of new staff had been carried out prior to them commencing work at the service. Application forms were completed as required and included information about the applicant’s previous employment history. Photographic evidence of the applicant’s identity had been obtained and was held in their recruitment file.

Improvements had been made relation to the management of medication. Medication was dispensed and administered to people on an individual basis and medication admistration records were signed only after the person had taken their medicines. Medication was safely stored and administered by appropriately trained staff.

Improvements had been made in relation to planning and monitoring people’s nutritional and hydrations needs. People’s dietary needs had been assessed and planned for and their needs were being met. Specific guidance for staff to follow about the support people needed to eat and drink was reflected in their care plans.

Improvements had been made in relation to the accuracy and maintenance of people’s care records. Charts which were in place for monitoring aspects of people’s care were completed as required. This included charts for monitoring people’s food and fluid intake, weight and skin integrity.

Improvements had been made in relation to monitoring and assessing the quality of the service people received. There were effective systems in operation for checking on aspects of the service and making improvement to the service people received.

We have made a recommendation about the environment. There was lack of signage and stimulus around the service to promote the wayfinding and stimulation of people living with dementia.

Procedures for preventing abuse and for responding to an allegation of abuse were in place and understood by staff. Staff were confident about recognising and reporting suspected abuse and they said they would not hesitate to do so.

Staffing levels and skill mix were calculated to meet people’s needs. There was the right amount of suitably skilled staff on duty to keep people safe.

The environment was free from hazards, clean and hygienic. Staff were aware of good infection prevention and control procedures and they adhered to them to minimise the spread of infection.

Staff received the training and support they needed. New staff completed an induction programme and received ongoing training relevant to their role, responsibilities and the needs of the people they supported.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and

The inspection was carried out over two days on 15 & 22 March 2016.

Adamstan House Nursing Home provides nursing care for up to 34 people. The service is situated in a residential area with easy access to St. Helens town centre and local amenities. Accommodation is over two floors.

The service does not have a registered manager because the previous registered manager recently left. 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 last inspection of the service was carried out in February 2015 and we found that the service was not meeting all the regulations that were assessed.

Improvements had been made in relation to how people’s rights were protected in relation to decision making. Since our last inspection in February 2015 staff had completed training in relation to the Mental capacity Act 2015 and the associated Deprivation of Liberty Safeguards. Staff had benefited from the training as they demonstrated a good understanding of the basic principles of the Act and how it impacted on their day to day practice. Staff gave examples of practices that may be considered restrictive and they understood the legal process which had to be followed if they considered a person was being deprived of their liberty.

Improvements were needed in relation to the management of medication. Four people’s medication was dispensed at the same time and their medication administration records were signed in advance of them taking their medication. These practices were unsafe and not in line with national guidance which states; administration should be completed before moving on to the next personand a record of medicines given should only be made when the person had taken their medicines.

Improvements were needed in relation to the recruitment of staff. Appropriate checks which were required by law where not carried out for new staff prior to them commencing work at the service. A staff member’s application form showed a five month gap in their previous employment history; however this had not been explored to determine an explanation for the gap. Recruitment records for two staff members did not include any photographic evidence of their identity.

Improvements were needed in relation to planning and monitoring people’s nutritional and hydrations needs. Although people’s care had been planned in relation to their dietary needs they were at risk of not having them met. This was because care plans did not provide specific guidance for staff to follow about the support people needed to eat and drink and changes in people’s needs were not reflected in their care plans.

Improvements were needed in relation to the accuracy and maintenance of people’s care records. Staff were required to complete charts as a way of monitoring aspects of peoples care, however they were not always completed as required. This included charts for monitoring people’s weight and skin integrity.

Improvements were needed in relation to monitoring and assessing the quality of the service people received. Although there were systems in place for checking on aspects of the service some of them were ineffective. Checks on care records failed to identify the lack of accurate recording and maintenance of care plans,monitoring records and staff recruitment records.

Procedures for preventing abuse and for responding to an allegation of abuse were in place and understood by staff. Staff were confident about recognising and reporting suspected abuse and they said they would not hesitate to do so.

Staffing levels were sufficient to keep people safe. There were sufficient staff on duty on both days of our inspection. However we were told that there had been occasions when the staffin

Our inspection was unannounced and the inspection team consisted of an adult social care inspector (ASC) and an ASC inspection manager. 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?

The service was safe.

People were safeguarded from abuse or the risk of abuse. Staff knew what their responsibilities were for safeguarding people from abuse and they had access to procedures for reporting any concerns to other agencies including the local authority safeguarding team for investigation.

People were protected from the risks associated with the spread of infection because staff followed the correct infection control procedures.

The premises were safe and any risks to people’s health, safety and wellbeing were managed.

Is the service caring?

The service was caring.

We saw positive relationships between staff and people who used the service. Staff were knowledgeable about people’s needs and preferred routines.

Staff were kind and polite towards people and they treated people with respect. Staff were patient and attentive in their approach towards people.

Staff consulted people about the care and support they received and took into account people’s individual needs, choices and preferences.

Is the service effective?

The service was not effective.

Consent was not always appropriately obtained for people who lacked capacity to make decisions about their care and treatment. Staff did not have all the information they needed to ensure people who lacked capacity received safe and effective care and support.

People’s healthcare needs were assessed and they received the care and support they needed with their health.

Records were completed at the right times well maintained, accurate and stored securely.

Is the service responsive?

The service was responsive.

People received person centred care and support. Staff responded to people’s individual needs, preferences and choices.

Care records had been updated with changes to people’s needs and following any advice obtained from others. Concerns about people’s health and welfare were referred onto the relevant external professionals.

People were provided with information about how to complain and they were confident about complaining. Complaints were properly investigated and responded to in a timely way.

Is the service well-led?

The service was well led.

The service had a registered manager. People were complimentary about the manager and the way she managed the service. People told us they thought the service had improved a lot since our last inspection in September 2014.

Staff were clear of their roles and responsibilities and their lines of accountability.

The service had an effective quality assurance system which identified and addressed risks to people’s health, safety and welfare.

Our inspection team was made up of two inspectors. We considered our inspection finding 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?

The service was not safe.

The rights of people who used the service had not been safeguarded because consent was not appropriately obtained for those who lacked capacity to make decisions about their care and treatment. People were deprived of their liberty without appropriate authorisation and staff had limited knowledge and understanding about the Mental Capacity Act and Deprivation of Liberty Safeguards.

People’s care had not been assessed and planned for, which meant staff did not have all the information they needed to ensure people received safe and effective care and support.

People who used the service were put at risk of abuse because staff lacked knowledge about safeguarding procedures and failed to report safeguarding incidents to the local authority safeguarding team for investigation. The practice of restraint was being used at the home without the proper legal processes being followed therefore putting people at risk of abuse.

People were not fully protected from the risks associated with the spread of infection because staff failed to follow infection control procedures.

Parts of the premises were unsafe and posed a hazard to people’s health, safety and wellbeing.

Is the service caring?

The service was not caring.

Staff did not always treat people with respect, for example staff shouted across the path of people who used the service and people were served food without plates.

Staff did not take into consideration people’s individual needs, choices and preferences when providing care and support. For example people were not consulted about their meals and where they sat.

Is the service effective?

The service was not effective.

There was a lack of person centred care and support. We observed one member of staff assisting three people with their meal during the same sitting. People’s care records had not been updated to reflect changes to their care need requirements, which meant people did not always receive effective care and support.

There was a lack of effective record keeping and a lack of appropriate reporting of incidents, which put people’s health safety and welfare at risk.

Is the service responsive?

The service was not responsive.

People did not receive person centred care and support because staff followed general routines and did not respond to people’s individual needs, preferences and choices.

Staff did not always respond appropriately to people’s needs because care records had not been updated with changes which had taken place.

Staff did not respond to people’s requests for assistance which compromised peoples, dignity and independence.

People told us they had raised complaints however, one person told us their complaint was not properly resolved and another person told us that their complaint was investigated but they did not receive any feedback. Complaints records did not include any information about the provider’s response.

The provider failed to respond to concerns identified at our previous inspection, putting people’s health safety and welfare at risk.

Is the service well-led?

The service was not well led.

The home did not have a registered manager. A new manager had been recently appointed but had not started work at the home at the time of our inspection visit. We were told that the deputy manager had been managing the home and that a named nurse was in charge of each shift in the absence of the deputy manager. Senior staff were not clear of their roles and responsibilities and they were unable to provide us with information and locate records, which we requested about the running of the home.

The service did not have a quality assurance system in place to show that identified shortfalls were identified and addressed. The provider failed to identify risks to people’s health, safety and welfare, including the lack of appropriate care planning, the risk of the spread of infection control and environmental hazards. The provider also failed to respond to complaints and appropriately report safeguarding incidents for investigation.

We identified a lack of acknowledgment and improvement of issues found during our previous inspections.

During our inspection, we spoke with two care staff, two nurses, the deputy manager, manager and the cook. We spent time speaking with the relatives of two people who lived in the home. One person who had lived in the home for some time also gave us their views on the care they received. We were also able to get feedback from a visiting health professional on the day of our inspection.

The nursing staff we talked to told us there had been a number of changes at the home since the last inspection. We asked for an example of these changes. We were told an increase in the number of permanent staff and in the way things were organised had helped them carry out their work more effectively. For example, individual nurses were now responsible for reviewing and monitoring a small number of people living in the home. When we spoke with one person living in the home they told us they were looked after well and that they didn’t usually have to wait long if they needed help. Their relative who was visiting that day, confirmed this.

A carer told us they were short staffed on the day we visited but usually the manager would get extra help if they could when this happened. The manager told us she could bring in extra staff if she needed to. However, on the day of our inspection, the manager confirmed they had been unable to find cover for the absence of a permanent staff member. This meant staff found it difficult to meet the needs of all the people in the home on that day.

We spoke with a visiting health professional during our visit. They told us there was good communication between the home and the community mental health service and that they were contacted immediately if people living in the home needed their help.

Before our inspection, we had written to the owner of the home,as they were operating in breach of a condition of their registration with the Care Quality Commission(CQC), by failing to have a manager for the home, registered with CQC. The owner of the home assured us that the application for registration would be submitted by the new manager immediately. At the time of writing this report, no application from the new manager, or any other person proposing to take up the position of manager, had been received by Care Quality Commission, to register as the manager for the home.

At our inspection in February 2013 we (Care Quality Commission CQC) found the service to be non-compliant in two regulations. We carried out an inspection June / July 2013 to assess if compliance had been achieved. We found continuing concerns and took enforcement action. An action plan was returned from the service stating that it would be compliant by 31 August 2013.

At this inspection (October 2013) we found that the issues identified at previous inspections had still not been addressed by the provider. People living in the home told us, “Everybody is excellent”, “I always get treated with respect” and “the girls (staff) are really lovely”. We spoke with visiting relatives, who commented on the limited availability of activities. One person said, “People do not receive any stimulation. The only thing people have is the television and the televisions don’t always work”.

A pharmacist inspector looked at how the home managed the administration of medicines. Some concerns were identified.

The records for the service delivery was disorganised and did not give assurance that a quality service was being provided to people. As a result people who lived in the home were placed at risk of receiving inappropriate or unsafe care.

We looked at how the service dealt with any complaints received. We saw that complaints were not addressed in a manner that made sure that complaints received a satisfactory reply or ensured that the service actioned any lessons learnt.

We spent time with a number of people using the service, as well as watching what was going on in lounges and the dining room. People we spoke to told us they liked the staff and that they found them kind and approachable.

We observed staff interactions with people and saw that the majority of the time they tried to inform people about their available choices. This included discussions about where they would like to sit at meal times. We observed on several occasions when people were given their main meal, they were not told what the meal was. We saw that menus were printed to assist people to make decisions, however one person told us that they could not read the menu and there was too much information.

People who lived in the home also told us that staff were, “really kind and considerate”. They told us that they could spend their day as they liked and staff were always happy to help them.

The majority of staff spoken with said that they were supported to access training. On the day of our inspection the manager had invited a training officer from social services to attend to discuss training opportunities.

Family members told us that staff do discuss with them when changes to their relatives care plans were made. One family member we spoke with told us they thought the home always informed them of any changes to their relatives needs.

We visited this home unannounced on Tuesday 17th January 2012. During the course of the site inspection we spoke individually with the manager, five people living at the home, five visitors, a qualified member of staff and a number of care assistants, as well as ancillary staff. Short informal chats also took place with some other residents and members of staff throughout the course of the day.

People living at the home told us staff were respectful and treated them with dignity, one person said, "They are all very caring and patient,” another said, "There always seems to be plenty of them and they always have time for us.” All the people we spoke to said good things about the way they were treated by all members of staff.

When asked, one person we spoke with said, "I feel safe and comfortable living here.” A relative told us that they felt their relative was, "Getting everything they need living at Adamstan House.”

Responses from staff and residents were all very positive and reflected how the home is run in the best interest of the people who live there. Other comments from people included, "I have no problems they are very good at what they do". A staff member said, "We all get along well, and work as a good team."

During our inspection in February 2013 compliance actions were made and an action plan was received from the provider as to how they would become compliant.

During the inspections of 27June 2013, 28 June and 03 July 2013 We identified further concerns.

People living in the home made positive comments, these included, “It’s a nice place and nice food” “The homes okay, the girls are really good” and “I love the place, I’m fine thank you”. We spoke with five relatives, some of their comments were, “It’s fantastic here” and” can’t praise the home enough”. During our inspection we observed staff spoke with people living in the home in a calm and sensitive manner.

A pharmacist inspector looked at how the home managed the administration of medicines. Some concerns were identified regarding the administration of medicines.

We looked at how the home checked and maintained quality. We found the management of records to be disorganised and did not allow the service to check on the quality provided. As a result people who lived in the home were placed at risk.