This inspection took place on the 4 and 12 January 2018. The visit on the 4 January 2018 was unannounced. The visit on the 12 January 2018 was announced.

Amberley Court 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. Amberley Court accommodates up to 39 people in one building with all bedrooms over two floors. The service provides care and support to older people. At the time of this inspection 29 people were using the 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.

During the last inspection of the service in December 2016 we identified breaches in relation to Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions; is the service safe, effective, caring, responsive and well-led to a rating of good. During this inspection we found that improvements had been made.

We have made a recommendation within this report in relation to ensuring that records and care planning documents are kept under continual review to ensure that up to date information is available at all times.

Systems were in place to help ensure that people's medicines were managed safely and appropriate storage facilities were in place.

People felt that the service was safe. Staff were aware of the procedures in place for safeguarding people. Staff had received training in relation to safeguarding people.

Staff supported people in a kind and caring manner whilst respecting individual’s privacy and dignity.

People’s living environment was clean and tidy and effective control measures were in place to protect people from infection.

Systems were in place to ensure that people’s rights were maintained under the Mental Capacity Act.

People’s needs were assessed and when a need was identified, care plans had been developed to inform staff as to what support a person needed. Family members felt that they were involved in their relative’s care planning process.

People had access to activities within the service with the support of an activities co-ordinator.

The registered provider had procedures in place that promoted the safe recruitment of staff. This helped ensure that people were supported by staff that were suitable to work with vulnerable people.

A complaints procedure and recording system was in place. People and their relatives knew who to speak to if they wanted to raise a concern about the service.

The CQC were notified as required about incidents and events which had occurred within the service.

People were cared for by staff who had received appropriate training. Staff completed a variety of training relevant to their role and responsibilities. This helped ensure that people receive safe effective care and support.

We visited the service on 19 August 2016. This inspection was unannounced.

Ranelagh Grange Care Home is registered to provide accommodation for persons who require personal care. The service accommodates up to 39 people and bedrooms are located on the ground and first floor of the building. There were 16 people using the service at the time of this inspection.

A registered manager was not in post at the time of the inspection visit. However the manager had applied to become the registered manager with the Care Quality Commission and her registration was confirmed following this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection of the service took place in May 2016. During that inspection we found improvements were needed in relation to the management of people’s medicines and the monitoring people’s fluid intake. After the inspection, we issued a requirement action in relation to the breach of the Health and Social Care Act 2008 which we identified.

Following the inspection the registered provider sent us an action plan stating that they had met the relevant legal requirement. During this inspection we found that the registered provider had made improvements in relation to the legal requirement, however we found other concerns in relation to the management of people’s medicines.

Improvements continue to be needed in the management of people’s medicines. Although we found that people’s medicines were safer, improvements were still required to ensure that all medicines were managed safely. This is a continued breach of Regulation 12(1) (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we have told the provider to take at the end of this report.

We have made a recommendation in relation to checks on people's medication. During this and previous inspections carried out at the service we found on going concerns with the management of people's medication, which were not identified during audits (checks) carried out at the service. Whilst improvements had been made we need to be assured that those improvements are sustained.

At the last inspection in May 2016 improvements were noted in the way people’s fluid intake was being recorded, however some charts were not always completed correctly. We made a recommendation that the service reviews the systems in place to record and monitor people’s fluid intake to ensure that accurate information was available at all times. During this inspection we were unable to assess the improvements made. This was because at the time none of the people who used the service required a record of their fluid intake. However documentation for recording people’s fluid intake had been improved so that it captured all the relevant information to ensure an appropriate record was kept.

People told us they felt safe living at the service. The environment was kept clean and free from hazards. Equipment and hazardous substances were safely stored and used appropriately. Staff received training in relation to keeping people safe and they were confident about the action they needed to take if they had any concerns about people’s safety, including safeguarding concerns.

People received the care and support they needed with their healthcare needs. They attended appointments as required with their GP and other health care professionals involved in their care. Prompt referrals were made for people to other professionals when concerns about their health and wellbeing were noted.

Risk assessments had been carried out when planning people’s care and appropriate risk management plans were put in place instructing staff on how to provid

We visited the service on 20 May 2016. This inspection was unannounced.

Ranelagh Grange Care Home is registered to provide accommodation for persons who require personal care. The service accommodates up to 39 people and bedrooms are located on the ground and first floor of the building. There were 17 people using the service at the time of this inspection.

A registered manager was not in post. The previous registered manager had resigned from their post in March 2016. A new manager had been employed at the service since March 2016 who was in the process of applying to register with the Care Quality Commission. In addition, a new deputy manager had been recruited who had started their role in February 2016. 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.

Inspections of the service took place in October and May 2015. During these inspections we found that the service was not meeting all of the regulations we assessed. We judged the service to be inadequate and the service was placed into special measures. A further inspection of the service took place in January 2016 and we found that there was not enough improvement to take the registered provider out of special measures. At this inspection we found that there was enough improvement to take the provider out of special measures. Whilst we found a number of improvements in most areas, the registered provider had not demonstrated full compliance with the Health and Social care Act 2008 (regulated activities) 2014. You can see what action we have told the provider to take at the end of this report.

In December 2015 we imposed an urgent condition on the registration of the registered provider to restrict admissions to the service until the Care Quality Commission was satisfied that people are receiving safe, effective care. During this inspection on 20 May 2016 we found that sufficient improvements had been made to remove this urgent condition. This condition was removed in June 2016.

Improvements continue to be needed in the management of people’s medicines. Although we found that people’s medicines were safer, improvements were still required to ensure that all medicines were managed safely. We found that improvements were needed in relation to the recording of medicines, assessments for people administering their own creams and the auditing of people’s medicines. This is a continued breach of Regulation 12(1),(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Improvements had been made to the systems in place to record people fluid intake. However, these charts were not always completed appropriately.

We made a recommendation that the service reviews the systems in place to record and monitor people’s fluid intake to ensure that accurate information is available at all times.

Improvements had been made to how the service monitored the environment and the care and support people required. However, further improvements were needed to as to how people’s medicines and fluid were monitored.

We have made a recommendation that the service develops a more robust and effective monitoring system to ensure that any issues highlighted are managed quickly.

New care planning documents had been introduced to record and plan for people’s needs and wishes. These documents demonstrated that people’s needs had been assessed and planned for.

Risk assessments had been developed in line with people’s care plans which meant that known risks to people had been considered and were planned for.

There was an improvement to the overall understanding of staff with regard to the Mental Capacity Act 2005. People’s care plans had been developed to includ

At the last inspections in May and November 2013 we had concerns regarding the care and welfare of people who lived at the home, the maintenance of accurate records and the medicines management.

The provider had prepared an action plan to make improvements within these areas. At this inspection undertaken in March 2014 we saw that improvements had been made.

Appropriate medication management practices were in place to protect people who lived at the home from risks associated with the unsafe use and management of medicine.

Care files and new format documentation had been implemented. Files were well organised and care plans along with risk assessments were person centred in their approach.

We found people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. There had been improvements in relation to the management of records but it did not enable the provider to meet the regulation completely. We saw evidence that incidents were being recorded for a person who had behavioural episodes but the behavioural monitoring tool (ABC chart) had not been reflected with the information. This meant that the monitoring of triggers and de-escalation methods were not consistently being recorded.

We also saw evidence that a person was prescribed medication and did not have a completed medication care plan within their file.

The purpose of our inspection was to follow up on several areas of none-compliance around medicines management which was highlighted during our last visit.

We spoke with three people who lived at Ranelagh Grange who told us that they were happy and liked living there. Comments included; “I like living here. I’m quite satisfied” and “I like the food here. There is plenty of choice” and “There is no where like home but I’m also quite happy here”.

At the last inspection we had concerns with regards to creams not always being applied to people who needed them. There were also issues around the recording of creams, eye drops, medicines in general and guidance for ‘when required’ medicines. During this inspection we still had some concerns over the recording of people’s creams. This issue mainly related to the night staff. The people we spoke with all required creams to be applied by the care staff. Three of the people told us that they felt they got their creams when they should do. However one person said to us; “I need cream putting on my back because of the pain. If staff are busy then sometimes it gets missed”.

We found that there were appropriate audit tools in place to monitor the quality of service provision at the home during our inspection.

The people using the service who were able to tell us said that they were happy living in the home. Comments included; ‘This is a very nice home where staff treat you well”, “I like it here. I stayed for a while on a temporary basis before I made my mind up to stay”, “We have a good time here, we have activities and outings and people are all very nice”. Whilst there is no place like home this suits me fine” “We are all very well looked after” ,”Staff sometimes have a lot to do but they always find time for a little chat with us”, ”Staff make sure we are comfortable and safe”.

Relatives of people living in the home told us they were happy with the staff and services provided. One person said that the home had organised more activities of late and all the people living in the home were encouraged to join in.

We spoke with four people who lived in the home about their medicines. All said they were happy living there and they thought their medicines were given to them correctly.

One person said ‘’they put my creams on in the morning but sometimes they forget because they are very busy’’.

Two other people said they had creams applied by care workers and they thought they were applied properly every day.

We spoke with five people who used the service. They said they were happy with the service provided and the care they received. Some comments made were;

"I'm happy here. The staff look after me very well. The food is nice. There is plenty for me to get involved in."

"I'm well looked after. It's a good place. The staff provide the support I need. My visitors are always welcomed."

"I'm happy. The food is very pleasant. The staff are very amenable, they listen to our views and respond to them."

"The staff are nice. The home is kept clean and the food is good."

Relatives spoken with said that the staff were friendly and helpful. They described the home as clean and comfortable and said they were kept informed about their relatives' well-being.

We asked health professionals who visited the home their views about the service provided. They reported that staff were attentive, caring and respectful

towards the people who used the service. Staff followed advice given and in general if there have been any matters of concern they have been dealt with in a timely manner. Some comments made were:-

“I think the staff are marvellous, I’m always impressed by the way they care for the people who live at the home.”

“The staff are lovely, they are good with the residents and there always staff around if they are needed.”

St Helens Council has made regular visits to the home over the last nine months as a result of concerns about the operation of the service. Following a recent visit the Intelligence and Outcomes Unit reported that improvements in a number of areas had been made.

There was no up to date information from St Helens LINk to inform this visit.

We spoke with eight people and a visiting relative. People said care workers were kind and helpful but two people told us they didn't get their medicines given to them properly all the time.

This visit was undertaken to follow up compliance actions we made at a visit to the home in February 2011 and to look at concerns brought to our attention by St Helens Social Services around care practices and the management of medication within the home. St Helens Social Services are continuing to investigate concerns that have been raised about the home.

An expert by experience accompanied us on this visit. An expert by experience has personal experience of using or caring for someone who uses a health, mental health and/or social care service. They made observations, spoke with the people using the service and to staff. The expert by experience found that the staff treated the people using the service with dignity and had a relaxed and caring manner. They found the home to be clean and well presented. They made very positive comments about the meal time experience of the people using the service. The expert by experience identified some issues where improvements could be made which have been included in this report.

The expert by experience spoke to 5 people using the service who were happy with the care and support they receive. They also spoke to the visitors of 3 people using the service who praised the care provided by the staff. Visitors said they were "very happy with the level of care given and with the carers’ interaction with residents.” “The food is good, the staff care is good and my relative is dressed well”. Another visitor praised the laundry service provided.

We spoke to health care professionals who visit the service. District nurses considered staff to be helpful and said that when advice is given to them about meeting peoples needs, this is followed. A concern was raised about whether the service is able to meet the needs of a person who can display challenging behaviour towards staff that could present a risk to other people using the service. The manager has asked social services to assess this persons needs to ensure that Ranelagh Grange is the right place for them to live.

St Helens LINk carried out a visit to Ranelagh Grange earlier this year and a summary of their findings is in our last compliance visit report. At this visit there is no up to date information from St Helens LINk. There was evidence at this visit that the home has been working on the recommendations from them around promoting dignity in care.

The people spoken with said that staff are kind and polite. They said staff are respectful towards them and they feel they get the support from the staff that they need. Relatives spoken with also held the same views.

Our observations showed that staff are polite and considerate and respectful.

The people using the service said that they receive good food that is varied and that there is a choice of meals.

The people using the service told us that the home is kept clean and tidy. Relatives spoken with considered that there is a good standard of cleanliness at the home and that the home is well maintained.

The people using the service are happy with the care they receive. They said they are asked their views about the service and know who to speak to if they wish to make changes to how they are cared for.

The people spoken with said they know how to complain if they are not happy with the service being provided.

Information from St Helens Council and St Helens LINks indicates that in general the home provides a good service for the people using it but that there are areas where improvements need to be made.

We visited this service on the 21 and 27 January 2016. The first day of the visit was unannounced.

Ranelagh Grange Care Home is registered to provide accommodation for persons who require personal care. The service accommodates up to 39 people and bedrooms are located on the ground and first floor of the building. There were 24 people using the service at the time of this inspection.

A registered manager has been in post since August 2014. 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.

An inspection was carried out at the service in May 2015 and we found the service was not meeting all of the regulations we assessed. We judged the service to be inadequate and the service was placed into special measures. A further inspection of the service took place in October 2015 and we found that there was not enough improvement to take the registered provider out of special measures. Since that inspection we have received concerns around the care and treatment of people using the service.

On 11 December 2015 we imposed a condition on the registration of the provider to restrict admissions to the service until the Care Quality Commission is satisfied that people are receiving safe, effective care.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘Special measures’. During this inspection we found a number of continued breaches and a new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People did not receive their medicines at the right time and some people did not receive their prescribed medication. Medication administration records (MARs) had not been completed at the right time and others had not been completed with accurate information to show the reason why people had not received their medicines.

Where there had been an increase to the level of risk people faced their care plans had not been updated to reflect the changes. Risk assessments were not completed accurately, therefore putting people at risk of receiving unsafe care.

Fluid monitoring charts did not provide staff with important information about the amount of fluid people were to be offered on a daily basis and this lead to people not being offered the appropriate amount of fluid which they needed to keep them hydrated.

Staff lacked an understanding of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards (DoLS) and they did not know which people were subject to a DoLS. This meant that the rights of people who were not always able to make or communicate their own decisions or needed their liberty restricting for their safety were not protected.

People’s confidentiality and dignity was undermined. Personal records belonging to people were not stored securely and they were left unattended in a communal lounge. A used commode and a commode without a lid was were left in people’s bedrooms.

Care plans had not been reviewed at the required intervals and people did not always receive the care and support in line with their care plan. Guidance about how to support a person with their behaviour had not been followed and the appropriate recording charts were not in place to help monitor the person’s behaviour.

The registered provider failed to make improvements to the service which had been brought to their attention by a number of different agencies. Insufficient systems were in place for the registered provider to monitor the quality of the service that people received at Ranelagh Grange.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.