About the service: Apple Mews is a care home which provides nursing and residential care for up to 45 people. Care is primarily provided for older people, some of whom are living with dementia. At the time of this inspection there were 29 people using the service.

People’s experience of using this service: Improvements had been made to the service following our last inspection in October 2018. At the last inspection we found issues with care records, staff support and training, staffing levels and the governance of the service. We identified two breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations related to Safe care and treatment and Good governance. At this inspection the provider and registered manager had driven improvement and made positive changes. Systems for overseeing the service were more effective. The changes had enabled staff to address most of the issues noted at previous inspections.

People told us they were happy living at the home and staff treated them with respect. Staff knew how to safeguard people from abuse. Medicine management was effective. People and relatives told us they felt the service had improved and was meeting their needs.

Most staff said they felt positive about how the service was being operated and that staff morale had improved. The registered manager used information following accidents and incidents to reduce the likelihood of future harm.

Staff had the skills and knowledge to deliver care and support in a person-centred way. 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 able to participate in a range of activities if they chose to do so. The service worked with a range of professionals to best meet people’s needs.

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

Rating at last inspection: Requires Improvement (report published 13 November 2018).

Why we inspected: Apple Mews Care Home had been rated as requires improvement since October 2017. We received an improvement plan following the last inspection of the service. We wanted to ensure the issues identified at the last inspection had been addressed.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

This inspection took place on 2 and 4 October 2018. The inspection was unannounced, which meant that the staff and provider did not know we would be visiting.

Apple Mews Care Home is a purpose built, detached building in a residential area of Middlesbrough. It is set out over three floors. This service provides support and accommodation for up to 45 people who are assessed as requiring residential or nursing care.

Apple Mews Care Home 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 is registered for up to 45 people. At time of our inspection there were 30 people living at Apple Mews Care Home.

There was a registered manager in place. 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.

At our last inspection in October 2017 we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to Safe care and treatment, Premises and equipment, Good governance and Staffing. Following the inspection, the provider sent us an action plan which detailed actions already taken and those yet to be completed. All actions had dates in place by which the registered provided expected them to be completed.

At this inspection we reviewed the action the provider had taken to address the issues we found at the last inspection. We noted that improvements had been made however we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to Safe care and treatment and Good governance. You can see what action we told the provider to take at the back of the full version of this report.

This is the second time the service has been rated Requires Improvement.

Information in care records including how to manage risks to individuals was not always in place and was sometimes contradictory.

Medicine were not always managed safely and medicine recordings were not always made appropriately.

Audits had not identified the issues we found with records and medicines during this inspection.

We received mixed feedback about the number of care staff on duty being sufficient to ensure people’s needs were met effectively.

Staff had not always received supervision in line with the provider’s policy. Staff however, said that they felt they could approach the management team if they had any issues.

Policies and procedures were in place to support staff in protecting people from harm, such as safeguarding and whistleblowing polices. Staff knew how to identify and report suspected abuse. People and their relatives felt the service was safe.

Safe recruitment practices were in place. Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with vulnerable people.

People were not always supported to have maximum choice and control of their lives. Best interest decisions were in place for people who were unable to make some of their own decisions however some of these required further work.

The environment was clean and staff knew how to help control the spread of infection. Equipment checks were undertaken to help ensure the environment was safe. Emergency contingency plans were in place.

People had access to a range of healthcare services such as GPs, hospital departments and dentists. People’s nutritional needs were met.

The premises were spacious and tidy however signage could be improved to better meet the needs of those people living within the home who have a dementia type illness.

People were supported by a

The inspection took place on 5, 6 and 16 October 2017. The inspection was unannounced.

Apple Mews Care Home is based in a residential area of Middlesbrough. The home provides personal care and nursing care for older people and people living with dementia. The service is situated close to the local amenities and transport links. The service is registered for up to 45 people and on the day of our inspection there were 35 people using the service.

At the time of our inspection the service had a registered manager. The registered manager was an area manager rather than the home manager who had direct responsibility for managing the home. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

People were not always supported appropriately with their medicines. We found that medicines were not always administered and managed safely. We found errors that were also not identified by the audits in place and some medicines were not stock checked correctly.

The premises were well presented and clean in most areas. However, we found that carpets on the first floor needed cleaning or replacing and the laundry room needed attention.

People were not always supported by enough staff to meet their needs. We received mixed feedback from relatives and people who used the service regarding staffing levels. The service relied heavily on the use of agency staff and this was impacting on the service people received.

People were supported to make decisions but we found that where best interest decisions were made, these were not recorded appropriately.

We found a quality assurance survey had taken place with stakeholders using questionnaires. There had been little uptake and no action taken to engage more people or to address issues raised in the feedback.

People had care plans in place, however some information in these plans was not recorded correctly including people’s food and fluid records. Audits by the home manager did not always pick up on inaccuracies in care records.

There were effective systems in place for continually monitoring the safety of the premises including maintenance checks and fire safety.

Records showed us there were robust recruitment processes in place.

People took part in planned activities and we observed many activities taking place. Throughout the inspection we saw that people who used the service, relatives and staff were comfortable and had a positive rapport with the staff.

People were supported by caring staff. We spent time observing the support that took place in the service. We saw that people were always respected by staff and treated with kindness. We saw staff communicating with people well.

The atmosphere of the service was busy and welcoming. People who used the service and their relatives told us they felt at home and visitors were always welcomed.

Care plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care plans showed that people’s health was monitored and referrals were made to other health care professionals where necessary, for example: their GP, dentist or optician.

Care plans contained individualised information and were person centred. This meant support needs were planned around the person and took into account their preferences.

Records showed staff were supported and able to maintain and develop their skills through training and development opportunities that were accessible at the service. Staff confirmed they attended a range of valuable learning opportunities. Although some were in need of refreshing, courses were already booked for staff to attend.

Staff were support