This inspection took place on 9 August 2018 and was unannounced. A second day of inspection took place on 14 August 2018 which was announced.

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

Appleby is registered to accommodate 55 people in one adapted building across two floors. At the time of the inspection we were informed that refurbishments had taken place and Appleby could now only accommodate 50 people. We had not been notified of this change in registration. At the time of the inspection 42 people were resident. The first floor specialises in providing care to men living with a dementia who may, at times, be anxious and distressed.

The service had a registered manager who had been in post on a full-time basis since February 2018. They were registered with the Commission on 7 August 2018. 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 this inspection we found breaches of regulation in relation to consent and good governance. Mental capacity assessments and best interest decisions had been completed however some were over a year old and had not been reviewed. For some people who lacked capacity their safety was maintained through the use of restrictive equipment such as bed rails and wheelchair lap belts but there was no recorded capacity assessment or best interest decision.

The quality assurance processes had not been sufficiently embedded to identity all the areas for improvement noted during the inspection.

Some care plans lacked detail whilst others were person centred and thorough. Some risks to people had not been assessed and some risk assessments were over a year old. Reviews of risk assessments lacked detail.

The quality of recording of medicines, in particular as and when required medicines and the application of prescribed creams varied. We did not find any people had come to any harm due to the administration of medicines and by the second day of inspection a fully audit had been completed, improvements made and an action plan implemented to ensure sustainability.

Staff were kind and caring in their approach and we observed genuinely warm relationships between people and staff. People told us they were treated with dignity and respect.

Staff understood safeguarding procedures and were confident to report any concerns.

Accidents, incidents and safeguarding concerns were analysed for trends and lessons learnt. Some practices had been amended in response to this analysis.

Concerns and complaints were logged, investigated and responded to. People and their relatives confirmed they had no reason to complain but were confident any concerns would be addressed.

Staff levels were assessed using a dependency tool and there were sufficient staff to meet people’s needs. Safe recruitment practices were in place.

The registered manager ensured staff were well supported, including the provision of formal supervision meetings and an annual appraisal. Staff new in post had their performance and support reviewed in probation meetings.

Training was provided and staff had the opportunity to develop their skills so they could support the nurses with evaluations and some clinical care.

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’s nutrition and hydration needs were met and they were supported to access healthcare professionals, such as speech and language therap

This unannounced inspection took place on 2 August 2016. We last inspected the service in October 2014. At that inspection we found the service was not meeting Regulations 13 of the Health and Social Care Act (Regulated Activities) Regulations 2010, which corresponds to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and relates to the management of medicines.

Following our inspection in October 2014, the provider sent us an action plan to show us how they would address our concerns.

We undertook this full inspection to check that they had followed their plan and to confirm that they now met legal requirements in all areas.

Appleby provides residential and nursing care for up to 55 people, some of whom are living with dementia. At the time of our inspection there were 37 people living at the service.

The service had a registered manager 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.

We found the provider had made positive changes and now met the current regulations in regard to the safe management of medicines. Medicines were stored and administered safely, and people received their medicines as prescribed.

We found people were safe at the service. The building was clean and well maintained, no trip hazards were noted, risks were assessed and staff were trained in safety, emergency and safeguarding procedures.

The service had sufficient staff on duty and they were supported and well trained. Staff recruitment and staff disciplinary processes, as far as possible, protected people from harm.

People received support to ensure they had enough to eat and drink and if they were identified as being at risk of malnutrition or dehydration, suitable monitoring systems were used to maintain their health. Referrals were made to health care professionals in a timely way when required and people were supported with a range of health care services to maintain good health.

The Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements.

People were supported by staff that were kind, caring and respectful and knew them well. People were treated with dignity and respect. Staff understood people's needs well and helped them to choice how they went about day to day activities or choosing what they wanted to do.

Complaints had been handled appropriately and in a timely way.

The registered manager and provider had a robust quality assurance system in place and sought feedback from people, their relatives and other visitors to consistently monitor the service provided.

We looked at the personal care records for six people who used the service. We found these were individualised and had been regularly reviewed. Charts were in place to record the care and support people were given throughout the day and night. These included positional changes, personal care and food and fluid charts. The staff we spoke with were aware of the importance of keeping the records up to date so each person's care needs could be monitored.

We spoke with a visitor who told us the staff kept them well informed about their relative's condition and they felt good care and support was provided.

We looked at the health and safety records in the home and saw these were regularly updated.

We found that people's personal records, and other records held in the home, were comprehensive, accurate and up to date.

We saw staff asked people's permission before they provided care and support. There was written evidence to show mental capacity assessments had been carried out and where people did not have capacity to make decisions, appropriate people were consulted on their behalf.

We saw people's needs were assessed and care was planned in line with their needs. Two relatives told us they were pleased with the care provided by the staff. Comments included, "I think they do a good job" and "I have no concerns, the care seems good."

There was sufficient specialist equipment in place to meet people's individual needs and there was a system in place to ensure it was well maintained and fit for purpose.

Staff were well supported and received regular supervision to help them carry out their roles. The staff told us they received good training and the manager and deputy manager were very supportive and approachable.

There was an effective complaints system available and comments and complaints made were responded to appropriately.

We looked at six care records and the majority contained detailed information and were up to date. However we found two people's care records did not contain up to date information about their care needs.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. People who could, told us they had confidence in the service, comments included, “It is a nice place to live" and "Staff are nice lasses."

People said they could receive medical and specialist attention when they needed it. We saw there were improvements to the management of skin care and integrity.

We saw people were helped to fulfil their social needs within the home and community. People we spoke with said, "There are things to do, I am getting my make up done", and "We get singers and I like to join in."

We saw, and people told us, their home was clean, free from offensive odours, comfortable and warm. They said, "I have my own room, it is very clean." We saw, and people told us, staff were kind and caring. People confirmed they were given the opportunity to comment on the service, change routine or raise complaints. They said their visitors were made to feel welcome and information sharing was improving.

People living in the home were not able to speak with us in a meaningful way so we therefore looked to see if they were getting the medicines that they needed when they needed them by looking at their medication records and the storage of medicines. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The people who lived in the home could not tell us directly about the care they received due to a variety of complex needs. We observed the care people received in the lounge and dining areas and spoke with the staff on duty.

We spoke with a visitor who told us they did not have any concerns about their relative’s care and the staff were approachable.

The people who lived in the home could not tell us directly about the care they received due to a variety of complex needs.

We spoke to five visitors and three said they were satisfied with the care their relative received. However two people said they had concerns about the cleanliness in the home and they felt the staff did not interact sufficiently with their relative.

We carried out an unannounced visit on 24 October 2014 and a further announced visit was made on 30 October 2014.

The home was inspected on 27 November 2013 when we found they were not meeting regulation 20, records. We carried out a follow up inspection on 19 February 2014 and found the home were meeting this regulation.

Appleby is registered to provide accommodation for up to 55 adults who require nursing or personal care, some of whom are living with dementia. It is a purpose built home near the centre of North Shields. There were 29 people living at the home when we visited.

A new manager had been employed in July 2014 but they were not yet registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

Due to their health conditions and complex needs not all of the people were able to share their views about the service they received. During our visit we spoke with five people who used the service and observed their experiences. We also spoke to three visitors, the area manager, the manager, five care staff and two visiting health care professionals.

The provider had policies and procedures in place to help keep people safe and to prevent abuse happening. The staff were aware of the procedure to follow if they observed any abuse within the home.

Checks were carried out prior to staff being employed in the home to help ensure they were suitable to work with vulnerable people.

We saw the premises were well maintained and equipment was checked regularly to help protect people’s safety.

At the time of our inspection there were sufficient staff on duty to meet people’s needs. The manager told us he had recently recruited two care workers and the home was fully staffed to care for the people who lived at the home. He was in the process of recruiting bank nurses and care workers to cover holiday and sickness in the home.

We looked at the system for dealing with medicines and found that there was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and have told the provider to take action to remedy this. You can see what action we told the provider to take at the back of the full version of the report.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. An emergency application to deprive a person of their liberty had been completed at the time of our inspection. The manager told us that he was liaising with the local authority about DoLS applications which may need to be made.

Menus were varied and a choice was offered at each mealtime. Staff were sensitive when assisting people with their meals and the kitchen staff were aware of special diets which some people required.

Staff told us, and records showed appropriate training was provided and the staff were supervised and supported.

The staff were aware of the needs of the people they cared for and were meeting these needs in a caring manner and were respecting people’s privacy and dignity.

We saw information to show that the home made prompt referrals to other health care professionals if required. Activities and outings were provided which people could participate in.

People were aware of the complaints procedure and they felt confident to use it if they needed to.

We looked at eight care records and found people’s needs had been assessed but some areas had not been linked to a care plan. We considered improvements were required to ensure staff had good information to meet people’s needs.

There were audits and checks carried out by the management team to help ensure standards were met and improvements put in place. The projects manager and manager had identified areas where improvements were required and had comprehensive action plans to address this.