About the service:

• Atfield House is part of Barchester Healthcare Homes Limited and is registered for 68 people. It is a care home with nursing that accommodates people with dementia care needs and people with frail elderly care needs across three units. At the time of the inspection 65 people were using the service.

People’s experience of using this service:

• The provider had systems in place to help safeguard people from the risk of abuse and staff knew how to respond to possible safeguarding concerns. There were also systems in place to identify and mitigate risks people face while receiving care.

• The provider ensured there were enough staff on duty to meet people’s needs. They also ensured safe recruitment procedures were in place and followed.

• Medicines were managed and administered safely.

• People’s needs were assessed prior to moving to the home. Care and support were delivered and monitored in line with current good practice guidance.

• Staff had up to date training, supervision and annual appraisals to develop and maintain the necessary skills to support people using the service.

• People's dietary and health needs had been assessed and recorded so any dietary or nutritional needs could be met. People were supported to maintain healthier lives and access healthcare services appropriately.

• The principles of the Mental Capacity Act 2005 were followed so people’s rights were respected.

• We observed staff to be kind and caring. People and relatives confirmed this. People were supported to make day to day decisions and have choice and control of their environment.

• People, and their relatives where appropriate, were involved in planning people’s care. Care plans contained details of how to meet people’s individual needs, including end of life wishes.

• There was a complaints procedure in place and the provider responded to complaints appropriately.

• The provider had systems to monitor, manage and improve service delivery and to improve the care and support provided to people.

• People using the service and staff reported the registered manager and deputy manager were available, listened and actively promoted an open and transparent work environment.

Rating at last inspection:

• The last comprehensive inspection was 13 July 2016. We rated the service ‘good’ overall with one breach of regulations in relation to safe care and treatment. In January 2017 we completed an unannounced focused inspection to check that improvements to meet legal requirements planned by the provider after our July 2016 inspection had been made, and found they had.

Why we inspected:

• This was a planned inspection based on the previous rating.

Follow up:

• We will monitor all information received about the service to understand any risks that may arise and to ensure the next planned inspection is scheduled accordingly. If any concerning information is received, we may inspect sooner.

We carried out an unannounced comprehensive inspection on 12 and 13 July 2016. During the inspection, we found a breach of a legal requirement as the service did not always follow safe practices. A wound management care plan was not being followed as directed by the tissue viability nurse and the service was not formally recording that they monitored people during the day to evidence that there were measures in place to minimise identified risks to people, particularly those people unable to use call bells.

After the inspection, the provider submitted an action plan detailing what they would do to meet the legal requirement in relation to the breach.

We undertook this unannounced focused inspection on 10 January 2017 to check that the provider had followed their plan and to confirm that they now met the legal requirement. This report only covers our findings in relation to the requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Atfield House on our website at www.cqc.org.uk.

Atfield House is part of Barchester Healthcare Homes Limited and provides care with nursing for up to 63 people. The home has three units consisting of two units for physically frail and older people and a third unit for people living with dementia. At the time of our inspection there were 57 people using the service.

The registered manager had been in post since 2012. 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 focused inspection on 10 January 2017, we found that the provider had followed their plan of action, dated 13 October 2016 and that the legal requirement had been met.

Wounds were initially seen and entered onto the electronic database by the deputy manager. The deputy manager was present when wounds were dressed and people’s care plans were audited weekly. The managers and nurses had a daily meeting, which included wound management as an agenda item. This provided the opportunity to share their own observations and update their colleagues on any external healthcare professionals’ visits.

The service had care plans for falls, call bell assessments and since the last inspection had begun to record hourly monitoring of people using the service.

Audits by the deputy manager were effective in identifying any gaps in the care plans and resolving them.

We saw improvements to how PRN (as required) medicines were recorded and topical creams had body charts with clear instructions on how to administer the creams.

The inspection took place on 12 and 13 July 2016. The first day of the inspection was unannounced and we told the provider we would be returning the next day.

The last inspection was carried out 1 May 2014 at which time the service was meeting the assessed regulations.

Atfield House is part of Barchester Healthcare Homes Limited and provides care with nursing for up to 63 people. The home has three units consisting of two units for physically frail and older people and a third unit for people living with dementia. There were 62 people using the service but two people were in hospital on the days we inspected. One bed was being held for respite.

There was 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.

In 11 of the 12 records we looked at, we saw people were receiving care and treatment in line with their care plan. However in one care plan the tissue viability nurse’s guidance was not acted upon by the staff, which meant the person did not receive the treatment they required.

There was a lack of recording for people who required regular monitoring.

We observed that some risk plans required people to be monitored as they were unable to summon help from their rooms but there was no record of when people were checked on during the day. Additionally we saw call bells behind beds could be difficult for some people to reach.

The service employed two activity co-ordinators but activities were not always meaningful to the people who used the service. We have made a recommendation that the provider review activity provision in line with the NICE guidelines.

Medicines were administered and stored safely but not always recorded correctly. During medicines administration, we observed a PRN (as required) medicine was recorded in the medicine notes and not in the PRN section of the MAR chart. We have made a recommendation for the proper and safe management of medicines at all times.

Staff were sufficiently deployed and appropriately trained.

The service had safeguarding policies and procedures in place.

The environment was clean and well maintained.

Staff were suitably supervised and appraised.

Healthcare needs were being met through assessments, monitoring and support from the relevant professionals.

Staff were kind and caring. They knew the people who used the service and were able to meet their needs.

Most people who used the service, staff and relatives told us the manager was approachable and they could raise concerns with them.

Monitoring and auditing records were well maintained.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Atfield House provides care with nursing for up to sixty four people. During the time of this inspection it was providing care for twenty seven people with a diagnosis of dementia and twenty nine frail/older people.

The home was arranged into different units. A frail/elderly unit arranged over two floors and a dementia unit which was on one floor. The dementia unit had its own enclosed courtyard. People living at the home all had single bedrooms. This afforded people privacy and independence.

We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). We found that while no applications had been submitted, policies and procedures were in place but no applications had been necessary. Staff that we spoke with were aware of what constituted a deprivation of liberty and what steps they would take if they thought somebody was being deprived of their liberty.

The premises and equipment were managed appropriately so people were safe. There was an ongoing monitoring programme for equipment and maintenance records at the home were up to date.

Care records at the home were up to date and reviewed regularly by a nurse. People were assigned key workers who worked closely with people and helped to support them. Staff attended training which helped them to support people more effectively.

People that we spoke with were satisfied with the care they received, however more than one person said that when two staff worked together they did not always engage with them.

A number of audits and checks were carried out at the home, these included weekly medication audits and care plan audits. Incidents were managed in a way to enable lessons to be learnt from them.

We spoke with fifteen people using the service, the relatives of three other people, the home’s manager and deputy manager and ten nursing and care staff. We also looked at the care plans for ten people, staff recruitment files and the procedures for responding to complaints received.

People told us they were happy with the care and support they received. One person told us “I like it here very much. I get all the help I need.” Another person said “I’m very happy, it’s lovely here.” A relative told us “it’s a very good home and I know my [relative] is safe and well cared for.”

We saw that people were consulted about the care and treatment they received and these were delivered in line with their care plan.

People told us they felt safe in the home and staff knew how to respond to any concerns about the safety of people using the service.

Appropriate pre-employment checks were carried out to make sure staff were suitable to work with people using the service.

Arrangements were in place to investigate and resolve, if possible, complaints from people using the service or their representatives.

During this inspection we talked with one visitor, two people who used the service, two members of staff and two management staff.

We carried out this inspection to check whether the home was complying with outcome 16 of the essential standards of quality and safety. We had inspected the home on 13 August 2012 and had found that people were not fully protected against the risks of receiving unsafe or inappropriate care and treatment. This was because accidents and incidents were not appropriately monitored and reported to management staff so they could take action to prevent recurrence.

We found that the system to manage accidents and incidents was being appropriate implemented so the provider could take action where required to prevent recurrence of accidents and incidents and to ensure the safety and welfare of people.

During the inspection, in addition to assessing whether the service was complying with outcome 4, we also looked at compliance with outcomes 1 and 16.

We spoke with three people using the service and two relatives to get their views on the quality of services provided by the home. We observed the support people received from staff throughout the inspection to help us understand their experiences of receiving care because many had complex needs which meant that they could not tell us their views about the care and support they received. We also spoke with five members of staff and three staff from the home’s management team.

Staff were aware of people’s choices and preferences and these were recorded in their care records. There were appropriate activities to keep people stimulated and staff were aware of the need to engage and interact with people, to improve their quality of their life. We however observed that improvement could be made to the way people’s privacy and dignity was maintained, because staff did not always knock on people’s door when they opened these. Two people who have been assessed as able to use their calls bells, did not have their call bells so their independence could be promoted and for them to summon help if they needed to.

A relative said “I am satisfied with the medical and general care” that the person they visited received in the home. Another relative said “we have been impressed and staff work brilliantly with [the person they visited]” Relatives we spoke with said they were kept informed of changes in people’s condition and of incidents or accidents. We found during our inspection that the standard for the management of pressure ulcers was not as good as it could have been to make sure people received appropriate care and treatment. This was because arrangements in terms of care planning and the provision of pressure relieving equipment when people developed pressure ulcers were lacking.

The home had a quality management system. The system to manage incidents/accidents was not effective to make sure people were protected from the risks of poor and inappropriate care and support.

People who use the service and relatives told us that they had received information about the services offered in the home before deciding to move in. Relatives said that they knew that the home had a good reputation but were impressed with the quality of the environment and the friendliness of its staff when they visited.

People were supported to make choices in their daily life and were involved in their care. For example, relatives and people were involved in the six monthly reviews of care plans or when the care plans were changed to reflect the changing needs of people. They also had the opportunity to contribute their views about the way the service was provided in meetings that were arranged about once every two months.

People and relatives confirmed that the provider carries out an annual satisfaction survey, of relatives, stakeholders and people to get their views about the quality of services provided in the home. A relative said that any issue or concern that is brought to the attention of management is promptly addressed.

Feedback from people and relatives showed that the home provided a good standard of care and support to people. Visitors said that their relatives were always appropriately dressed and appeared well cared for when they visited. Relatives were confident that staff would monitor people’s condition if they were not well and would take prompt action where required. One person said that “they [staff] would come around and check that I am alright”.

We noted that many people were asleep for most of the one hour during which we carried out our structured observation. We found that a lack of interactions and engagements with people accounted for them being sleepy.

We carried out our inspection on Saturday 26 May 2012 from 10.55am to 5.25pm and on Wednesday 30 May from 7.35am-1.25pm. We talked with three people using the service. We also used a number of different methods to help us understand the experiences of people using the service because many had complex needs which meant that they could not tell us their experiences. This included talking to the relatives of four people and using the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

On the Memory Lane unit we observed that people could make choices how they spent their day. We saw people sitting in the lounge or in the dinning area and some walking down the corridors. Relatives we talked to confirmed this. They reported that people’s preferences, likes and dislikes were taken into account when care and support was provided to people. For example in the afternoon we observed one person watching one of their favourite programmes on the TV.

Relatives who spoke with us said they were involved in drawing up and reviewing care plans so they knew the care people received. They said staff always informed them when there were changes in people’s condition. The care records of people that we saw, had the signatures of people’s relatives to confirm this.

Relatives who talked with us were mostly satisfied with the care and support people received. Three of them said the people they visited were always appropriately dressed and had a good standard of personal hygiene. Three people using the service told us that they were satisfied with the personal care they received. We also observed that people received appropriate personal care during our inspection. People’s care records confirmed that people received at least a bath or shower weekly according to their preferences.

When we carried out our observation, we saw that the four people we observed slept for most of the time we carried out our observation. We looked at the care plans of the four people addressing their social and recreational needs which said they needed to be stimulated and engaged. Our observations showed that people did not receive enough stimulation and engagements for them to spend their time in a more meaningful manner. People therefore did not always receive the care that had been planned and documented for them.

We found that people went to bed or got up at times that were not always recorded in their care plans to show that they received care and support according to their preferences, choices, individual needs and to protect them against the risks of receiving inappropriate and unsafe care.