This inspection took place on 21 and 23 May 2018. The first day of our inspection visit was unannounced. The provider was given notice of the other date, as we needed to spend specific time with them to discuss aspects of the inspection and to gather further information.

Austhorpe House was last inspected in May 2017 and was rated as Requires Improvement. At that inspection, we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not have enough suitably trained staff to meet people's needs, and the provider did not have robust recruitment practices. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) Safe, Effective, Caring, Responsive and Well Led to at least good.

At this inspection, we found that improvements had not been made to ensure the provider delivered nursing and personal care that met legislative requirements. We found that the provider remained in breach of regulation 19 (Fit and proper persons employed). We also found a further four breaches 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 back of the full version of the report.

Austhorpe House 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. Austhorpe House provides personal and nursing care for up to 28 people over two floors. At the time of our inspection, there were 20 people living there. Austhorpe House provides personal and nursing care to people living with a range of health conditions, including physical disabilities and people living with dementia.

The service had 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.

The provider continued to recruit staff that was not compliant with regulations. The checks made on potential employees were not sufficiently robust. The provider had failed to make improvements in recruiting their own staff and were reliant on the high use of temporary staff. This had impacted on the quality of service provided as people’s preferences had not always been met. We found there were inconsistencies in people’s care records. Risks to people’s safety were assessed but information was sometimes conflicting and lacking in detail about the action staff should take to minimise them. This presented concerns that, due to high levels of agency staff used, not all of them would be aware of the measures required to ensure people’s safety.

The provider had failed to provide sufficient numbers of suitably qualified and competent staff. This had led to incidences whereby the kitchen could not operate and cleaning schedules were not carried out.

People told us they felt safe at the service. Staff had an understanding of how to safeguard people from risk of abuse and were confident the registered manager would ensure any allegations of abuse were appropriately managed. Staff were trained in relevant areas, including health and safety and moving and handling. People’s medicines were not always managed safely, and records gave conflicting information

People were supported to have sufficient to eat and drink, but mealtime experiences were not always enjoyable for people. People felt that improvements needed to be made to the quality of the food, but efforts to do this by the registered manager had been inhibited by the provider. People's needs were not fully met by the adaptation, d

The inspection took place on 24 May 2017 and was unannounced.

Austhorpe House is in a rural location and consists of an old building on two floors and with a more modern and purpose built ground floor extension to one side. It provides nursing care for up to 28 older people, some of whom may be receiving palliative care at the end of their lives. The service provider says they will only accommodate 24 people. At the time of this inspection, there were 19 people using the service.

There service is required to have a registered manager in post. 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. At the time of this inspection, the previous registered manager had supported a new manager through their induction and had left the home. The incoming manager had assumed full managerial responsibilities for the service around three weeks before our inspection but had not yet registered with CQC.

At the last inspection in July 2016, we asked the provider to take action to make improvements to medicines management and this action has been completed. Medicines were being managed in a safer way and the manager was working with the pharmacy supplying medicines to ensure further improvements were made.

However, we found that other improvements to the service were needed to ensure it supported people safely and effectively. Although there were enough staff to support people safely, recruitment practices were not contributing to protecting people from the employment of unsuitable staff as robustly as they should. Staff had also not received some elements of training they needed to support people competently and safely. Time-limited training was not renewed and updated promptly when it was needed to ensure staff remained up to date. Concerns about recruitment and training meant that we identified breaches of two regulations.

Improvements were needed to the way that risks were assessed and to address the lack of guidance for staff about the action they needed to take to minimise these. Care records lacked detail about these risks as well as about how staff should meet people's individual needs and preferences. The effect of this was mitigated to some extent because of a core of long-standing care staff who had got to know people well and how they liked to be supported.

There were systems in place to assess the quality and safety of the service people received. However, this did not always result in improvements being made in a timely way and the service provider had not been able to adhere to their own timescales for improvement. The manager was aware of shortfalls within the service from both internal and external audits. However, they had not been in post long enough to speed up the pace of improvement and to sustain it. The manager anticipated that this would improve with the strengthening of the management team by appointing a deputy manager.

Staff were kind, caring and compassionate approach in the way they supported people and took people's preferences into account. They supported people in a way that respected their privacy and dignity. Staff understood the importance of seeking both people's views and their consent before delivering care and of acting in a way that took into account people's best interests.

Staff supported people to eat and drink enough and to gain advice and treatment about this and other aspects of their health and welfare. People had opportunities to engage in activities of interest to them if they wished to do so and felt well enough to participate. Staff encouraged people with this to contribute to people's emotional and social wellbeing.

You can see what action we told the provider to take at the back of the full ver

The inspection took place on 20 and 21 July 2016 and was unannounced.

Austhorpe House is in a rural location and consists of an old building on two floors and with a more modern and purpose built ground floor extension to one side. It provides nursing care for older people, some of whom may be receiving palliative care at the end of their lives. At the time of our inspection, there were 23 people using the service.

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.

The provider's management structure made it difficult for the registered manager, as a nurse, to receive regular professional development and clinical supervision. The registered manager was struggling to proactively monitor and assess the quality and safety of the service. Their ability to do this in a structured and systematic way, rather than just on a day-to-day basis, was compromised by the need to cover nursing shifts regularly. Some of the concerns we identified had not been picked up and addressed by either monitoring systems within the home or the provider's oversight of the service.

Medicines were not always accurately recorded, accounted for and disposed of when they were no longer needed. This compromised the way the service could show they always administered medicines as the prescriber intended and minimised the risk of misuse or error. The registered manager had plans for addressing other potential risks to people's safety within the home.

Risks to people's health and welfare were assessed. The registered manager had plans to address potential risks within the environment and sought to address these with the providers. There was a lack of clear guidance within individual care plans about minimising risks for each person. However, the impact of this on people's safety and welfare was minimised because there was a consistent and stable staff team who understood how to support people safely and mitigate these risks.

Staff were aware of their obligations to report any concerns that people were at risk of harm and abuse. They were recruited in a way that contributed to protecting people from staff who were unsuitable to work in care services. Although some people were concerned they had occasionally to wait for support, they felt there were enough staff to support them safely. The registered manager was aware of the importance of keeping people's care needs and occupancy levels under review to ensure staffing levels continued to be safe.

People received a service that was effective. Staff received training and support to meet people's needs competently. The registered manager was arranging further training for staff to understand their legal obligations towards those who could not give informed consent to their care. Staff understood the principle of seeking consent from people to deliver their care and in involving others who knew people well to help determine what was in people's best interests.

People had a choice of meals and enough to eat and drink to meet their needs. Where people needed assistance to eat and drink, staff supported them. As far as possible, people were supported in a way that made their mealtime experience pleasant and enjoyable. Staff ensured they monitored people's health and welfare and sought advice from other health professionals to promote people's wellbeing.

People experienced support from staff who had developed warm, compassionate and caring relationships with them. Staff treated people with respect for their privacy, dignity and independence. They considered people's individual preferences, needs and wishes so that they could deliver care focused on each person. People valued the support they ha

We considered all of the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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?

People are treated with respect and dignity by staff. People told us that they felt safe. We saw that the environment was safe, clean and hygienic. Equipment used at the home was well maintained and had been regularly serviced. There were enough staff on duty to meet the needs of people living at the home. However, people told us that they occasionally had to wait for assistance because the staff were busy.

Systems were in place to make sure that managers and staff learned from events such as accidents, incidents, complaints and investigations. This reduced the risk to people and helped the service to continually improve.

The home had proper policies and procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Although no applications had needed to be submitted relevant staff had been trained to understand when an application should be made and in how to submit one. This means that people will be safeguarded as required.

Is the service effective?

People told us that staff did their best to reduce the length of time they were kept waiting for help, when they rang the call-bell. They told us that they received the care and attention they required in a way that met their needs. Through our observations and speaking with staff we noted that staff understood the care and support needs of each person. One person told us. “This is a lovely, comfortable home and the staff will do anything to help you. You only have to ask.” Staff had received training to meet the needs of people living at the home.

Is the service caring?

People were supported by staff who used a kind and attentive approach. We saw that staff were patient and encouraged people to be as independent as possible. People told us that the staff did not rush them. Our observations confirmed this. A visitor told us, “I am happy with the care given to my relative. The members of staff are so polite and respectful.”

Is the service responsive?

Care and risk assessments had been completed before people moved into the home and when their needs had changed. A record was held of their preferences, interests and diverse needs. People told us that staff members consulted them and encouraged them to make their own decisions. People had access to planned activities on most days. One person told us. “We have things to do to occupy us, such as a quiz or game of dominoes.”

Is the service well led?

All of the staff spoken with had a good understanding of the whistleblowing policy. Quality assurance processes were in place and people told us they were asked if they were satisfied with the care and support they received. Visitors and staff said they had felt listened to when they made a suggestion or raised their concerns.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home. Quality assurance records seen by us showed that identified shortfalls were addressed promptly. This helped to ensure that people received a good quality service at all times.

We spoke with people who lived at the home and relatives who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations, decision making and activities.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted.

Relatives told us that people received the nursing care and support they needed and that staff were very kind.

Medication was administered, recorded and stored accurately and safely.

Staff members were trained and were supported to provide an appropriate standard of nursing care and support through increased supervision and staff team meetings.

Quality audits were being carried out to ensure the views of people were gathered on the quality of the service provided, policies and procedures were being followed and people were safe.

We spoke with people who used the service and their relatives who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations and decision making.

The plans of care contained the information staff members needed to ensure that the health and safety of people was promoted.

People who used the service and their relatives told us that people received the nursing care and support they needed and that staff were very kind.

Staff members were not fully supported because they did not receive supervision. This meant that people using the service could not be sure that staff had their competency and the standard of care and support they provided to people monitored.

People were given support by the provider to make a comment or complaint where they needed assistance.

We spoke with five people who lived in the home. They told us that their needs were met and that they were consulted about the nursing care and support that they were provided with. People were complimentary about the staff that cared for them and told us that they always treated them with respect and that their privacy was respected. They told us that there were enough staff on duty to assist them and that they felt safe living in the home. They also told us that the environment was comfortable and clean and that they were provided with good quality meals and all the equipment they needed.