We undertook an inspection of Boughton Manor on 14 November 2018. The inspection was unannounced. Boughton Manor is situated in the village of Boughton near Newark. Boughton Manor 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.

The home was registered for up to 40 older people. There were 27 people living at the home at the time of the inspection. We were told that the potential shared bedrooms were now used as single occupancy. Everyone living in the care home had a diagnosis of Dementia and required nursing support. There was a complex range of people’s support needs.

At the last inspection, in 22 November 2016, we rated the service as ‘Good’. This inspection was a responsive comprehensive inspection, which means it was brought forward in our schedule due to concerns. These concerns related to a recent Local Authority audit which raised concerns about the service’s management of risk and incidents. Our inspection found similar concerns and we have rated the service as ‘Requires Improvement.’.

During this inspection we found concerns about the management of risk and assessment of mental capacity. We found two breaches 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. This is the first time the service has been rated as Requires Improvement.

During this inspection we found this service was not consistently safe. Risks associated with people’s behaviour were not managed safely. Behaviour care plans did not contain all the required information to guide staff support. We found staff were responding differently to people’s needs. The registered manager was not aware of this due to staff recording across different forms and these not being audited regularly.

Mental capacity assessments were not always decision specific and people’s rights were not fully protected. Staff training was in date and staff received regular supervision. People told us that they were given choice of meals and said the food was good quality.

There were sufficient staff to meet people’s needs. Recruitment of care staff and nurses was managed safely. People’s physical health needs were clearly assessed and care planned, and medicines were managed safely. We had some concerns about infection control procedures after toileting support.

We found the service was not always caring. Staff interactions were task focused rather than specific to the individual. Staff had variable knowledge on people’s diverse needs, and care plans did not provide sufficient information to support a caring approach. There was evidence of people being involved with care planning. People were treated with dignity and privacy.

Care was not responsive to people’s needs. We saw four people who had experienced incontinence and we needed to prompt staff to support them. We saw minimal activities within the care home and people sat for long periods without engagement. People had been consulted for end of life care planning.

We found the service was not consistently well led. Multiple audits were in place, which had resulted in some improvement. However, audits had not reviewed behavioural support records and this meant we could not be sure people’s needs would be met. We found that risks were not managed consistently or effectively across the service and this had not been recognised by the registered manager. People, their representatives and staff had opportunities to feedback on the running of the service. Visiting professionals told us that the registered manager was always pro-active in responding to concerns.

At the time of our inspection there was a registered manager in place. A registered manager is a person who has been registered with the Care

We undertook the unannounced inspection on 22 November 2016. The service provides residential and nursing care for 27 people who are living with Dementia. On the day of our inspection 27 people were using the service. The service is provided across two floors.

The service had a registered manager in place at the time of our 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 and associated Regulations about how the service is run.

People were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The registered manager shared information with the local authority when needed and acted on concerns when they were raised to them. Risks to people’s safety were assessed and reviewed on a regular basis. These risks were managed in such a way as to both protect people and allow them to retain their independence wherever possible.

Staffing levels in the service were sufficient and the registered manager regularly reviewed staff levels to ensure that they remained safe depending on the needs of the service. People received their medicines safely from suitably trained staff. Staff had a full understanding of people’s care needs and received regular training and support to give them the skills and knowledge to meet these needs.

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were protected from the risks of inadequate nutrition and dehydration. Specialist diets were provided if required. Referrals were made to health care professionals when needed.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care They were treated in a caring and respectful manner by staff who delivered support in a relaxed and considerate manner.

People, who used the service, or their representatives, were encouraged to be involved in decisions about their care and their environment, and systems were in place to monitor the quality of service provision. People also felt they could report any concerns to the management team and felt they would be taken seriously.

During the inspection there were 21 people using the service. The manager told us the numbers of people living at the home had been reduced due to the imminent refurbishment programme. We spoke with four people who used the service and three relatives and asked them about the care they or their family member received. We carried out a tour of the building and reviewed records relevant to the running of the service. We observed staff interaction with people throughout the home.

We spoke with the manager, care manager, district manager, four team leaders, two care assistants and two district nurses.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Throughout this inspection we focused on these five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People received care in an environment that was safe. The communal areas, bedrooms that we looked at within the home were generally clean and tidy, although there were some boxes of pads left in a corridor.

We saw people received their prescribed medication and this was handled and stored safely. We observed staff administer people's medication in a safe manner whilst ensuring they respected their wishes and maintained their dignity.

People were supported to move about in a safe manner, using more than one staff member where required and using equipment where needed in a safe way.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS are part of the Mental Capacity Act 2005. Correctly applied DoLS make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom. The safeguards should ensure that care homes only deprive someone of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them.

The care manager told us there were no people who currently needed a DoLS order, but they would ensure that anyone who did require an assessment, it would be completed and submitted to the authorising body in a timely manner.

Staffing levels had been increased since the last inspection. There were now enough qualified, skilled and experienced staff to meet people's needs and to keep them safe. One person who used the service told us, "I feel safe and they look after me well here.”

Is the service effective?

There were sufficient staff on duty to meet people’s needs. A visiting relative said, “I’m very happy with the staffing at the home. We have built up a rapport with staff, we get information we need from them and they are able to ask us questions about [our relative] and their needs.”

Improvements had also been made in relation to the documentation about the service. We saw an Infection control audit was recently completed at the home, which detailed the necessary changes being made to the service to control the spread of any infection.

People were consulted on decisions relating to their care. People we spoke with felt included and relatives we spoke felt their opinions and views on decisions regarding their family member were welcomed.

One relative of a person who lived at the home told us, “I can’t fault them. New staff have started recently, they all seem to be asking questions about what can they do for the best for [my relative].”

Is the service caring?

We spoke with relatives of people who used the service and asked them if they felt their family member was safe and well cared for by the staff. One person told us, "The last few months have seen a vast improvement. The carers are brilliant, they get on really well with people, and they do seem to really care."

We observed staff interact with people who used the service. They were caring and attentive in their approach and did not rush people. They observed people's dignity and wishes at all times. We observed a person being transferred by hoist to a soft chair in the dining area for lunch. Two staff supported them during hoisting and talked to them to tell them what was happening and offer reassurance and checking the person was happy and comfortable with what was happening.

Is the service responsive?

We saw staff respond to people's needs throughout the inspection. We saw staff responded promptly to people’s requests for support. When people needed help, staff were there to assist them.

The management welcomed people's views and responded to them. Questionnaires had been issued to people who used the service and their relatives. The responses received were positive. We saw a person’s care records with their known allergies listed. Care plans detailed the list of substances or foods which they were known to be allergic to, with the likely reaction and guidelines for treatment.

Is the service well-led?

We asked people who used the service, their relatives and staff whether they felt the service was well led by the management team. A person who used the service told us, "The new manager seems very nice." A relative we spoke with told us, "I have been impressed with the care they are providing to my relative. The new manager is great, they are always willing to listen to any concerns we have."

We saw improvements had been made since the last inspection. We saw there were now regular audits in such areas as care plans, medication and infection control. Staff spoke positively about the new manager. One staff member told us, “we’ve had a lot of changes here, but the new manager seems to be settling things down, we hope they will stay.”

Another member of staff told us they felt listened to, and staff meetings were held to allow staff to express any concerns and share information about the needs of individuals.

During this inspection there were twenty six people who used the service. Due to the complex nature of the needs of the people who used the service; we used a variety of methods to ascertain information relating to the care and support provided. We spoke with four relatives of people who used the service, two care assistants, registered nurse, maintenance person, housekeeper, laundry assistant, domestic assistant, deputy manager and the manager.

People were consulted before decisions about their or their family member's care were made. A relative we spoke with told us, "I am always kept up to date; they (staff) go through the care plan with me.”

People were protected against the risks of unsafe or unsuitable premises.

There were not enough qualified, skilled and experienced staff to meet people's needs. Domestic staff we spoke with told us they could not complete their daily cleaning duties due to the lack of staff. We were told that there were not enough staff working at night to ensure people were kept safe.

Staff were supported in their role. Staff were trained and received regular assessments of their work.

The provider did not always have an effective system to review incidents. Evidence that the provider had requested the views of people who used the service, their representatives and staff on the quality of the service could not be provided.

There was not an effective complaints system available in a format that met people's needs.

The purpose of this review was to assess the improvements made since our last inspection. We did not request information directly from people using the service on this occasion. Overall, we found that the provider had taken sufficient action to address the shortfalls we had identified during our previous visit.

We used a number of methods to help us understand the experiences of people using the service, because people had complex needs which meant that we were not always able to establish their experiences of living at Boughton Manor. These methods included observation and speaking to relative's of people using the service.

Relatives of people using the service told us that care staff involved them in their relatives care, treatment and support programme. They also told us that people received input and treatment from visiting health care professionals when required. They told us that people were encouraged to participate in a range of social activities and they were satisfied with the activities provided.

Relatives of people who used the service told us that they felt people were safe in the home and felt that the staff would always promote people’s safety. They felt that staff had the right qualifications, skills and knowledge to perform their duties in a safe manner but expressed concerns in relation to the staffing levels maintained at Boughton Manor.

Relatives of people who used the service told us that they were provided with the opportunity to comment on the quality of service provision within a quality assurance process which was performed on an annual basis.

On the day of our site visit to Boughton Manor there were 25 people living at the care home.

We spoke with three people who live at Boughton Manor. Many of the people who are currently living at the care home have needs that make communication difficult, however we were told that: “The staff are very nice.” “I’m happy.” “It’s alright” and “Good enough.”

We spoke with three people who live at Boughton Manor who unfortunately were unable to give any insight into the care that they were receiving. Observations during the sight visit showed that the staff were caring, respectful and friendly in their approach to people at the home.

We asked three people who live at Boughton Manor about the food. Two people were able to tell us that: “The food is alright.” “I like the food, it’s OK.”

We spoke with three people about their experiences of living at Boughton Manor. We asked each person if they felt safe, and they all said that they did. None of the people we spoke with were able to tell us about the policies that the home had for keeping them safe, or give any insight into staff training in safeguarding procedures.

This inspection took place on 17 and 18 March 2015 and was unannounced. Boughton Manor provides accommodation, nursing and personal care for up to 40 people with dementia and people with physical health needs. On the day of our inspection 26 people were using the service. The service is provided across two floors with a passenger lift connecting the two floors. The downstairs area was open to enable people to access all communal areas of the home.

The service had a registered manager. 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.

People had not been fully protected from the risk of acquiring legionella from the water supply in the home. People did not always receive their medicines as prescribed and accurate records were not always kept about people’s medicines. People’s medicines were safely stored.

People felt safe living at the home and staff knew how to protect people from the risk of abuse. Relevant information about incidents which occurred in the home was shared with the local authority.

People were supported by a sufficient number of staff and the provider ensured appropriate checks were carried out on staff before they started work.

Staff had the knowledge and skills to care for people effectively. We found the Mental Capacity Act (2005) (MCA) was being used correctly to protect people who were not able to make their own decisions about the care they received.

People received support from health care professionals such as their GP. Staff used the guidance provided by healthcare professionals in order to support people to maintain good health. People had access to sufficient quantities of food and drink throughout the day.

Positive, caring relationships had been developed between people and staff and staff responded to people in a compassionate manner. People and their relatives were able to be involved in the planning and reviewing of their care and people were supported to make day to day decisions. People were treated with dignity and respect by staff.

People received care that was responsive to their changing needs and staff ensured care plans were reviewed on a regular basis. People were provided with information about how to complain and complaints received were investigated and responded to in a timely manner.

There was a positive and transparent culture in the home, people who used the service and staff felt able to raise any issues with the manager. There were different ways people could provide feedback about the service. There were effective systems in place to monitor the quality of the service people received and these resulted in improvements being made to the service where required.