This inspection took place on the 23 and 24 October 2017 and was unannounced on the first day.

We last inspected the service on 5, 6 and 8 December 2016 when we rated the service as inadequate. At that time we found the service was in breach of seven regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, these were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. At that inspection we made one recommendation, which was in relation to how the provider handles informal complaints.

Due to the concerns we identified during that inspection, we wrote to the provider and requested they take a number of voluntary actions. This included ensuring all care plans and risk assessments be reviewed by the end of January 2017, reviewing staffing levels, assessing staff competence, keeping CQC informed about the recruitment of a suitable deputy and sending CQC an action plan. We requested the provider sent us evidence of the completed actions, and we would review this to inform our decision making as to whether any formal enforcement action was required. The provider agreed to take these actions.

This inspection was to check improvements had been made following the last inspection and to review the ratings.

Bowerfield House is a purpose built care home owned and operated by Maria Mallaband Group. The home provides nursing and personal care for up to 26 older people living with dementia. It is a two storey building situated adjacent to a larger sister home located on the same site. All bedrooms are single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor, an enclosed garden area to the rear of the building and car parking is available within the grounds. At the time of our inspection there were 24 people living at Bowerfield House.

On entering the home we were met by the registered manager who was eager to show us the improvements they had made following the last inspection.

Systems to make sure the safekeeping and administration of medicines were followed and monitored were in place and reviewed regularly. Medicines were stored safely in locked clinic rooms and were administered by designated trained nurses. Any specific requirements or risks in relation to people taking particular medicines were clearly documented in their care records.

Risk assessments were in place for people who were at risk of falls and in relation to people’s skin integrity. Additional risk assessments were in place to meet people’s individual needs for example specific dietary requirements.

Staff we spoke with confirmed they had received safeguarding and whistleblowing training (raising a concern about a wrong doing in the workplace) and knew who to report concerns to if they suspected or witnessed abuse or poor practice. Records showed care workers received regular supervision to help make sure they were carrying out their duties safely and effectively.

Records in relation to the Mental Capacity Act 2005 were complete and up to date. Any restrictions were deemed to be in people’s best interest and the least restrictive.

People were supported by sufficient numbers of care workers and nurses. Staff we spoke with told us they had undergone a thorough recruitment process and undertaken employee induction and training appropriate to their job role. This helped to make sure the care and support provided was safe and responsive to meet peoples identified needs.

We saw people who required encouragement and prompting to eat and drink receive the required level of staff support at meal times. We saw staff offered people a choice of meals as displayed on the menu.

We saw positive and caring interactions between care workers, nurses and people who used the service, which helped to make sure their dignity and privacy was respected and their wellbeing was p

This inspection took place on 05, 06 and 08 of December 2016 and was unannounced on the first day. We last inspected Bowerfield House on 19 and 22 October 2015 when we rated the service as requires improvement overall and identified breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found sufficient improvements had not been made and the service remained in breach of the regulations.

Since our last inspection we had received a number of concerns that related to areas including sufficient staffing, staff turnover, activities and management of the home. We identified breaches of seven of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. We made one recommendation, which was in relation to how the provider handles informal complaints.

Due to the concerns we identified during our inspection, we wrote to the provider and requested they take a number of voluntary actions. This included ensuring all care plans and risk assessments be reviewed by the end of January 2017, reviewing staffing levels, assessing staff competence, keeping CQC informed about the recruitment of a suitable deputy and sending CQC an action plan. The provider agreed to take these actions. We requested the provider sends us evidence of these completed actions, and will review this to inform our decision making as to whether any formal enforcement action is required. We will update the section at the end of this report once any enforcement action has concluded.

Because of our concerns, we also raised a number of safeguarding alerts with the local authority. These were not progressed formally under safeguarding, but were passed to the local authority’s quality assurance department to follow-up.

Bowerfield House is a purpose built care home owned and operated by Maria Mallaband Group. The home provides nursing and personal care for up to 26 older people living with dementia. It is a two storey building situated adjacent to a larger sister building on the same site. All bedrooms are single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor, an enclosed garden area to the rear of the building and car parking is available within the grounds. At the time of our inspection there were 23 people living at the home.

We found medicines were not being kept safely, which presented a risk to people living at the home. On our arrival at the home we found a large quantity of medicines received from the pharmacy had been kept in the conservatory area of the home, which was accessible to people living at the home. We also observed one occasion when the medicines trolley was left open and unsupervised in the clinic room. Entry to this room was restricted only by a door guard that some people living at the home may have been able to release. We also found thickening agent was kept in an unlocked cupboard in the ground floor lounge/dining area, which presented a risk of asphyxiation if people inadvertently consumed this.

Staff had not regularly reviewed risk assessments in relation to areas including malnutrition, falls, and pressure sores. This meant the provider could not be certain that appropriate measures were in place to reduce such risks. We also found staff were not following guidance in one person’s care plan in relation to reducing their potential risk of choking.

Numbers of staff providing direct care and support to people had not increased since our last inspection, despite the interim manager at that time recognising that staffing levels at particular times of the day required review. The provider had started using a dependency tool, which indicated there were sufficient numbers of staff. However, thi

We carried out this inspection in response to concerns raised regarding the training and development activities provided for staff. We saw that the home had systems in place to ensure that staff received appropriate development and support.

We looked at three care records. We saw that assessments of health needs were carried out and that family members were involved as appropriate.

We saw that the home had systems and processes in place to ensure that the quality of the service was monitored.

On the day of our visit we were told there were 23 people resident at the home and we spoke directly with three people who lived there. We also spoke with staff and visitors to the home.

People who lived at the home said they were happy with the care and support provided and that they were looked after. They told us that staff respected their rights, their privacy and their dignity. All three people we spoke with said they felt safe. One person said: "They treat me well and know me inside out.” People told us that they liked their rooms, that they enjoyed the food and that staff were polite. They said they had choice and staff consulted them about their care. The family members we spoke to were positive regarding the care people received at the home. Comments included: “It’s a lovely place” and “Staff are so supportive.”

We found that people felt confident to express any concerns. Members of staff had a good understanding of safeguarding procedures and told us they would report any concerns immediately.

We noted that all staff members received the training and support they needed in order to provide safe and effective care for people using the service.

We found that systems were in place to monitor the quality of the service provided. We saw evidence to demonstrate that people were regularly consulted about all aspects of the care and facilities provided at the home

The majority of people living at Bowerfield House had a diagnosis of dementia or suffered from short term memory loss, because of this people were unable to make comments on the care and treatment they received. This report is based on our observations of people living at Bowerfield and our discussions with their relatives.

One visitor told us that they thought Bowerfield House was the best place they had found for their relative. Other visitors described staff as, “Good” and “Excellent,” and said that staff were approachable and genuine. One person said that staff at Bowerfield House were, “Dedicated and worked very hard.”

Some visitors said that sometimes they did not feel there were enough staff on duty, particularly on the first floor of the building.

One person said of the service, “Better than it’s ever been and it’s improving.”

Another person told us that if their relative was ill the GP was always contacted and their family was contacted and kept informed of their relative’s progress.

One relative told us that they hadn’t seen their relatives care plan,” but we know there is one and that it is being followed because care needs are being met.”

Another visitor said, “I never met such caring people”

Visitors said the home was always clean and tidy.

Some visitors were concerned about the changes to the management of the service and one person said that they thought senior managers should be more open and tell them what was happening.

Another person told us that relatives and carers meetings had been held but they were unable to attend because they were held at 6pm in the evening and asked if future meetings could sometimes be held in the afternoon. Other people told us they hadn’t had any feedback from the last meeting and asked for the minutes to be displayed on a notice board in the home or for a news letter to be sent out.

This inspection took place on 19 and 22 October 2015. Our visit on the 19 October was unannounced. The service was previously inspected on 21 August 2013; we found that the service met the standards assessed.

This inspection was brought forward following concerns raised relating to staffing levels and the high number of safeguarding alerts raised with the local authority.

Bowerfield House is a purpose built care home owned and operated by Maria Milliband Group.

The home provides personal care and accommodation for up to 26 older people. It is a two storey building situated adjacent to a larger sister building on the same site.

All bedrooms have single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor. There is an enclosed garden area to the rear of the building accessed via a conservatory area. Car parking is available within the grounds.

When we visited the service there was no 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.

We identified four 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 this report.

We found that there was a high turnover of staff and there were insufficient numbers of suitably qualified staff to meet the needs of the people who used the service. At busy times staff were unable to meet the demands of the people who used the service, resulting in people having to wait for assistance. There was a reliance on agency and bank workers, meaning services would be provided by staff who did not always know the people well. We saw that the staff who were permanently employed knew people’s needs and provided care in a kind and respectful manner.

The responsibilities of housekeeping staff were not clear, and there were no defined roles with domestic staff expected to clean, work in the laundry and in the kitchen. This meant that staff would not be able to focus on a particular duty and would sometimes be called to assist in other areas leaving jobs incomplete.

There was no system in place to provide staff with supervision or appraisal so there was no way to monitor the performance of individual staff members or to allow them to meet formally with their supervisors to discuss any issues or concerns they might have.

Where risks to individuals were identified we saw that detailed risk assessments had been completed with clear plans in place to show how to minimise the risk and that these plans were reviewed on a monthly basis. Where safeguarding alerts had been reported to the local authority incidents were investigated appropriately and protective measures were put into place. However, we saw that recorded incidents were not always followed up as safeguarding alerts. We have made a recommendation about identifying and reporting incidents which may lead to harm.

There were no restrictions in place on people’s movement within the home. People were involved in planning their care, and where they lacked capacity to consent to care and treatment the appropriate steps were taken to protect their rights.

People told us they liked the food and we saw meals were fresh and looked and smelled appetising. Their dietary needs were taken into account, and they were given choices of what to eat.

Procedures were in place to manage people’s medicines safely.

Recruitment and selection procedures were in place to help ensure that the staff employed at the home were suitable to work with vulnerable adults.

The communal areas of the home were not always clean. Policies and procedures to minimise the risk of infection were followed but there had been no audit of infection control measures for ten months.

People told us they found that the permanent care staff knew them well and were kind and caring. One person told us, “I can’t fault the carers who are there. They are brilliant”. Care was taken to ensure that individual’s privacy and dignity was respected and we observed staff treating people who use the service in a compassionate and kindly manner. Staff were familiar with their needs and wishes. People who used the service were offered meaningful choices about the details of how their service was delivered, and good relationships had developed between staff and the people who lived at Bowerfield House.

We saw that records were detailed and included appropriate information about individual needs. Care plans were instructive and written in a way which reflected the person’s abilities and strengths but did not deflect from their needs.

There were systems in place to monitor the quality of the service provided, but these were not always followed regularly, and we saw that some checks, for example, an infection control audit, had not been completed since December 2014.

Where the home received complaints, there was evidence of an acknowledgement, investigation and follow up report. Where these had been substantiated we saw that apologies were sent, and action was taken to prevent future occurrences.

There has been a succession of six mangers in the past seven years. This turnover of mangers did not lend to consistency and changes in leadership lead to upheaval. The staff we spoke to were positive about the interim manager in place whilst the provider recruited a permanent manager.

An activities co-ordinator was in post who on both days of our inspection had arranged for visiting performers to come in to Bowerfield House to provide entertainment for the people who lived there, but people told us that this was unusual and that there was rarely anything for people who used the service to do.