The inspection was unannounced and took place on 17 and 24 September 2018.

Bucklow Manor Care Home 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. Bucklow Manor is registered to provide accommodation with personal care for up to 56 people. The accommodation is located over two floors and there are numerous small lounges throughout the building. On the day of our inspection there were 22 people living in the home.

This is the first inspection of this home under the current provider. We found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the provider was not taking all reasonable steps to mitigate the risks to people. This is the first time that the service has been rated ‘Requires improvement’. You can see what action we have taken at the back of this report.

Bucklow Manor has 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.

Staff were not always aware of the risks to people and these were not always clearly documented in care plans with appropriate risk assessments in place. The registered manager did address these concerns and action was taken by the second day of our inspection.

The registered provider did not have effective systems in place to assess and monitor the quality and safety of the service. Some of the issues which were identified as part of this inspection, had not been picked up by provider’s audits.

Staff recruitment was safe and appropriate checks were completed to ensure that staff were safe to work with vulnerable people.

Staff had completed safeguarding training and safeguarding incidents were appropriately referred to the local safeguarding team. Staff were clear on their responsibilities to raise safeguarding concerns.

Medication was being stored and administered safely. Regular medication audits were being conducted and any issues identified were addressed.

There were sufficient staff to meet the needs of the people living in the home and they were recruited safely.

Care plans reflected people’s life history and their needs and were person centred. People and their relatives told us that the care they received was responsive to their needs.

People and their relatives felt confident that issues that they raised would be addressed. Complaints were recorded and dealt with in accordance with the provider’s complaints policy.

People and their relatives were positive about the staff working in the home as well as the care that they received whilst living there.

The provider was acting in accordance with the Mental Capacity Act 2005 to ensure that people were receiving the right level of support with their decision making. People were involved in the care plans and had signed their consent to care where able. Where people lacked capacity, appropriate paperwork was in place to ensure that decisions were made in their best interests.

Staff members confirmed they received regular training and supervision and we verified this in the provider’s records.

We saw regular checks on the property were undertaken and the premises were safe without restricting people’s ability to move about freely. The home included several dementia friendly design features including the garden which had been specifically landscaped and designed for people living with dementia.

People had access to activities within the home and told us that they were happy with the activities on offer.

This inspection took place on 7 May 2015 and was unannounced.

Bucklow Manor is registered to provide accommodation for 49 people who require nursing care and/or who are living with dementia. It is located near the town of Knutsford. The home is divided into two parts; a nursing section and a section for people who are living with dementia. There were 26 people living in the home on the day of our visit.

The home had a manager in post who had applied to be registered with CQC. 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.

At our last inspection in January 2015 we found that improvements were needed in respect of the training, professional development, supervision and appraisal of staff and with regard to missing records such as quality audits.

We also served warning notices on the provider with regard to the care and welfare of service users and how they assessed and monitored the quality of service provision.

Following this the provider sent us an action plan telling us about the improvements they intended to make.

We noted improvements to the home during this inspection and evidence to show the compliance actions and warning notices had been met.

The experiences of people who lived at the home were positive overall. People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. People remarked that the food was good.

We found the home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and staff followed the Mental Capacity Act 2005 for people who lacked capacity to make decisions for themselves.

We saw that people’s medicines were securely stored and safely managed. The provider had a policy to guide staff regarding the safe management of medicines. Staff were aware of the actions to take in the event of an error when giving medicines.

There were robust recruitment checks in place so that people were protected from being supported by unsuitable or unsafe staff.

We looked at the duty rotas and spoke to staff about the numbers of staff on duty. We found there were adequate numbers and skill mix of staff on duty to meet the needs of people living at Bucklow Manor. We saw agency staff were rostered to work at the home but the same staff members worked each week to provide continuity of care.

We saw records which showed that staff training had taken place and all staff were up to date with appropriate training so that people could be confident they were properly cared for.

The home had a complaints procedure in place and we saw that complaints were logged and actions taken following investigations were recorded so that the service could be improved.

We considered all the evidence we had gathered under the outcomes 'care and welfare'; 'staffing'; 'assessing and monitoring the quality of service provision' and 'records'. This helped us to answer two of the five questions we always ask:

• Is the service effective?

We found that due to staff vacancies there was a high use of agency workers and issues with communication, staff training and supervision. This impacted upon the ability of the service to provide continuity and person centred care. We also found that a number of nurses had not completed key clinical training. Likewise, training records highlighted that the majority of staff had not completed induction or dementia training. There was also a significant number of staff who had not completed mandatory training.

• Is the service well led?

We found that the service did not have effective quality assurance systems in place. Although the provider had established systems and templates to enable monitoring of the service provided, a number of quality assurance records could not be located to provide evidence of regular audits and action taken. Furthermore, the whereabouts of other key records such as survey questionnaires, complaint documentation and staff supervision records was not known. Care plans and associated documentation were also in need of review.

We undertook an inspection of Bucklow Manor on 27 May 2014.

During the inspection we spoke with the registered manager, the clinical lead nurse, and five staff members. We also spoke with six of the people who lived in the home.

We considered all 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

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

Is the service safe?

We could see that appropriate checks were undertaken before staff began work. We found that recruitment processes were robust and that all the pre- employment checks required by the relevant regulations had been carried out before staff started working at the service. Staff had attended for an interview, their employment history had been accounted for and checks, such as references and criminal records disclosures, had been obtained. This helped to ensure people that were supported by staff who were fit to carry out their roles and responsibilities and were suitable to work with people who lived in the home.

Is the service effective?

We looked at four care plans and saw that people and their relatives were involved in the planning of their care. We saw that risk assessments were in place to support people's particular needs such as support with moving and handling. We saw that the care plans had been significantly improved during the previous two months. We saw that more robust evaluations were taking place and that care plans had been updated to reflect the changing needs of the people in the home.

We saw that people's nursing care needs were now being very closely monitored and that the care that people were receiving had been improved as staff had been trained to carry out specific tasks to meet people's needs.

Is the service caring?

We spoke to six people who lived in the home and they all said positive things about the care that they received and the staff who supported them. One person said; "The care is good and the staff are kind and helpful." However a number of people commented on the staff changes and how this was not helpful for giving them consistent care. One person said; "There is a different face everyday. I have to tell them how to care for me. I worry about the people who can't say what they want."

We observed that relationships between staff and people who lived in the home were warm and friendly and we saw that people were relaxed in the company of staff. We saw groups of people chatting to staff in a calm and friendly atmosphere. We saw that the staff were skilled in supporting people who had dementia whilst encouraging them to maintain their independence. We observed staff join in with one person singing which produced a very positive response.

Is the service responsive?

We looked at the care files for people who were on modified diets because of their specific health requirements. We met with these people and staff working with them to review assessments, care plans, monitoring records and actions being taken.

We saw that people were weighed weekly and the results were recorded in a file in the main office as well as in people's individual care files. A recognised assessment tool was being used in the care plans and it was correctly used and recorded. We were able to see that these people were receiving the appropriate care and that people's weights were closely monitored and maintained.

We saw that menus were displayed on tables and that people were offered choices. We spoke with the chef and they were well informed of the people's needs and likes and dislikes. We saw that the chef catered for specific requests that people made and they knew the people well.

Is the service well led?

We saw that quality audits were carried out by the provider. We looked at the audit completed in January and saw that action had been taken in response to the issues raised. We looked at the manager's audit file and saw that the provider had put in place a monthly audit plan. The manager told us that they completed these each month and the information was checked at head office.

We saw that care plans had been audited monthly during the last two months by the clinical lead and that this was part of an improvement plan for care plans being carried out in the home.

We spoke with six people who lived in the home and one relative. They all told us that they were happy living in the home and that they received good care. One person told us; “We have nice rooms and we are well looked after.” Another person said; “The food is smashing here and the staff are very good.”

The staff we spoke to during our visit told us that they enjoyed working at the home because the standard of care was high and the level of training was good. They said that they were supported by the manager and the lead nurse who were always available to offer advice and support.

We looked at the procedures and systems in place to protect people and saw that safeguarding issues were dealt with appropriately in the home.

We looked at the medication administration procedures and saw that medication was administered in accordance with the home’s policies and procedures.

Our observations, documentation we reviewed and the people we spoke to assured us that the people who lived in the home were experiencing care and support to meet their needs.

During our visit to the home we spoke to four service users who all seemed happy with the care they were receiving. They told us; "This is a nice place to live," and "My bedroom is nice and big." One also told us "I've never complained but if I don't like it- I tell them."

We spoke to three relatives. One told us that their relative was "safe" and that they had looked at a few homes but had chosen this one because it was the "best by far." Another relative told us that the home was quite nice but "some carers are better than others."

The staff we spoke to during our visit told us that they enjoyed working at the home because the standard of care was very good and that they had access to lots of training. They said that they were supported by the manager who was always available to offer advice and support.

Our observations, documentation we reviewed and the people we spoke to assured us that the people who lived in the home were experiencing care and support to meet their needs.