About the service:

Cambrian House is a residential care home, providing personal care and accommodation for up to 25 people. There were 20 people using the service at the time of the inspection.

People’s experience of using this service:

¿ The service continues to be rated ‘Requires Improvement overall. Four of the five key questions were found to meet the characteristics of requires improvement.

¿ We found breaches in two regulations in relation to people’s safety and good governance.

¿ Risks to people were not always identified or followed up following falls to ensure people were safe. Staff were not following the provider’s own policies and procedures in relation to this.

¿ There were conflicting views on whether staffing numbers were sufficient.

¿ Improvement was need in relation to medicine prescribed on an ‘as needed’ basis.

¿ Staff were not always fully trained to provide them with the necessary skills and knowledge to fulfil their roles.

¿ Although people said there were activities on offer, relatives and staff believed they could be improved.

¿ A new manager was in post who intended to apply for registration.

¿ Quality Assurance audits were not always completed and failed to identify shortfalls highlighted at the inspection.

¿ People felt safe and relatives believed their family member to be safe living at the home.

¿ Staff knew what to action to take to safeguard people if they suspected abuse.

¿ People found staff members to be kind and caring.

¿ People’s consent was sought prior to care and support taking place.

¿ People’s privacy and dignity was respected.

¿ People liked the food provided and had their healthcare needs met.

Rating at last inspection: At our last inspection the provider was rated as ‘Requires Improvement’ overall (report published 20 February 2018). We published a focused report on 02 August 2019. The rating for well led was changed to ‘Good’ although the overall rating remained ‘Requires Improvement.”

Why we inspected: This inspection was part of our scheduled plan of visiting services and to follow up on the concerns identified as part of the previous comprehensive inspection.

Enforcement: Information relating to the action the provider needs to take can be found at the end of this report.

Follow up: We will ask the registered provider for a clear action plan to address the breaches of regulation. As this is the second consecutive time the registered provider has been rated requires improvement we will also request a plan from them on how they intend to achieve good at our next inspection. We will continue to monitor the service to ensure people receive safe, high quality care. Further inspections will be planned for future dates. We will follow up on breaches of regulations we have made at our next inspection.

This inspection took place on 12 July 2018 and was unannounced.

Cambrian 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. The home provides accommodation with personal care to a maximum of 25 older people, some of whom are living with dementia. There were 20 people living at the home when we visited.

We previously carried out an unannounced comprehensive inspection of this service on 3 November 2017. Breaches of legal requirements were found. These related to the provider’s failure to mitigate the risks to people’s health and safety, and the lack of effective governance and quality assurance systems and processes. We served a ‘warning notice’ in relation to the lack of good governance of the service, which required the provider to be compliant with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 within a given timescale.

We undertook this focused inspection to check that the provider was now meeting the legal requirements of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cambrian House on our website at www.cqc.org.uk.

A registered manager was in post and present during 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 2008 and associated Regulations about how the service is run.

At this inspection, we found the provider was now meeting the legal requirements of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They had addressed the identified fire safety deficiencies at the service, and were monitoring the home’s fire safety arrangements to ensure the safety of people, staff and visitors. The registered manager had clearer oversight of staff training needs, and had plans in place to address these. The provider had quality assurance systems and procedures in place to enable them and the registered manager to monitor and improve the quality and safety of people’s care and support.

The registered manager promoted a positive and inclusive culture within the home. People and their relatives had confidence in their management of the service, and felt able to freely approach them with any suggestions or concerns. Staff were motivated in their work, and felt supported and valued by an approachable and accessible registered manager.

The registered manager took steps to involve people, their relatives and staff in the service, worked collaboratively with community professionals, and sought to strengthen the service's links with the local community.

Cambrian House provides accommodation and personal care for up to 25 people. On the day our inspection commenced there were 21 older people living at the home some of whom were living with dementia.

We previously undertook a comprehensive inspection of this service on 06 and 08 March 2017. At that inspection the provider was rated good overall with the well led question rated as requires improvement.

Since our previous inspection we have received information of concerns from different sources including the local authority. These concerns including the treatment people were receiving and issues regarding the safe care of people.

As a result we undertook a comprehensive inspection to look into those concerns on 26 October and 02 and 03 November 2017.

There was a manager in post but they had not yet applied to register with the Care Quality Commission. 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 registered provider has continually not managed to have a registered manager in post.

People’s safety had not always been taken fully into account regarding fire safety. Concerns were shared with the fire service who advised the manager on action which needed to take place. A lack of fire training and measures to ensure environmental and maintenance could have placed people at risk.

People were not always supported by staff who had consistently received the necessary training to fulfil the role of the work they were employed to do. People told us they were not always effectively supported by staff in a timely way.

The providers records were not always easy to retrieve to evidence checks carried out to ensure people were carried for safely.

People told us they received their medicines as prescribed but staff practices did not always ensure medicines were recorded as given at the time of administration. Staff did not always ensure items which were potentially hazardous were stored securely which could impact on people’s safety.

People were able to access healthcare professionals to meet their needs. People told us they liked living at the home and liked the staff that provided their care and support. Some felt people had at times to wait for their needs to be responded to. Activities were provided for people to have fun and time was able to be spent with staff members. Staffing levels were seen as suitable to ensure people’s needs were met although there was concern expressed about night staff levels and a lack of knowing who was leading the night shift.

There was an awareness of responsibilities regarding safeguarding and potential abuse. People felt safe living at the home and staff were aware of their responsibilities if they witnessed abuse. At the time of our inspection one safeguarding regarding care provision was under investigation with the local authority although the new manager had no knowledge of the on-going investigation and was not able to locate any records regarding internal investigation. People told us they were aware of how to complain about the service provided.

Risks to people’s care and care plans were in place and reviewed. These had involved people and their family members. Although staff spoke about people’s right to privacy and dignity these were not always seen to be put into place. People were able to access healthcare support as required. There were mixed comments regarding the food available to people.

There was a lack of recent and accurate quality monitoring. Documents requested to evidence people were living in a safe environment were available but difficult to retrieve. Many of the shortfalls identified during the inspection were not known to the registered provider as they had not identifie

Cambrian House registered to provide accommodation and personal care for people for 25 people. At the time of our inspection 24 people were living there. The inspection took place on 6 and 8 March 2017 and was unannounced.

There was a manager in post at the time of our inspection. This person was not however registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered provider, 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 previously inspected Cambrian House in February 2016. At the time of that inspection we rated the location as good overall. We found the well lead section to be requires improvement due to having no registered manager in post.

Staff had received training to obtain the skills and knowledge to support people's needs. Staff felt supported by the management and liked working at the home. Staff valued the team work within the home. People living at the home were protected from abuse and staff and management were aware of their responsibilities to report any concerns they had about people’s safety. The registered provider undertook to increase staffing levels following a change in the dependency needs of people who were living at the home.

People's permission was usually sought by staff before they helped them with anything and people had the right to make choices. When people did not have the capacity to make their own specific decisions these were made in their best interests. The manager had knowledge about lawfully restricting people to keep them safe.

People had a choice of food to eat and had drinks available to them. People had access to healthcare when they needed it. People received their medicines as prescribed by their doctor.

Staff provided care and support to people which was personalised and responded to changes in their needs. People's preferences and wishes were known to staff and were respected. Staff were aware of how to uphold people’s privacy and dignity. People who lived at the home were consulted about their care to ensure it responded to their needs in ways they wished. There was a system for handling and resolving complaints.

The manager and the registered provider had systems in place to monitor the quality of the care provided and to monitor events which took place in the home to assist keeping people safe.

The inspection was unannounced and took place on 2 February 2016. We carried out an unannounced comprehensive inspection of this service on 4 March 2015. A breach of legal requirement was found and areas that required improvement. After the comprehensive inspection, the provider wrote to us to say what they would do In relation to breach of the Health and Social Care Act 2008 (Regulated Activities Regulations 2014. The breach was due to shortfalls in how consent to care was obtained. We found that improvements had been made at this inspection.

Cambrian House is registered to provide accommodation and personal care for adults who may have a dementia related illness for a maximum of 25 people. There were 25 people living at home on the day of the inspection. There was a manager and were currently registering with us. A 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 aware of what constitutes abuse and the actions they should take if they suspected someone was being abused. People were supported to remain safe in the home and told us they were comfortable. People’s risks were assessed which included risk of skin damage and falls. Where risks were identified there was a plan to manage the risk. We saw that staff were unhurried and staffing reflected the staffing requirements assessed by the manager.

Medicines were managed by senior care staff people’s prescribed medicine had been recorded when taken. We saw that staff remained with people and offered a drink when administering their medicines. Medicines were kept securely and staff who had responsibility for medicine administration had received training and were aware of the actions to take should an error occur.

People were supported to make their own decisions. Staff told us how they supported people to make decisions, such as offering two alternatives, considering their prior wishes and consulting people significant to the person for their views.

People had access to healthcare when they needed. People’s care records showed contact with a variety of healthcare professionals. People were supported to eat and drink. They were offered a choice of food and drink. People’s mealtime experience was positive and staff attention was on people during this time.

People were supported by care staff that responded patiently and positively, whilst listening to them People were included and involved in decisions about their care and care staff ensured they were treated with dignity and respect. People were supported to maintain relationships with people important to them. There was no restriction of visitors.

Staff knew people as individuals and had knowledge about them and their personal histories. People’s care records contained information about the person’s past life including family make up and previous occupation and significant life events. Staff were aware of people’s backgrounds which helped them have meaningful conversations with people about topics of personal interest.

People and relatives told us they had no current concerns about the care or home and would be happy to raise if they did. The care staff told us they would resolve any minor compliant or concern at the time it was raised. They said they would refer significant concerns that they were unable to resolve to the management team.

This manager had been in post since February 2015 and CQC had not received an application which contained the relevant information to progress the manager’s registration. The recent change in the management structure will need to demonstrate that people continue to receive care that meets their needs. The quality of the service was monitored on an on-going basis through observations of practice and

The inspection was unannounced and took place on 4 March 2015. At the last inspection on 30 April 2014, we asked the provider to take action to make improvements in how care and treatment was planned, and this action has been completed.

Cambrian house is registered to provide accommodation and personal care for adults who may have a dementia related illness for a maximum of 25 people. There were 21 people living at home on the day of the inspection. There was a manager in place however they had not been registered with us. 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 told us that they felt safe and free from the potential risk of abuse. Staff told us about how they kept people safe. During our inspection we observed that staff were available to provide advice or guidance that reduced people’s risks. People received their medicines as prescribed and at the correct time.

People and relatives told us there were enough staff to support people at the home. Staff at the home felt there were enough staff to meet the needs of people living at the home.

People told us they liked the staff and felt they knew how to look after them. Staff were provided with training which they felt reflected the needs of people who lived at the home.

Assessments of people’s capacity to consent and records of decisions had not been completed in their best interests. The provider could not show how people gave their consent to care and treatment or how they made decisions in the person’s best interests. Therefore, people had decisions made on their behalf without the relevant people being consulted.

People were supported to eat and drink enough to keep them healthy. We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. People had not always been involved in the planning of their care due to their capacity to make decisions. However, some relatives felt they were involved in their family members care and were asked for their opinions and input.

People had not always been supported to maintain their hobbies and interests or live in an environment that supported their needs. Relatives we spoke with told us they were confident to approach the manager if they were not happy with the care provided to their family member.

The provider and manager had made regular checks to monitor the quality of the care that people received and look at where improvements may be needed. The management team had kept their knowledge current. The management team were approachable and visible within the home which people and relatives liked. The manager agreed that a review of care plans would be needed.

You can see what action we told the provider to take at the back of the full version of this report.

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 that supported them and from looking at records.

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

At the time of our inspection the provider did not have a registered manager in post.

Is the service safe?

People were protected against the risks associated with medicines because the provider appropriate arrangements in place to manage medicines.

There were systems in place to make sure that the manager and staff learnt from events such as accidents and incidents. For example, where people had fallen it had been reviewed to identify areas of concern. This meant that the provider demonstrated that they leant from incidents that effected people’s safety.

Is the service effective?

People were provided with some choices of suitable and nutritious food and drink. The provider had not been able to demonstrate that specialist dietary needs had been assessed and included when the menus were planned. For example, people who required additional nutrition when their meal was prepared.

People told us that their visitors were able to see them in private and that visiting times were flexible. They also told us the home were accommodating and welcoming to visitors.

The staff told us told us their training had been kept current and that they knew further training had recently been arranged. For example, training had been booked for staff to learn about providing activities for people who lived at the home. Staff told us they had received formal supervisions with the deputy manager. This meant the provider could not demonstrate that the staff employed to work at the home had the skills and experience needed to support the people living there.

Is the service caring?

During this inspection we looked at the delivery and planning of care for people who used the service. We found care and treatment had not always been planned and delivered in a way that was intended to ensure people’s safety and welfare. We have asked the provider to tell us how they plan to make improvements in this area.

Staff told us they were clear about their roles and responsibilities. Staff told us that they felt the quality of the service had continued to improve, but information between senior staff and care staff could be better. For example, they felt that they did not always have time to review people’s care plans and only had care information provided verbally. This meant that there was limited information provided to staff about the care people needed.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People told us: “They are (staff) nice here” and: “I get around; they (staff) help if I need it”.

Is the service responsive?

People completed a range of group activities within the service. People told us they were supported by staff to play games and activities that they enjoyed. The provider told us that they planned to improve individual activities for people and their preferences would be considered when planning these.

The provider told us that they regularly sought the views of people and relatives. This meant that the provider had been able to provide us with examples of how they had considered the views of people in running the home.

Is the service well-led?

The provider had quality assurance systems in place and we saw records that showed areas of the home had been reviewed. For example, the monthly room checks showed how any improvements needed had been completed. This meant that the provider had an effective system in place to identify areas that required repair or improvement.

We inspected Cambrian House and spoke with seven people who lived at the home and spent time observing their care and treatment. We also looked at their care files and other supporting documents. We had discussions with the area manager, deputy manager and three staff about how people were being supported. Staff told us that: “This is their home and I promote that with everyone here”.

People’s needs had been assessed and their care and treatment was planned and delivered in line with their individual care plan. Staff told us they were aware of each person’s needs and how to give care and support to meet those needs. When asked people told us: “It’s Ok here, friendly staff” and: “It’s fine, they are kind” and: “It’s not like your own home, but I do like it here”.

We saw that people looked comfortable in their home and with the staff that supported them. We saw that staff were kind and caring in their approach to people who lived in the home.

The provider and registered manger of the home had taken steps to monitor and assess any comments or complaints that had been received. The home welcomed feedback from everyone and a quality assurance survey had been completed in September 2013. The results of this survey showed a positive outcome for people who lived at the home.

Records we saw had been reviewed and updated. These were kept securely to protect the information held about the people who lived at the home.

We carried out an inspection on 10 December 2012. We found failures to ensure that people received appropriate care and insufficient staff were rostered to provide the care. We served a warning notice to the registered provider and registered manager dated 24 December 2012 about the need to improve people's care and welfare.

During this inspection we reviewed the improvements that had been made to address the shortfalls. We found that a range of actions had been made and that the registered provider and registered manager were meeting the regulations.

The registered manager showed us the improvements that had been made to ensure that people received appropriate care and support. We found that extra staff had been rostered to give them the time to provide care when people needed and wanted to receive it.

Most people were unable to express their views verbally, so we spent time observing how staff supported them. We saw staff giving people appropraite support and advice about their needs.

We talked with two people who used the service, a relative and a visiting external professional. We spoke with the registered manager, a senior care worker, two care workers, the cook and housekeeper.

We saw that people were relaxed and comfortable within their environment. The people we spoke with told us they were satisfied with the standards of care and when it was provided. People we spoke with told us they were supported to get up and go to bed when they wished to.

Two inspectors carried out this inspection. We spoke with two people who were using the service, three relatives, two visiting professionals, the registered manager, two care workers, the cook and the handyman. We were unable to hold a conversation with some people who lived in the home. Both inspectors used our Short Observational Framework for Inspection (SOFI) tool. This helped us to understand the experiences people had from living in the home. We also looked at relevant documents that supported us in making our judgements.

We last inspected the service on 4 September 2012 and found that the registered provider was not meeting the essential standard for staffing. The registered provider sent us an action plan that told us how safe staffing levels would be maintained. During this inspection we found that no improvements had been made. The registered provider was failing to provide adequate numbers of staff to meet people's care needs.

We spoke with a relative who told us they visited two or three times a week. They said, "Care is very good but the problem is lack of staff." They also commented, "We visited one day last week, X was unwashed and still in bed at 11:30." We talked with staff who explained how the staffing shortage resulted in people not receiving their care when they needed it.

Some people living in the home were unable to communicate verbally with us in a meaningful way. We used a number of different methods to help us understand the expereinces of people who used the service.

We saw that staff treated people with respect, protected their privacy and right to make decisions for themselves. Care workers provided discreet assistance to people and politely suggested ways they were able to help them.

We observed that people in the home were comfortable and relaxed within their environment. The registered manager and care workers were friendly and helpful when they provided assistance. People who used the service told us they were happy with the care they received from care workers.

The allocated staffing levels for the home were not sufficient to meet the needs of the people who were residing in the home at the time this inspection was carried out. This meant that people were not receiving their care when they wanted or needed it.

The home had a system in place to monitor the quality of the service being provided and for ensuring that ongoing improvements were being made for the benefit of the people who were using the service.