This comprehensive inspection took place on the 8 and 9 October 2018 and was unannounced.

Cranwell Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Cranwell Court is registered with the Care Quality Commission to provide personal care for up to 56 older people who may be living with dementia in one adapted building. The main area of the service is the Residential Unit and accommodates older people who may be living with dementia. There is a separate wing, known as the Enhanced Dementia Unit, which provides support to older people living with more complex needs around their dementia. The placements in this unit are all contracted by the Clinical Commissioning Group (CCG)and supported by NAViGO, a Community Interest Company and a not for profit social enterprise that emerged from the NHS, to run all local mental health and associated services in North East Lincolnshire. People there are jointly supported by the service and NAViGO along with input from professionals from the CCG. There were 54 people using the service at the time of this inspection.

At our last inspection in April 2016 we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

People continued to feel safe using the service and staff ensured that risks to their health and safety were reduced. Suitable numbers of staff were recruited and deployed to meet people’s needs. Safeguarding policies and procedures were in place and staff were aware of the procedures to follow in the event of concerns. People were supported to take their medicines safely. Good standards of hygiene were maintained.

There was a positive and inclusive atmosphere within the home. Staff were compassionate, kind and caring and had developed good relationships with people. Staff knew people well and promoted their dignity and respected their privacy. Care plans were person-centred and detailed. People who used the service were provided with the care, support and equipment they needed to maintain their independence. They participated in a wide range of meaningful activities within the service and in the community.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and procedures in the service supported this practice.

People’s nutritional needs were assessed and they enjoyed good food. Staff worked closely with healthcare professionals to make sure the care and support met people’s needs and they received medical attention when necessary.

Staff received a range of training and we received positive feedback about the effective care and support they provided. The registered manager used supervisions and an annual appraisal to support staff’s continued professional development.

The provider and registered manager consistently monitored the quality of the service and made changes to improve and develop the service, considering people’s needs and views. People, relatives, visiting professionals and staff all gave us positive feedback about the management team. Effective systems were in place to manage complaints and concerns.

Cranwell Court is registered to provide personal care for up to 52 older people. The home was purpose built and accommodation is provided over two floors with both stairs and lift access to the first floor. Local facilities and amenities are within walking distance. There is an enhanced dementia unit on the ground floor.

The service did not have a registered manager in post. There had not been a registered manager at the service for 20 months; the service had been managed during this time by a number of senior managers. A new manager had been appointed in February 2016 and was due to commence work at the service at the beginning of May 2016. 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.

This inspection was unannounced and took place over two days. The previous comprehensive inspection of the service took place on 28 January 2014 and was found to be non-compliant with six of the regulations inspected. We undertook follow up inspections on 24 April and 8 September 2014 and found compliance had been achieved.

Staff supported people to make their own decisions and choices where possible about the care they received. When people were unable to make their own decisions staff followed the correct procedures, they involved relatives and other professionals when important decisions about care had to be made and used least restrictive practice. However, improvements were needed with the recording of decisions about the use of bed rails, physical interventions, covert medicine administration and for decisions about resuscitation.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered provider had followed the correct process to submit applications to the local authority for a DoLS where it was identified this was required to keep the person safe. At the time of the inspection there were six DoLS authorisations in place and the service was waiting for assessments and approval of the remaining applications they had submitted.

Staff had been recruited safely and were deployed in suitable numbers to meet the needs of the people who used the service. Staff had access to a range of training in order to meet people’s needs. They also received induction, supervision, support and appraisal in order for them to feel confident when supporting people. There was a system to identify when refresher training was required.

Staff had completed safeguarding training and understood their responsibilities to report any abuse or episodes of poor care they witnessed or became aware of. This helped to ensure the people who used the service were protected from the risk of harm and abuse.

Assessments of people’s needs were completed and care was planned and delivered in a person-centred way. Positive behaviour plans directed staff to effectively support people’s behaviour that challenged the service. Robust systems to monitor and review all incidents were in place. People we spoke with told us they felt safe living in the home.

We found people’s health care needs were met. They had access to a range of community health care professionals when required. When people required closer monitoring due to their nutritional intake or risk of developing sores, this was completed consistently.

People liked the meals provided to them and there was sufficient quantity and choice available. Staff supported people to eat their meals in a sensitive way when required. We saw there was plenty of drinks and snacks available in between meals.

Staffs approach was seen as kind and caring; they took time to speak to people, they respected their privacy and dignity and involved them in day-to-day decisions. Staff had dev

This inspection was carried out by an adult social care inspector and was completed to follow up an inspection on 29 and 30 April 2014, when we issued a compliance action in relation to the management of medicines. 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 who used the service and the staff who supported them, and from looking at records. In this report the name of the registered manager appeared who was not in post and not managing regulatory activities at this location at the time of the inspection. Their name appeared because they were still on our register at the time.

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

Is the service safe?

At our last inspection on 29 and 30 April 2014 we issued a compliance action as we found shortfalls in the appropriate supply of medicines and issues with aspects of medicine records.

At this inspection we found the provider had implemented new systems to obtain medicines and ensure people’s treatment was continuous, as intended by prescribers. We found new checks had been introduced to identify when medicine stock was running low and this prompted staff to ensure appropriate stocks were ordered and supplied.

Is the service effective?

People were supported to self- administer their medicines following assessment. Effective monitoring systems were in place to ensure their safety.

Staff had received appropriate professional development and support in relation to the safe handling of medicines.

Is the service caring?

We observed that the member of staff was kind, caring and patient, allowing people time to take their medicines.

Is the service responsive?

People’s health and medicine prescriptions were reviewed on a regular basis.

Is the service well-led?

Learning from audits took place although the development of clear action plans to address any shortfalls identified would better evidence the improvement work carried out.

Staff were clear about their roles and responsibilities.

We spoke with several people who used the service and four relatives. This confirmed that they were involved in making decisions about their care and everyday life. Comments included, "We discuss the menu with the cook and there is a good choice", "I decide when I go to bed and if I join in with activities." Relatives told us, "This is a fantastic home", "I haven't had any problems or concerns" and "I am always kept informed of what's happening."

People who used the service told us the care and support offered to them was of a good standard. Comments included, "The staff are wonderful" and "They are all lovely, you can't fault them."

We also spoke with four relatives and they told us they were involved in the planning of their relative's care. They also said that consultation took place with other professionals.

Several people who used the service told us the food was 'very good' and the menu was varied and plentiful.

We saw that the home was clean and hygienic and the major refurbishment work had been carried out in consultation with the people who used the service, their families and appropriate regulators.

At site visit on 14 July 2011 people told us they were happy to live in this home. They could tell us how they had been assessed prior to their admission date and who had been involved with that assessment. They described staff as "patient" and "caring" and told us they had all their needs met through a 24-hour period. They are able to express their views about the care being delivered to them as well as about the running of the home. They told us call bells are answered promptly.

We visited the home to check if the provider had made the required improvements to the issues we highlighted during our last inspection of the service completed on 30, 31 January and 5 February 2014. The inspection visit was carried out by three inspectors; a contracts officer for North East Lincolnshire Clinical Commissioning Group also attended the inspection visit.

The majority of people who used the service had complex needs which meant that they were not able to tell us about their experiences.

We considered the findings of our inspection to answer questions we always ask:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found

Is the service safe?

At the last inspection we found people who used the service were not properly protected against the risk of unlawful or excessive control or restraint. At this inspection we found the provider had made improvements with the records to support the management of behaviours which challenged the service and use of physical interventions. The records we saw showed people's behaviours were being managed safely and appropriately. The manager told us, and records confirmed, that the number of incidents had reduced.

Improved systems were now in place to ensure the manager and staff learned from events such as incidents, accidents, complaints, concerns and investigations. This reduced the risks to people and helped the service to continually improve.

At the last inspection we found shortfalls in the recording, administration and effective ordering of medicines. At this visit we found the provider had changed pharmacy providers, improved the storage arrangements and improved the recording and administration procedures. However, we found some people had not received their medicine because it had not been available.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the provision of adequate supplies of medicines to ensure people’s treatment is continuous, as intended by prescribers.

Is the service effective?

At this inspection we found the provider had made improvements to ensure people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met. From our observations and time spent at Cranwell Court, we saw that the people living there were receiving the care and support they needed in an individual way and wherever possible staff tried to facilitate choice.

People were asked for their consent prior to care and support and were asked for their views about activities of living on a daily basis. Care records we viewed showed more consideration of the Mental Capacity Act 2005(MCA). Mental capacity assessments were carried out and best interest meetings held when people lacked capacity and important decisions were required, this included the use of any physical interventions.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager had arranged for the local lead in DoLS for the area to visit the service, to advise on the recent changes in the application of DoLS.

Records and discussions showed staff had received further training, direction and support which enabled them to be more skilled and confident when supporting people, especially in relation to their dementia and health care needs.

People we spoke with were complimentary about the staff and said they were kind and caring. Comments about the staff included, "I like the staff, they are always pleasant and helpful” and “The staff are always very kind and patient; they are lovely with all the residents.”

Is the service caring?

We found the service provided a calm and homely environment that enabled people to live an independent lifestyle where possible. We found that staff were understanding of people’s individual needs. People’s preferences, routines, likes and dislikes had been recorded and care and support was provided in accordance with people’s wishes and choices.

People were supported by kind and attentive staff. We saw that staff showed encouragement and patience when supporting people.

Relatives spoken with were happy with the care provided to people and they commented on positive staff attitude. They said, “I have been extremely happy with the care my relative gets”, “They are always nicely dressed and clean” and “The atmosphere is calm and friendly, Xxxx is well looked after and settled here.”

Is the service responsive?

The provider had considered the specific needs of people with a dementia related condition when planning the environment. Recent improvements had been made to the décor on the enhanced unit, with the provision of new flooring and lighter coloured furniture in the communal areas. However, we did note the considerable amount of pictures, murals, wall hangings and mobiles in some of the corridors on the residential unit may be overwhelming for some people with dementia related needs and mentioned this to the manager to look into.

We found improvements with the level of personalised information contained in the care plans. Records showed that where people’s needs had changed staff had taken appropriate action to regularly review care plans.

People had access to a range of health and social care professionals such as GPs, psychiatrist, dieticians, speech and language therapists, social workers, dentists, opticians and podiatrists. There was evidence the staff team sought appropriate advice, support and guidance both routinely and during emergency situations.

Visiting health professionals told us they considered the staff had made good improvements with the quality of recording in the care plans, although some professionals felt the consistency of recording and staff feedback when they visited could still be improved.

Is the service well-led?

Following the last inspection we were informed that the Nominated Individual for the provider had taken over the management of the service on a temporary basis. The provider had also secured additional senior management support from their other service location to support the necessary improvement work.

We found improvements had been made to the way the provider monitored the quality of the service and the processes to identify, assess and manage risks to people’s health, safety and welfare. We found the manager had reviewed the audit programme and had completed regular audits in areas which had been highlighted at the last inspection. We saw that there were improved systems in place to monitor people’s health and welfare and these systems had been maintained and had influenced the care provided.

We found staff had a better understanding of the ethos of the service. Staff were clearer about their roles and responsibilities and considered the service was much more organised. Comments from staff included, “There have been a lot of improvements in the last few months. We get a lot more support from the management now. They are approachable and deal with things” and “The last few months have been hard work but worth it.”

Records showed the management team had worked with key organisations, staff, people who used the service and their representatives in recent weeks to secure improvement and maintain those standards. We found improvements had been made to the overall management of the service and also to outcomes for the people who used the service, to ensure they received more consistent, safe care that met their needs.