This unannounced inspection took place on 12 July 2018. Four Seasons is a purpose built home set in the Breightmet area of Bolton. The home is close to local amenities and public transport. Car parking is available in the grounds of the home.

Four Seasons 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.

Four Seasons is registered to provide care for 121 people who require nursing, residential and care for people living with dementia. The home also provides an intermediate care service. This supports people who have been discharged from hospital and need rehabilitation to support them in preparation of returning to their own home or to alternative care setting.

The home is split into five houses. On the day of the inspection there were 97 people using the service. There were 12 people in Spring house, 21 people in Summer house, 28 people in Winter house, 17 people in Autumn house and 19 people Autumn Berry house.

The home had a manager in post who was in the process on registering with the Care Quality Commission (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. The manager has been registered with the CQC before and has several years’ experience of managing care homes.

At our inspection on 18 October 2017 we found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to the safe administration of medicines and governance and a new breach in relation to staffing levels.

At this inspection we found that good progress had been made in addressing the breaches and an improvement had been made within the service.

You can read the reports from previous inspections on our website at www.cqc.org.uk.

On arrival at the home the front doors were secured. Visitors had to ring the bell to gain access into the home. This helped to keep people safe and to prevent unauthorised people from entering the home. We saw visitors were welcomed into the home and people could see their visitors in private if they wished.

There was a large comfortable reception area. The reception area had a café area for people to sit in with their guests. The home had accessible gardens with tables and chairs. There were a number of pet rabbits which were cared for by people living at the home.

Information about the home and the facilities offered were available in the reception area.

The service used the local authority safeguarding procedures to report any safeguarding concerns. Staff had been trained in safeguarding topics and were aware of their responsibilities to report any possible abuse.

Recruitment procedures were robust and ensured new staff should be suitable to work with vulnerable adults. We noted in one staff file that this person had no contract of employment and no job description. We discussed this with the manager who sent us a copies of the missing documents following our inspection.

in the main,the administration of medicines was safe and had improved in most of the houses with the exception of Winter house.

Most of the houses were clean, tidy and fresh and the environment was maintained to a good standard. Winter house was malodourous and the décor required attention.

There were systems in place to prevent the spread of infection. Staff were trained in infection control and provided with the necessary equipment and hand washing facilities.

Electrical and gas appliances were serviced regularly. Each person had a personal emergency evacuation plan (PEEP). A PEEP informs the fire ser

This unannounced inspection took place on 18 October 2017. Four Seasons is a purpose built home set in the Breightmet area of Bolton. The home is close to local amenities and public transport. Car parking is available in the grounds of the home.

Four Seasons is registered to provide care for 121 people who require nursing, residential and care for people living with dementia. The home also provides an intermediate care service. This supports people who have been discharged from hospital and need rehabilitation to support them in preparation of returning to their own home or to alternative care setting.

The home is split into five houses. On the day of the inspection there were 109 people using the service. There were 22 people in Spring house, 24 people in Summer house, 25 people in Winter house, 18 people in Autumn house and 20 people Autumn Berry house.

The home had 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 and associated Regulations about how the service is run.

At our inspection 23 January 2017 we found continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to safe care and treatment. This was because the service had failed to ensure medicines were being managed safely. We also found a continued breach in governance with regard to recording of personal care charts. You can read the report from our last inspections on our website at www.cqc.org.uk.

At this inspection we found two continued breaches of the of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to the safe administration of medicines and governance and a new breach in relation to staffing.

On the 18 October 2017 we found that medicines were not were not always being given safely and as prescribed. We found this was a continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to safe care and treatment. This was as the service had failed to ensure medicines were being managed safety

We found that suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred.

Staff were able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

We found staff had been safely recruited, received ongoing training relevant to their role and had regular supervision meetings.

Staffing levels were not sufficient in some areas of the home to meet the needs of people who used the service.

We found during our inspection and observing interactions that there was a friendly and respectful rapport between staff and people who used the service.

People's care records contained enough information to guide staff on the care and support required. The records showed that risks to people's health and well-being had been identified and plans were in place to help reduce or eliminate the risk.

We looked around the building and found it had been maintained, was clean and hygienic and a safe place for people to live. We found equipment had been serviced and maintained as required.

There were personal emergency evacuation plans (PEEPs) in place for each individual at the home. These were updated when changes occurred and outlined the level of assistance each person would require in the event of having to be evacuated.

We looked at health and safety records and saw an up to date fire risk assessment, liability insurance certificate, gas and electrical safety certificates. A number of hea

Four Seasons is a purpose built two storey building. Car parking is available at the front of the home. The home is close to local amenities and public transport. The home is registered to provide care and support for 121 people. Four Seasons provides nursing and residential care and care for people living with dementia.

The inspection took place on 06 April2017 and was unannounced. This was a focused inspection which means we were only looking at two domains, safe in relation to medicines and well-led in relation to governance.

This focused inspection took place in Spring House following a previous focused inspection on 20 January 2017 to follow up concerns in relation to the safe administration of medication and governance.

There was a home manager in place whose was in the process of applying to become the 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.

We found Spring House was safe, clean and clutter fee and appropriate health and safety measures were in place. Risk assessments had been completed.

Staffing levels in Spring House on the day of the inspection were sufficient to meet the needs of the current occupants of the house.

The home had an up to date medicines policy; the section on self- medication was awaiting ‘sign off’. Medicines were given as prescribed and were safely stored.

There was evidence within the care plans of good partnership working with other agencies. Referrals were made appropriately and advice followed by staff to ensure the best outcome for people who used the service.

People we spoke with told us the staff were kind and caring. We saw respectful interactions between staff and people who used the service throughout the day.

We saw that people were treated with dignity and respect and their opinions and views were listened to. Independence and autonomy was encouraged

Appropriate information was given out to patients and their families.

Care records included a range of health and personal information. They evidenced patients likes, dislikes, preferences and choices were taken into consideration.

There was an appropriate complaints procedure and this was included in the information given to people. There had been no recent complaints and the service had received a number of compliments.

Feedback from patients during their stay in Spring House were positive about accessibility and support from staff at the home.

Staff told us the management and other team members were approachable and supportive.

A number of audits and checks were carried out at the service. The results were analysed to ensure continual improvement to the service.

Four Seasons is registered with the Care Quality Commission (CQC) to provide nursing and personal care for up to 121 people. The building is two storeys with car parking facilities and is situated in the Breightmet area of Bolton.

The home had a registered manager in place at the time of the 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.

At our previous inspection in October 2016, we had found a continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment. This was as the service had failed to ensure medicines were being managed safely. You can read the report from our last inspections on our website at www.cqc.org.uk.

This focused inspection was carried out on 23 January 2017 to follow up previous concerns in relation to the safe administration of medication. Good progress was found within three units of the home; and in these areas medicines were found to be managed safely.

Since the previous inspection in October 2016, the purpose of Spring Unit had been changed to provide intermediate care. This type of care is used to provide additional short term support to people when they no longer require hospital care. People using this support may then return home, or receive an assessment for long term care and support. Additional multi-disciplinary staff were employed to provide additional onsite support such as physiotherapy and pharmacy services. On the first day of the inspection 23 people were resident on the Spring Unit.

Within this part of the home we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment; and good governance. This was as the service had failed to ensure medicines were being managed safely, which placed people at risk of harm. In addition, the governance system in place to monitor the safety and efficiency of the new scheme had been ineffective, which meant the issues we found at the time of the inspection had not been identified by the service and addressed. Appropriate records were not being adequately maintained.

Due to our concerns, we liaised with the provider, the local authority and the local clinical commissioning group (CCG). At this point, the Spring Unit closed to all new admissions to enable a full review to be undertaken and for actions to be taken to improve. We carried out a further day of inspection on 20 February 2017, at this time there were 11 people resident on the Spring Unit. We found improvements had been made to reduce the level of risk to people receiving care. Due to the lower level of risk, admissions to the unit recommenced with additional monitoring arrangements in place from the CCG. A further inspection was planned to check the effectiveness of the actions that were put in place.

Four Seasons is a purpose built two storey home situated in the Breightmet area of Bolton and is registered with the Care Quality Commission (CQC). Four Seasons provides nursing and residential care including care for people living with dementia. The home is registered to provide care and support for 121 people.

The home had a registered manager who was registered in April 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 and associated Regulations about how the service is run.

At our inspection of 15 August 2016 we found that the service has made significant improvements. However we found a number of failings in relation to the safe administration of medicines .

On the 22 August 2016 the service sent an action plan relating to the medication issues noted at the inspection of Four Seasons Care Home on 15 August 2016. This action plan had been formulated from the verbal feedback provided at the inspection. The service had taken immediate action to review systems in the home to minimise further medication issues, most notable of which is the agreement to move over to blister packed medication from Boots with their Monitored Dosage Systems (MDS).

We carried out a focused inspection on 27 October 2016 to check that medicines were now being handled safely. This report only covers our findings with regard to the management of medicines. You can read the report from our last comprehensive inspection on our website at www.cqc.org.uk.

During this inspection we found there were still areas of poor practice that were a cause for concern.

This unannounced inspection took place on 15 August 2016. Four Seasons is a purpose built two storey home situated in the Breightmet area of Bolton and is registered with the Care Quality Commission (CQC). The home is located close to local amenities and public transport. Four Seasons provides nursing and residential care including care for people living with dementia.

The home is registered to provide care and support for 121 people. The home is split into four areas known as houses. At the time of this inspection there were 77 people living at the home. On the day of the inspection there were 13 people living in Spring house, 24 people in Winter house, 20 in Autumn house and 20 people in Summer house. We were informed by the registered manager that four people were currently in hospital. This gave an overall total of 81 people on the home’s register.

At our previous inspection on 20 and 21 January 2016, we found multiple breaches of the Health and Social Care 2008 (Regulated Activities) 2014. We identified two breaches in relation to person-centred care, three breaches in relation to safe care and treatment, one breach in relation to safeguarding, one breach in relation to meeting nutrition and hydration needs, one breach in relation to premises and equipment, two breaches in relation to good governance and two breaches in relation to staffing. As a result of this the home was placed into special measures meaning significant improvements were required, or further enforcement action could be taken. Following this inspection, the home sent us an action plan of the improvement they intended to make.

Following the inspection in January 2016 the home had been closely monitored by the local authority contract and monitoring team and the local clinical commissioning group (CCG). Both agencies told us they had noted improvements throughout the home.

At this inspection we found that the service has made significant improvements. However we found a number of failings in relation to the medication. On the 22 August 2016 the service sent an action plan relating to the medication issues noted at the inspection of Four Seasons Care Home on 15 August 2016. This action plan had been formulated from the verbal feedback provided at the inspection. The service had taken immediate action to review systems in the home to minimise further medication issues, most notable of which is the agreement to move over to blister packed medication from Boots with their Monitored Dosage Systems (MDS). We are considering our enforcements actions in relation to this.

The registered manager was registered in April 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 and associated Regulations about how the service is run.

We arrived at the home at 06.30. This gave us the opportunity to speak with the night staff and to observe the early morning routine. The night manager confirmed most people were still asleep; the people who were up and dressed were sat in the lounges.

We found that people were able to move freely around the houses, the only restrictions being if floors were in the process of being cleaned and were wet, the doors were locked to prevent accidents.

We looked around the home and found it to be clean and tidy. The atmosphere was calm and relaxed.

We saw that improvements to the environment had been made especially for people living with dementia in Spring and Winter houses.

We found that staffing levels in each of the houses were sufficient to meet the needs of the people living in them. Staffing spoken with confirmed that staffing levels had improved and the use of agency staff had greatly reduced.

We looked at the training records and these indicated what training staff had completed and when refr

This unannounced inspection took place on 20 and 21 January 2016. The home is a purpose built two storey building. Car parking is available at the front of the home. The home is close to local amenities and public transport. Four Seasons provides nursing and residential care including care for people living with dementia.

The home is registered to provide care and support for 121 people. The home is split into four areas known as houses. On the first day of our inspection there were 26 people living in Winter House, 15 living in Spring House, 27 living in Autumn House and 27 living in Summer House.

The home has a large reception area with appropriate information to inform people about the home and the services provided, including safeguarding and whistleblowing procedures. There is also a café (not staffed) with vending machines for drinks and snacks. There is access to the garden from the reception area.

The home had a registered manager at the time of the 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.

At our inspection in May 2015 we found three breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, good governance and person centred care. At this inspection, we noted breaches of Regulations 9, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we found that medication was not being administered in a safe and timely manner and that on occasions people had run out of their prescribed medicine. The provider had not taken reasonable steps to ensure people’s care and support needs were being met. The provider had failed to ensure that people who used the service were protected from abuse and improper treatment. The nutritional and hydration needs of people were not being met. Systems or processes were not established and operated effectively to ensure compliance with the regulations and sufficient numbers of suitably qualified, competent, skilled persons were not deployed.

People who used the service were not cared for safely. Appropriate care was not provided and staff had failed to access timely professional advice. This placed the health and welfare of people at risk of harm.

We found there was conflicting and confusing information in the care records. Without clear and accurate records to monitor and manage potential health care risks to people it was not possible to know if people were receiving the care and support they required. Information was not always followed in accordance with the care plans and this potentially posed a risk of harm and poor care to some people who used the service. We found that charts that were important to people’s health and wellbeing were incomplete.

Systems were not in place to prevent and control the risk of cross infection. People who used the service were potentially at risk from poor practice.

We found that staffing levels and skill mix at the home were insufficient. We observed people were left unobserved in the lounges for long periods of time. The home relied heavily on the use of agency nurses and care staff.

We looked at the staff training records. Staff training was on going, however due to some of the concerns raised it was evident that training was not embedded into the home to ensure good, safe quality care was being delivered. Staff confirmed that staff supervisions were ad-hoc and we found staff appraisals were inconsistent.

We found areas were locked and this restricted people’s freedom of movement around their home.

The environment in places required cleaning and some en-suite bathrooms were cluttered and were being u

This was an unannounced inspection and was carried out on 19 January 2015. Four Seasons provides residential, nursing care and specialises in caring for people living with a dementia related condition. The home is registered to accommodate care for 121 people on two floors. The home is separated into four different areas known as units. On the day of our visit there were 26 people on Summer Unit who required nursing care. On Autumn Unit there were 32 people who required residential care. Dementia care is provided on Spring Unit where 23 people were living and on Winter Unit where 24 people were living. On the day of our inspection 105 people were living at the home in total.

The home has no registered manager. ‘A registered manager is a person who is 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’. Within the last three months there has been a number of people from the management team and four relief managers overseeing the service.

The home has a large reception area and a café where people could meet with visitors for refreshments. People could only access this area with staff or visitors. During our inspections in September 2014, October 2014 and January 2015 we had not seen the café being used. There is an outside courtyard and garden area for people to access with seating areas.

People’s safety was compromised as following the Fire Inspection on the 19 January 2015 the Fire Safety Officer identified several breaches of the Regulatory Reform (Fire Safety) Order 2005. Staff had not received appropriate fire safety training to ensure the safety of people living at the home.

Care plans contained risk assessments which identified hazards. We also saw that the care plans had documentation to show how people’s health was to be monitored. However, in some cases these were incomplete and it was noted that some referrals which should have been made to health professionals had not been made, therefore the home was not acting in people’s best interests.

We spoke with two healthcare professionals who told us the home was not always responsive to people’s needs.

We spoke with people who lived at the home and their relatives. Comments received included, “Things are a getting bit better”, and “Is this manager going to stay, there have been so many changes”.

At the time of our inspection, people's freedom of movement was restricted. The dining rooms were locked between meals on the day of the inspection. Unless people were in their bedrooms we found that the bedroom doors were also locked.

There was no formalised planned programme of activities and events, and no records of activities recorded to show how people had spent their day. There was a lack of meaningful activities that provide stimulation for people living with dementia. Three new activity coordinators had been appointed in December 2014.

During the inspection we observed the lunch time meal dining experience. We saw people were encouraged to eat and drink. We saw people were offered a choice of meal and if people required assistance to eat their meal, this was done in a sensitive and dignified manner.

The home had safeguarding policies and procedures in place and safeguarding alerts were being made appropriately. However, levels of staff training were low and one member of agency staff was unsure what they would do if they identified a concern.

We saw that complaints information was available to people in the foyer of the home.

The service did have an audit process in place, however the service was not making the best use of the information it collated to improve the quality of the service or to put measures in place to improve people’s safety.

We saw that there were gaps in staff training. Staff supervisions and appraisals were overdue meaning staff were not appropriately supported by the management.

During this inspection the Inspection team gathered evidence to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This inspection was carried out due to further serious concerns around the safety and well-being of people who used the service being raised following a previous inspection.

During the inspection we looked at respect and involvement, care and welfare, nutrition, safeguarding, medication, staffing, and quality assurance.

This is a summary of what we found, using evidence obtained via observations, speaking with staff, speaking with people who used the service and their families, and looking at records:

Is the service caring?

We saw staff administering interventions in a considerate and respectful way offering appropriate reassurance and explanation. However, it seemed the only opportunity staff had for interacting was when they were engaged in a task.

We felt on the whole that staff were committed and dedicated to their caring roles. They were positive and hopeful that changes were being made and would lead to a better standard of care at the home.

We witnessed some instances where staff ensured people’s dignity was respected and some examples of people’s dignity being compromised. People were not given stimulation or having meaningful interactions with staff.

We asked a person who used the service if they felt they staff understood their needs and they responded, “Yes, I do”.

Is the service responsive?

We saw that people’s preferences for a male or female carer were not always adhered to, which meant they were not having choice around their care. One person who used the service said they preferred a female carer and told us she did not like to have personal care carried out by men.

Another relative, when asked about male or female carers said, “Yes, he gets embarrassed with young girls".

We saw references to a person’s cultural and spiritual needs within a care plan. However, it was unclear if or how these needs were being met in a practical way.

We saw little evidence of any meaningful activities or interaction with people who used the service. The environment was bland and provided little stimulation for people living with dementia.

A relatives’ meeting had been held recently and this was very positive. We were told relatives were very interested in being involved in some of the dementia training and in interviews for the recruitment of new staff.

We asked if staff responded well to people being unwell and were told they did. One relative said, “Yes, they have had to call the GP out and I have asked that he doesn’t go into hospital unless absolutely necessary, and they do seem to be able to look after him properly".

There was an emergency on one of the units on the day of the visit. A person who used the service was extremely poorly and staff responded to the situation efficiently and in a caring and compassionate manner.

Is the service safe?

One person who used the service was observed to be in a kirton recliner chair. The care plan reflected the fact that this person had suffered a number of falls and was at considerable risk. An urgent Deprivation of Liberty Safeguards (DoLS) application had been made for this person, to ensure they were not unlawfully deprived of her liberty due to being strapped into this chair.

We looked at Deprivation of Liberty Safeguards (DoLS) and saw that the manager, in collaboration with the local authority DoLS lead, had begun to put through the most urgent applications for authorisation. These appeared to be appropriate and thorough and we felt this issue was well on the way to being addressed.

Staff still had little awareness of the Mental Capacity Act (2005) (MCA), and DoLS. However, this lack of knowledge was being addressed by the management team, in conjunction with the local authority MCA and DoLS lead.

We spoke with three visitors on one of the dementia units. All of them felt the unit was safe.

On one of the units the nurse in charge had to be sent home as they smelled strongly of alcohol. We referred this matter to the local safeguarding team. The management team immediately made arrangements for the person’s shift to be covered by another nurse in the building and to cover subsequent shifts for the immediate future.

Another nurse commenced giving out medication it was observed that Medication Administration Sheets, (MARS) had already been signed by the nurse who had been sent home, prior to the medication being actually given to people. This took some time to put in order as there was the potential for people to be given too much medication.

Staffing levels were still an issue at the home on the day of the visit. A number of new employees had been recruited but were awaiting the return of Disclosure and Barring Service (DBS) checks or references. This had resulted in agency staff still being utilised regularly by the home. The management team told us they tried to ensure they used agency staff who had been at the home before, but this was not always possible.

On the day of the visit there were a number of agency staff who had been on the night shift. There were also some agency staff working the day shift.

Is the service effective?

On one of the dementia units the staff the previous night had consisted of two agency staff and one permanent staff member from another unit. They told us they found it difficult to deliver care as effectively as they would like to because they did not know the people on the unit well.

We saw that most files contained up to date information about the personal and health requirements of the people who used the service. Partnership working was on-going and there were appropriate referrals within the files to other services, such as nutrition and dietetic service.

New systems had been implemented by the new unit manager on the residential unit. Staff told us these systems were working very well and they were all positive about the new routines. We saw the atmosphere on this unit was calm and tasks appeared to be being carried out efficiently and well.

We asked staff about nutrition and hydration. One told us that dieticians and GPs are involved. Others understood the need for certain types of diet and they were able to explain how many drinks were offered during the day and told us people could have a drink any time if they requested one.

A visitor told us their relative was often awake in the night and was given drinks and sandwiches or a biscuit by the night staff.

Is the service well led?

The home had a manager registered with the Care Quality Commission. However, on the day of the visit there was a management team overseeing the home and they facilitated our visit.

In house medication audits had been carried out by the Quality Assurance Manager on all of the units and all had failed. There was an action plan in place and the management team were in the process of addressing the shortfalls.

Spot checks were now being regularly carried out by the management team. Any shortfalls identified were addressed.

A number of audits had recently been implemented which highlighted issues. Action plans were put in place and actions completed.

Appropriate notifications were being sent in to Care Quality Commission as required.

We inspected this service on 2 September 2014. The inspection team consisted of two inspectors, a pharmacy inspector from the Care Quality Commission (CQC) and an expert by experience. An expert by experience is a person who has had personal experience of using or caring for someone who uses this type of service.

During the inspection we looked at respect and dignity, consent, care and welfare, nutrition and hydration, management of medicines, staffing and quality assurance. We also gathered evidence to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of what we found, using evidence obtained via observations, speaking with staff, people who used the service and their families, and looking at records.

The home had two dementia care units, a residential unit and a nursing unit.

Is the service safe?

We spent time on the dementia units; the majority of the people living on those units were not able to tell us about their care and support and relied on relatives acting on their behalf. One relative told us, “The staff are very good, there’s just not enough of them”. We spoke with people who used the service, all of the people spoken with told us that they felt safe from abuse and that their privacy was respected.

The service had systems in place to help protect people living at the home from harm. Staff had access to policies and procedures to guide them in areas such as safeguarding from abuse, Mental Capacity Act 2005 (MCA), Deprivation of Liberty Safeguards (DoLS), confidentiality and recruitment. We found that not all staff had adhered to these policies.

Staff were provided with training in areas such as safeguarding, MCA and DoLS. Staff spoken with had a good understanding of safeguarding; however their understanding of MCA and DoLS was limited, therefore people’s rights were not protected where important issues needed to be addressed and decisions made.

We saw risk assessment forms had been completed where potential hazards had been identified with regard to pressure care and falls and use of bed rails; however we found that these were not always being followed.

On the day of our inspection we found that staffing levels needed to be increased to meet the needs of the people living at the home.

The home was clean and spacious allowing people with mobility difficulties to move freely around the home.

Is the service effective?

We spoke with the staff on night duty and with the day staff. Staff spoken with were dedicated and committed to people they were caring for.

Prior to the inspection some staff told us they did not feel comfortable in reporting any concerns or issues to the home’s senior management team as these were not dealt with appropriately and in confidence.

People’s needs had been assessed before they moved into the home to ensure their needs could be met by staff. Where possible people who lived at the home were involved in writing their care plan. Any special dietary needs, mobility and equipment needs had been assessed and identified.

We saw that people’s orientation needs were taken in to account with the help of appropriate signage around the home to help people identify where bedrooms, bathrooms and toilets, lounges and dining rooms were located.

Is the service caring?

Individual care records were in place for people living the home. These records provided staff information about how to care for and support people. Plans were reviewed regularly but not all information was up to date.

We spent time observing how care was provided. We saw that privacy and dignity was respected when staff supported people with their personal care needs. Staff addressed people by their preferred name and were heard asking people’s permission to provide care and explaining to people what they were about to do before carrying out any intervention.

For people who had difficulty in communicating we observed people’s body language and facial gestures were positive when staff approached them.

Is the service responsive to people’s needs?

Information was available about the service and what people could expect should they choose to live at Four Seasons. Assessments were carried out prior to people being admitted to the home to help ensure that people’s needs could be met by the staff.

People were offered a range of activities both in and away from the home. We saw that one of the activities coordinators spent time sitting and speaking with people on the dementia units giving them individual attention.

We were told that visits were made to the home by local clergy so that people’s cultural and religious needs were met.

Staffing levels could be improved especially on night duty to enable staff to meet the needs of people they were supporting more effectively.

Is the service well-led?

The home had a manager who was registered with the CQC. However, on the day of our visit there was another manager overseeing the home with a team of senior management offering support.

We had been made aware by a number of staff that issues or concerns that had been brought to the registered manager’s attention and to other senior staff had not been dealt with appropriately in line with company policies nor had they been dealt with in confidence. This was being addressed by the management team.

The CQC had not been notified as required of all accidents, incidents and deaths which had occurred at the home in line with current regulations.

The management team currently working at the home were in the process of checking and addressing any shortfalls found in the audit checks and will continue to monitor ensuring effective systems are in place to improve the service.

We visited Four Season Care Home on 8 October 2013. The inspection started at 07.00 am so we had the opportunity to speak with the night staff before the end of their shift.

On arrival at the home we found most people were still in bed. Some people were up, dressed and sat in the lounges. Some had been offered a hot drink.

We found the home to be warm, clean and tidy. We looked on all four units and found the home to be sufficiently staffed by waking night staff, apart from one unit where we were told one member of staff had to go home due to unforeseen circumstances.

We saw people who used the service were well presented and we observed staff interacting with them in a friendly, polite manner and respecting their dignity and privacy.

At this inspection we focused on the two dementia care units. We looked at four care records and other information that was kept providing evidence that the home was properly managed.

We spoke with people who used the service and relatives. One person told us, “Everything is fine, I am well looked after”. Another said, “The staff are very good”. A relative told us, “The care, dignity and respect shown to my X is fantastic. All the staff are brilliant”. Another said, “X has settled really well and is well looked after”.

We saw staff had access to relevant policies and procedures including safeguarding procedures and contact details.

We saw a number of compliment cards from relatives displayed on the units.

The people we spoke with were very complementary about the care given and about the staff.

One person spoken with said, “The staff are very good, they look after us really well”.

Another said, “I have no complaints about the home or the care I receive”.

One person told us, “My relative is really well looked after and I feel that they are safe in their care”.

This was an unannounced inspection and was carried out on 11 and 12 May 2015. Four Seasons provides residential care, nursing care and specialises in caring for people living with dementia. The home is registered to provide accommodation, care and support for 121 people on two floors. The home is separated into four different areas known as houses. On the day of our visit there were 17 people in Summer House who required nursing care. In Autumn House there were 30 people who required residential care. Dementia care is provided in Spring House where 20 people were living and in Winter House where 22 people were living. On the day of our inspection 89 people were living at the home in total.

The home had no registered manager at the time of the inspection. The acting manager was supported by a management team. A registered manager is a person who is registered with the Care Quality Commission (CQC) 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 acting manager confirmed that they had submitted an application to register with the Commission. Following our inspection the acting manager’s application was successful and in June 2015 was registered with the CQC.

At our inspection on 19 January 2015 we found five breaches of the Health and Social Care Act (Regulated Activities) 2014. At our inspection on 11 and 12 of May 2015 we found that progress had been made in a number of areas and these regulatory breaches had been met. We found three new regulatory breaches relating to Staffing, Good Governance and Person Centred Care.

At our inspection on 19 January 2015 the Fire Safety Officer found a number of concerns relating to fire safety within the home. During this inspection, we found action had been taken to address the identified issues. This was confirmed by the Fire Safety Officer who attended the home during the inspection.

The home had a large reception area with appropriate information to inform people about the home and the services provided, including safeguarding and whistleblowing procedures. There was also a café (not staffed) for people to purchase refreshments.

We saw the garden area had new furniture and the flags had been made even to help prevent people from tripping. We tested the depth of water in the garden pond and found this could compromise people’s safety. We discussed this with the maintenance team and the acting manager and recommended that the pond should have an appropriate guard to ensure people’s safety. In the interim period we saw that a metal fence was erected around the pond.

At our inspection in January 2015 we found that medication was not being safely administered. At our inspection in May 2015 we found that progress had been made in the safe handling of medicines. During the inspection we found that some medicines were not always administered as prescribed and recording was inconsistent. We made a recommendation for the acting manager to action this.

During our inspection in January 2015 we found staff had not received adequate training. Since this inspection, the management team had focused on improving training levels within the home. At this inspection, over 80% of staff had completed their mandatory training, which showed good progress from the previous levels of training within the home.

We saw that the care plans had all been reviewed and contained good information, however we saw that staff did not always adhere to the care plans.

We found staffing levels at the home were defined by the number of people living in each house and not by the levels of dependency. This meant that at times there were insufficient staffing levels to offer the care required.

We saw the activities were limited and that the activities coordinators, due to a lack of staff were deployed to serving drinks instead of providing meaningful activities.

The service had made improvements in the paperwork relating to the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS). MCA sets out the legal requirements and guidance around how to ascertain people’s capacity to make particular decisions at certain times. Staff did not consistently understand and work in line with people’s care plans relating to DoLS.

The home was currently being supported by the local authority and the Clinical Commissioning Group (CCG) to help continued improvements.