About the service: Gables Care Home is a care home that was providing personal and nursing care to 51 older people and people living with a dementia at the time of the inspection.

People’s experience of using this service:

• The premises, infection control processes and governance processes had improved but continued and sustained improvement was needed.

• People received their medicines when needed. Staff safeguarded people from abuse. Risks to people were assessed and action taken to address them. The provider ensured there were enough suitable staff working to support people safely.

• Staff were supported with regular training, supervision and appraisal. People received support with food and nutrition, and staff helped them access a wide range of healthcare professionals. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

• People and their relatives spoke positively about the support they received from staff, who they described as caring and kind. People were treated with dignity and respect.

• People received person-centred support based on their assessed needs and preferences, and were involved in designing and reviewing this. Clear complaints procedures were in place to address issues at the service.

• Since our last inspection a new management team was in place, and staff spoke positively about their leadership. Systems were in place to ensure the voices of people, relatives and staff were heard. The service worked with other organisations and agencies to promote people’s health and wellbeing.

Rating at last inspection: Requires improvement (Report published 4 October 2018).

Why we inspected: We received information of concern from local authority commissioners and other professionals visiting the service. This inspection was brought forward due to the information we received.

Follow up: We will work with the provider following this report being published to understand and monitor how they will make changes to ensure the service improves their rating to at least Good.

This inspection took place on 29 August 2018 and was unannounced. This meant the provider and staff did not know we would be attending.

The service was last inspected in January 2016 and the overall rating for the service was good. The safe domain was rated requires improvement as medicine records were not always completed correctly. We spoke with the registered manager of the service at that time, who said action would be taken to address these issues. When we returned for this latest inspection we found that medicines were not managed safely. We also found issues with the maintenance and cleanliness of the premises, and saw that governance and management processes were not always effective.

This is the first time the service has been rated requires improvement.

Gables Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Gables Care Home accommodates up to 64 people across four units. Two units provide general nursing and residential care, and two units provide nursing and residential care for people living with a dementia. At the time of our inspection 57 people were using the service.

The service had a manager who was applying to be the registered manager at the time of our inspection. A registered manager is a person who has registered with the 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 manager was registered as the registered manager shortly after our inspection, and will be referred to as the registered manager in this report.

Risks arising out of people’s health and support needs were assessed and plans put in place to reduce the chances of them occurring. Accidents and incidents were monitored to see if lessons could be learned to keep people safe. Plans were in place to support people in emergency situations. Policies and procedures were in place to safeguard people from abuse. We received mixed feedback on staffing levels from people, relatives and staff but this was monitored by the provider and registered manager. The provider’s recruitment process minimised the risk of unsuitable staff being employed.

People’s support needs and preferences were assessed before they started using the service and care plans drawn up to meet them. Staff were supported with regular training, supervision and appraisal. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. The service had well established links with external professionals in the local community. People were supported with managing food and nutrition. The premises had been adapted for the comfort and convenience of people living there.

People spoke positively about the support they received from staff, describing it as kind and caring. Relatives also praised staff and described the service as caring. Staff treated people with dignity and respect. People were supported to maintain their independence as much as possible. Throughout the inspection we saw numerous examples of staff delivering kind and caring support. The registered manager and staff were committed to ensuring that everyone felt welcome at the service and could live as full and free a life as possible. People were supported to access advocacy services where needed.

People received person-centred support. People were supported to access activities they enjoyed. Policies and procedures were in place to investigate and respond to complaints. At the time of our inspection nobody was receiving end of life care but

This inspection took place on 25 and 26 January 2016 and was unannounced. This meant that the provider did not know we would be visiting. The service was last inspected in 2013, and at that time was meeting the regulations we inspected.

Gables Care Home is a purpose built 64 bedded service. It provides nursing and personal care for older people, including people living with dementia. There are four units within the service, set out over both floors. At the time of the inspection 56 people were using the service.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines were not always managed in a safe way. Medicine records were not always completed fully, and care plans for people using ‘when required’ medicines contained limited detail. We made a recommendation about medicines management

Risks to people arising from their health and support needs or the premises were assessed, and plans were in place to minimise them. A number of checks were carried out to monitor the safety of the premises.

Staff understood safeguarding issues and felt confident to raise any concerns they had.

Robust recruitment procedures were in place to ensure that only suitable staff were employed.

Needs of people were assessed on a regular basis to ensure that staffing levels were sufficient to support people safely.

Staff received training to ensure that they could appropriately support people, and the service was starting to use the Care Certificate as the framework for its training.

Staff received support through supervisions and appraisals, though we did not see any records of these.

Staff understood and applied the principles of the Mental Capacity Act and the Deprivation of Liberty Safeguards to ensure that people’s rights were protected. Care plans contained evidence of mental capacity assessments and best interest decisions.

People were supported to maintain a healthy diet, and people’s dietary needs and preferences were catered for.

The service worked with external professionals to support and maintain people’s health. Care plans contained evidence of regular involvement in delivering people’s care by external professionals.

Staff treated people with dignity, respect and kindness. People and their relatives spoke highly of the care they received. Staff knew how to adapt their communication to have meaningful engagements with people.

The service provided people with information on advocacy services

Care was planned and delivered in way that responded to people’s assessed needs, including any specialist needs they had. Care plans were regularly reviewed to ensure people’s needs were met and relevant changes were added to care plans where needed.

People had access to a wide range of activities, internally and in the wider community.

The service had a clear complaints policy that was applied when issues arose. There was evidence of investigation of complaints and outcomes were documented.

Staff were able to describe the culture and values of the service, and felt supported by the manager in delivering them.

The manager and provider carried out regular checks to monitor and improve the quality of the service.

The manager understood their responsibilities in making notifications to the Commission.

We spoke with five people who used the service and the relatives of two people. We also spoke with the manager, the area manger and four staff.

People who used the service expressed satisfaction with the care and service that they received. One person told us, “Everyone is lovely, you only have to ask for help and someone helps me straight away.” Another person told us, “I’m alright and the girls are good.” A relative we spoke with told us, “I have no worries when I go home, he/she is well looked after.”

We used a number of different methods to help us understand the experiences of people who used the service, because some people had complex needs which meant they were not able to tell us their experiences.

There was a friendly and relaxed atmosphere between people living and working at the home. We observed staff interacting well with people and supporting them which had a positive impact on their wellbeing. People's views were taken into account in the assessment and care planning process.

We saw that the home was clean and there were systems in place for ongoing cleaning and infection control.

The home and grounds were safe and secure and systems were in place to ensure maintenance was carried out when required.

We saw the service had appropriate equipment and regular checks and servicing of equipment was undertaken to ensure that it was safe.

We saw the home had a complaints procedure in place and this was accessible to people and their relatives.

During the inspection we spoke with two relatives. One relative told us, “It’s nice and friendly, it has a homely atmosphere.” Another relative told us, “Staff showed us Mam’s care plan and talked to us about it.”

We saw that staff interacted well with people living at the home and they spoke to people in a courteous manner. The atmosphere in the home was relaxed and staff frequently smiled at people to offer reassurance and spoke clearly and at a steady pace with people. People who used the service were observed to be well presented and were dressed appropriately.

We found people's personal care records contained sufficient information about their needs and the care required to meet those needs.

Some people who used the service were less able to express their views due to complex needs. We did speak with one person who told us that he/she was bored and would like to talk more. He/she said that he/she liked football and followed Middlesbrough Football Club. He/she said that staff treat him/her well.

We used a number of different methods to help us understand the experiences of people using the service. We spoke with three relatives of people that used the service. Comments made by relatives included:

“It’s really good in here. It’s good from the time I walk in. I’m made welcome and always get a cup of tea.”

“Staff are helpful and courteous and he/she gets well looked after.”

“Everything is working fine and if you need help the carers are always there.”

“It’s lovely”

“Staff are tremendous, there is not one member of staff you could say anything wrong about, they are always lovely.”

During the inspection we walked round the home and sat in the dining area of the nursing dementia unit which also looked into the lounge. We observed staff interacting well with people who used the service, staff were attentive and spoke to people courteously and respectfully.

Some of the people that use the service at The Gables have dementia and therefore not everyone was able to tell us about their experiences.

To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

Some people using the service were able to tell us about their experiences. The people we spoke to said that they could make choices such as when to get up, what to wear and what they wanted to do during the day.

People said, "I want to go home, they are looking after me here but I like my own home". We were told that "All the girls are lovely" and "Although there never seems to be enough carers nothing is too much trouble for them".

During the inspection we spoke with one person that used the service. They told us that the care was generally alright and they could go to bed and get up when they wanted but that others could not.

We spoke with one relative and they told us that the younger girls were good with their relative. They also told us they had complained to the manager about an issue and had received a response from the home. They told us the food can be repetitive but there are plenty of drinks.

We saw that staff interacted well with people living at the home and they provided support and encouragement in a sensitive and dignified manner. The atmosphere in the home was relaxed and staff frequently smiled at people to offer reassurance and spoke clearly and at a steady pace with people. People who used the service were observed to be well presented and were dressed appropriately.