This unannounced inspection took place on 8 and 15 May 2017. This meant the registered provider, staff and people using the service did not know that we would be carrying out an inspection of the service.

Germaina House provides accommodation for up to 18 people requiring personal care. The service caters for people with physical impairment, mental health conditions and those who have a dementia type illness. Germaina House consists of two large Victorian mid-terraced houses which have been converted in a residential area of Redcar. There are gardens to the front of the property and a communal courtyard to the rear of the property. During inspection there were 16 people using the service who were supported by the registered manager, general manager and 19 staff.

The registered manager has been registered with the Care Quality Commission since October 2010. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff understood the procedures which they needed to follow to raise a safeguarding concern. Staff training in safeguarding adults was up to date and safeguarding alerts had been made when needed.

Risk assessments were in place and had been reviewed regularly. Care plans included details of these risks. Staff demonstrated a good understanding of people’s risks and the actions which they needed to take to reduce any risks when we spoke to them.

Personal emergency evacuation plans were in place for each person and detailed safe exit routes, important health conditions and any difficulties with mobility.

People told us there were enough staff on duty at the service during the day and at night. People told us staff always responded to them when they needed support.

There were good systems in place for managing people’s prescribed medicines. Staff had taken action to request medicines reviews for people by their GP.

Staff told us they were supported to carry out the role which they were employed to do. They received regular supervision, appraisals and training. People told us staff had the knowledge, skills and experience to care for them safely.

Staff had followed the Mental Capacity Act 2005 and deprivation of liberty safeguards had been applied for and granted for 11 people. A best interest’s decision had been made for one person to have a lap belt on their wheelchair to prevent them from falling, however this decision had not been recorded. The senior lead took immediate action to address this.

People spoke positively about the nutrition and hydration which they received and told us there was always a choice. Staff followed guidance from health professionals when people became at risk of dehydration or malnutrition.

Care records detailed the health and social care professionals involved in people’s care. During inspection we observed people receiving visits from professional regarding their care. People told us they could see their GP whenever they needed to.

The service helped people to remain as independent as possible. Staff had started to introduce dementia friendly signage. The general manager told us that plans to further improve the facilities for people living with dementia were being considered.

People spoke positively about the staff who provided care and support to them. People told us their privacy and dignity was always maintained and staff gave them the time they needed.

We saw that staff knew people well. We observed many positive interactions between people and staff. Staff told us about people’s life histories and current health and well-being needs.

Staff involved people in their care and encouraged people to make their own decisions. Where people were unable to do this, staff sought support for people from loc

This inspection took place on 01and 15 December 2015. The first day of inspection was unannounced and we attended the service at 06:00; the service knew we would be returning for the second day of our inspection.

Germaina House can provide accommodation for up to 18 people who need require help and support with personal care. The service is made up of two large Victorian mid-terraced houses which have been converted in a residential area of Redcar. There are stair lifts on each set of stairs to assist people to the upper floors. At the time of our inspection there were 12 people living at the service.

There was a registered manager at the service. 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 previously inspected the service in July 2015 and found that the service was not meeting all of the standards which we inspected. We found that there were not enough staff on duty at night to provide appropriate care and support to people; some people were left waiting at night. Apprentice staff were left unsupervised and people were left in communal areas for up to 30 minutes at a time. Fire risk assessments and evacuations were not up to date; there was a lack of readily available choices at meal times and there was not always evidence of consent. We found that people’s privacy and dignity was not always maintained. Training, supervision and appraisals were not up to date. Records were not person-centred and there were gaps throughout all records looked at during inspection. There was a lack of leadership in place at the service and little evidence of quality assurance processed in place. We issued two warning notices in relation to staffing [staffing at night, training, supervision and appraisals] and good governance [quality assurance including record keeping]. We also issued four requirement notices in relation to safe care and treatment, dignity and respect, consent and person-centred care.

At this inspection we found that the service had taken action to address each breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection, we found that there were enough staff on duty at night to provide care and support to people.

People who used the service told us their call bells were answered within a reasonable amount of time. This meant people’s privacy and dignity was maintained.

Staff on duty at night were trained to dispense medicines which meant people who needed medicines at night received them without delay.

Safeguarding training was up to date and staff demonstrated good knowledge and understanding of the procedures they needed to follow should they suspect abuse may be taking place.

The service worked in partnership with a local college to allow students on placement at the service. We saw students shadowed experienced members of staff at the service.

Staff were allocated appropriately across the service which meant there was a visible staff presence at all times.

Fire risk assessments had been updated and staff had attended promptly during fire evacuation tests.

The service was clean and cleaning records were up to date. People had access to their own toiletries which were stored in their own rooms when not in use.

Training was up to date for moststaff; where gaps had been identified, records showed that planned dates for training for staff had been booked in.

Supervision and appraisals for all staff had been carried out and future dates had been planned.

There was a choice of readily available food at each mealtime. People could always have something different if they wished. Staff were aware of people’s dietary preferences and records had been updated to

Germaina House is a Victorian converted mid-terraced house situated in a residential area of Redcar. The home can accommodate up to 18 people providing residential care and support.

Our inspection team was made up of two inspectors and one expert by experience. We carried out this responsive inspection to follow up on concerns identified at our previous inspection in December 2013. We gathered evidence against these particular outcomes which enabled us to answer two of our five key questions; Is the service safe? And, is the service effective?

We looked at a range of records, spoke with the registered manager and members of the management team, including the administrator. Throughout the inspection visit we also spoke with three staff of varying roles and we spoke with six people who used the service.

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, the manager and staff.

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

Is the service safe?

We found that people were not protected from the risk of infection because appropriate guidance had not been followed and people were not cared for in a clean, hygienic environment. Staff had not received appropriate training in relation to infection prevention and control. As a result there were ineffective systems and procedures in place to ensure that people who lived at the home were protected from the risk of infection. We found that the home did not carry out deep cleaning of mattresses, sofas, chairs and carpets throughout the home. We found that the laundry process for washing and sterilisation of soiled clothing was not in line with recommended practice.

We did see that the home had taken action to ensure that spillage kits (to assist with the safe cleaning of bodily fluid spillages) were in place. We also saw that they had addressed our original concerns around the sluice and laundry rooms and installed a new sink and repaired damaged walls.

We found that people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises. From our observations we saw that keys were left in doors giving people who lived at the home access to restricted areas such as the sluice room. We also saw that a cupboard, in one of the upstairs bathroom, containing a boiler that was out of use and which contained loose electrical wires was unlocked with a key in it.

From observations we found that areas of the home were in a state of disrepair. We found that carpets in the top floor bathroom required replacement as it was tired, old, worn and stained. Strip lighting required repair and was hanging loosely at one side. We found that bathroom taps were not clearly marked as hot and cold and in some instances were chipped or large pieces of the fixture broken. The woodwork and paintwork throughout the home required attention as it was scuffed, chipped and marked where equipment had caught it.

Fire exits were appropriately signed internally within the premises, however there was no signage to the exterior of the premise identifying these exits to members of the public to ensure that there kept clear at all times.

We found mechanical engine parts, belonging to a family member of the registered manager, were stored in the garden that people who used the service, staff and visitors had access to. This posed a significant risk to the safety of these individuals and we instructed the manager to take immediate action to have these items removed. These items were removed before we concluded our visit.

We did see that the home had replaced carpets on the ground floor, combustible materials had been locked away securely and personal medication was now longer stored in the office.

We found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. We saw that care records did not contain sufficient information to ensure that appropriate care and support was delivered to people who used the service. For example, we saw that the care records outlined people's behaviours but they did not go on to explain any identified triggers for specific behaviours, or detail any interventions that staff should carry out when these behaviours arose.

From discussions with management we also identified concerns around the retention and destruction of records.

We did see that the home had taken action to address the storage of confidential care records and employment files.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care home. The registered manager had a good understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards and we found that there were two people living at the home who were subject to such safeguards. We did note that these safeguards had been put in place in response to concerns identified by visiting professionals who instructed the manager of the need to apply for DoLS.

Is the service effective?

We found that people were cared for by staff who were not supported to deliver care and treatment safely and to an appropriate standard.

We spoke to the manager and her support staff about the development of supervisions and appraisals designed to support staff. They told us that whilst some staff had been allocated dates to attend appraisal sessions, no appraisals had yet been completed. The management staff that we spoke with told us that they remained unclear about what an appraisal or supervision session should entail. They went on to inform us that they had enrolled on a management course which would include a session on management and support of staff but that they were not yet completing this module. This meant that staff were not adequately supported by management and that the professional development, including training needs, were not being tailored to individual staff requirements.

From our observations within the home and from discussions with staff we did find that the service had training sessions planned in relation to emergency first aid, medication, food safety and end of life care. We also saw that staff were undertaking accredited professional training within the adult social care sector.

What people told us

We spoke with six people who used the service. People told us that they were happy and content living at the home.

People told us that they felt safe when care and support was being delivered to them.

Comments that these people made included, "I am quite happy in here, I get good food and am well looked after. I could not manage on my own" and "Excellent staff in here, you only have to ring if you want anything, the bell is answered quickly. I have my own TV and record player, I like to listen to music. I am treated kindly and with respect, what more could you want. I am quite happy inhere. I like my food in my own room and there is no objection to that."

One person we spoke with did raise concerns around the consistency in the standard of care delivered from staff. They said, "The two best in here are X and Y, nothing is a trouble for them to do for me. Well, the others, it is just a job for them, there is no love from them. Some days I am happy but I have cried inwardly."

At our last inspection in May 2013 we found that care records did not always provide sufficient information to ensure care was delivered appropriately and effective systems in place to assess and monitor the quality of the service. Since the inspection in May 2013 we have received information of concern about nutrition, staff support, staff attitude and peoples safety we looked at these issues during the inspection.

On the day of our visit there were sixteen people living at the home. We saw that improvements had been made to the care plans; however we saw areas of concern in relation to record keeping.

We looked around the home and saw concerns about potential fire risks and the state of decoration in the environment.

We found that the home was clean; however areas identified in the last infection control audit had not been rectified.

We saw that people were safeguarded form abuse and staff had a good understanding of safeguarding. We saw that people had access to suitable equipment which had been checked regularly to ensure it was safe to use.

We found that staff had access to a range of training however we could not find evidence that staff received support in the form of appraisals or supervision.

We looked at how the service assessed and monitored the quality of the service since our last visit and saw that some improvement had been made.

During the inspection we spoke with seven people who used the service. They told us they were treated well, the staff were very good and the food was good. One person said, “The staff are always helpful they have a nice attitude and are caring.”

We also spoke with the manager, assistant manager and two members of staff. We saw that there was a friendly and relaxed atmosphere between people living and working at Germania House. We saw that the staff treated people with respect and gave them choices.

We saw that people’s likes and dislikes were taken into account in the assessment and care planning process. We saw that people were assessed and individualised care plans had been developed. We found that not all of people’s needs had been assessed and suitable care plans developed.

We saw that people had their needs assessed and that care plans were in place. However we found that people's needs had not always been met.

We found that in each care record a clear record of communication was kept with other health professionals.

We found there were appropriate arrangements in place to ensure a suitable skill mix and adequate staffing levels.

We found that appropriate systems were in place to ensure the safe use and management of medicines.

We found that there were not appropriate systems in place to monitor and review the quality of the service.

We spoke with six people who use the service. They told us they were treated well, the staff were nice and they felt safe at the home. One person said “I am in the best home.” Another person told us the home was “Very good, I have no grumbles” and “The staff are friendly and helpful.”

People who use the service told us they liked how the home was decorated and one person said they were pleased that they had their own furniture in their bedroom.

People who use the service told us that a number of activities were carried out. However some people said they did not participate in these through choice or due to their illness.

We saw 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.

This inspection took place on 16, 20July 2015 and 21 August 2015. The first day was unannounced which meant the staff and provider did not know we would be visiting. The provider was informed we would be returning for the second day of inspection. On the third day the provider was unaware that we would be visiting and we commenced the visit at 6 am.

Germaina House can provide accommodation for up to 18 people who need require help and support with personal care. The service is made up of two large Victorian mid-terraced houses which have been converted in a residential area of Redcar. There are stair lifts on each set of stairs to assist people to the upper floors. One the first two days of our inspection there were 17 people living at the service; on the third day of our inspection there were 15 people living at the service.

The registered manager has been registered with the Care Quality Commission since October 2010. 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 previously inspected Germaina House in June 2014. At that inspection we found the service was not meeting all the standards which we inspected. We found that infection control and prevention procedures were not always carried out appropriately. The boiler was in the process of being repaired and was accessible to people who used the service which meant they were at risk of harm. Staff training, supervision and appraisals were not up to date. There were gaps in the records.

At this inspection we found that safeguarding alerts had been recorded and investigated by the registered manager. Not all staff understood their roles and responsibilities when dealing with a potential safeguarding alert. Safeguarding training was not up to date; this meant staff did not have the necessary knowledge and skills to deal with a potential safeguarding alert.

Risk assessments for the day to day running of the service were in place but a fire risk assessment had not been updated regularly. This risk assessment should have been updated each year. This meant that we did not know if the risks to people around fire safety were still relevant. Some people had person specific risk assessments in place however some people did not, for example a person at risk of falls did not have a falls risk assessment in place. This meant the service had not assessed the risks to the person and had not put measures in place to reduce their potential risk of harm.

Fire drills had not been completed; however on the second day of our inspection we saw the registered manager had completed a fire drill with staff. The administration office was cluttered with boxes and paperwork piled on top of one another. This posed a potential health and safety risk to people and staff.

Staff employed at the service did not wear a name badge. Some people did not wear a uniform. This meant that we did not always know if people were employed. We also did not know what people’s designated roles were.

Certificates for equipment and for the health and safety of the service were in place.

Some people required the care and support of two staff at all times. There were enough staff on duty throughout the day to provide this. At night we found that the one waking member of night staff could not facilitate this. People told us that their buzzers were not always answered and impacted upon their dignity because they could not always get to the toilet when they needed to.

People told us they needed to wait for the day staff to come on duty before they could get up because there were not enough staff on duty during the night. On the third day when we visited early in the morning we found that although the registered manager had previously acted as a sleeping night staff due to our raising concerns about the staffing levels they had acted as a waking night. We found that they were working as waking night staff and then undertaking the management role during the day.

We also found that despite the registered manager having some mobility difficulties no consideration had been given to either the level of support they may need to provide to people overnight or the risks this might poise. We discussed our concerns at length and the registered manager agreed to provide two waking night staff and not to undertake this role themselves. We confirmed that this change to the rota had occurred.

Each week, a member of staff not trained in medicines worked at night. If people required medicine throughout the night they had to alert the registered manager [sleeping night member of staff]. This meant there was a delay in people receiving their medicine at night if needed.

Good procedures were in place for managing medicines. Only staff who had been trained could handle and distribute medicine to people. Medicine records had been completed and topical cream records provide details about when and where to apply creams.

There were gaps in the provision of infection control and prevention at the service. Infection control training was not up to date, there were not always enough supplies of hand washing equipment available and some floors, vanity units and shelves displayed bare wood which meant they posed a risk to infection prevention and control. We found that the registered manager took action when these concerns were highlighted during our inspection.

There were gaps in supervision and appraisal. Supervision was not carried out regularly [as identified in the service’s policy]. We could not be sure about the effectiveness of the supervision which staff were receiving. Most staff [18 out of 23] had not received an annual appraisal. This meant staff were not receiving the guidance and support needed to carry out their roles.

Training was not up to date. Care staff did not have person specific training, such as Dementia and Parkinson’s Disease or training appropriate to the environment which they worked in, such as Mental Capacity Act and Deprivation of Liberties Safeguards. Staff were not aware of their roles and responsibilities to determine whether a person was capable of making a decision.

People spoke positively about the food and hydration which they received. However there was no choice of meals readily available at mealtimes provided at the service. People were supported to put on weight when needed and staff understood the action they needed to take if people lost weight consistently. We could see that people’s general practitioner and a dietician would be involved when needed.

Apprentice staff often worked unsupervised. From our observations, they did not appear to know the people they were caring for.

Consent forms for photographs had been signed but not dated which meant that we did not know if they were relevant. One person had refused a ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) certificate to be put in place; however we saw this person had this certificate in their care records. In another person’s care records we could see that they had refused an influenza vaccination but records showed this person had been given one. This meant we did not know if this person had consented to this.

The door at the service was locked which meant that people could not leave when they wanted to. People’s consent for this had not been sought and a risk assessment had not been carried out. Some people did have a Deprivation of Liberties Safeguard in place; however this locked door had been in place prior to this safeguard. This meant there was a breach to people’s human rights.

People gave mixed views about their relationships with the staff team. We could see that staff [who had worked at the home for some time] knew people well and were aware of their individual needs. Staff told us they enjoyed working at the service.

There were significant gaps in the care records. Records were not personalised and reviews did not contain the information needed to provide the most up to date care and support for people Reviews did not always show who had been involved in making decisions about the people they related to.

People’s privacy and dignity were not always maintained. We did see staff knocking on people’s doors but we also witnessed personal care being given when a door was left open. Equipment needed to support people was not returned to them in a timely manner or was not always accessible to people, for example, commodes taken for cleaning were not returned promptly or were not in the places people needed them to be.

There was a lack of activities taking place in the home and people told us they did not get to go out when they wanted to. We food that some people spent the majority of their time in their own rooms which increased the risk of isolation to people.

A complaints policy was in place and we could see the action which would be taken if a complaint was made. At the time of our inspection nobody had wanted to make a complaint.

The staff team were supportive of one another. They all described feeling ‘happy’ in their roles at the service. We did see that there was no strong leadership at the service. Roles were not defined which meant that some people carried out tasks outside of their designated roles. Tasks were carried out on an ad-hoc basis which meant some tasks were missed. There were no quality assurance process in place such as audits, surveys or meetings with people, their relatives and staff.

Following our inspection we spoke with the Local Authority Contracts and Commissioning Team to discuss our findings. Following this, we raised a number of safeguarding alerts [which are detailed within the main report].

When we visited on the third day we found that the provider had taken very serious note of the concerns that had been raised. They had employed two additional members of staff, one of whom was a very experience senior staff member. We found that this senior member of staff clearly understood the requirements of the regulations and was making very positive changes to the way the service delivered care. They told us that the provider and registered manager had given them full automony to make any changes they deemed necessary. We found that they had created a new care record format and this was seen to assist staff maintain accurate and up to date information about the people who used the service and their needs.

We found six breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the premises and equipment and records. You can see what action we told the provider to take at the back of the full version of this report.