Green Bank provides accommodation, care and support for up to 20 people. The service provides support to older people, those living with dementia or mental health conditions, or people with long term health needs such as diabetes. At the time of our inspection 17 people were living at the home.

Green Bank is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

This comprehensive inspection took place on 30 July and 6 August 2018 and was unannounced.

Previous inspections of Green Bank had identified recurring issues around safe care and treatment and governance. The provider has been non-compliant with regulation since 2016 with repeated breaches. Following the last comprehensive inspection in July 2017, the overall rating for the service was Requires Improvement with breaches of regulation. At that time, we served warning notices to ensure people’s safety and well-being. A focussed inspection in December 2017 showed that improvements had been made and the warning notices had been met.

At this inspection, although some improvements had been made, there remained areas of concern. We found several recurring issues that were also identified at the last comprehensive inspection in July 2017. There were also shortfalls in quality monitoring and management oversight of the service. Whilst the registered manager was transparent and responsive to addressing these issues again during the inspection process, this indicated the provider had been unable to sustain improvement in these areas. We did not find these inconsistencies had impacted on the safety of people, but this failure to sustain improvement demonstrated a lack of leadership and oversight.

Green Bank had a registered manager who had been in post since October 2010. A registered manager is a person who has 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.

Quality systems and audits were in place to monitor the service people received, but did not always effectively identify areas for improvement. We found shortfalls within areas of quality assurance, which meant the provider did not always have clear oversight of some areas, such as cleaning schedules and maintenance. One person told us, “The cleaning is good on the whole” but “I’m not sure it gets done every day.” One member of staff said, “The cleaning is not always good enough.” The environment was not always well maintained.

Staff were employed using appropriate recruitment practices, though did not receive regular supervision and appraisal. Staff received essential training and were positive about the training the provider offered, but there was a lack of suitable training for staff employed in multiple roles, meaning they were not skilled and qualified to undertake some of the tasks assigned to them. There were not always sufficient numbers of staff deployed in line with the providers assessment of the needs of people living at Green Bank.

Care plans and other documentation was not always updated in line with people’s changing needs. People had access to some activities, but these were limited and not always person-centred.

People were protected from avoidable harm. There was a safeguarding policy and staff received training. Staff knew how to recognise the potential signs of abuse and knew what action to take to keep people safe. Staff told us “Any concerns, I’d raise with the manager straight away.”

Good systems and processes to keep people safe were maintained. One person told us, “Wonderful care and I feel safe.” Risks to people had been identified an

We inspected Green Bank on the 01 December 2017. This was an unannounced focussed inspection.

Green Bank 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.

Green Bank provides accommodation, care and support for up to 20 people. On the day of our inspection 16 older people were living at the service. The service provides care and support to people living with dementia, people at risk of falls and people with long term health care needs such as diabetes.

In May 2016 we carried out an unannounced comprehensive inspection at Green Bank where two breaches of Regulation were found. We undertook an inspection in July 2017 to see if the improvements made had been made and embedded into everyday practice. We found that not all improvements had been sustained: the management of medicines were not always safe and risks to people were not always mitigated. We also found that further improvements were needed to ensure management oversight of care delivery and documentation. At this time we served Warning Notices to ensure peoples safety and well-being and further improvements to the organisational audits.

We undertook an unannounced focused inspection of Green Bank l on 30 November 2017. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in July 2017 had been made. The inspector inspected the service against two of the five questions we ask about services: is the service safe and well led, This is because the service was not meeting some legal requirements. This report only covers our findings in relation to the key questions of whether the service is Safe and Well-led. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection. You can read the report from our last comprehensive inspections, by selecting the 'all reports' link for Green Bank on our website at www.cqc.org.uk.

This inspection found that improvements had been made and the breaches of regulation had been met. Whilst these improvements had been made, time was now needed to fully embed the new systems to sustain improvement. The rating over all remains 'requires improvement' as the provider needs to be able to demonstrate they can sustain into the future. This will be assessed at their next comprehensive inspection.

At this inspection there was strong managerial oversight to ensure documentation was kept up to date and ensured people received safe, effective, caring and responsive care. A range of audits had been introduced and completed monthly. When audits had identified issues there was evidence of recorded actions taken to address the issues. For example, poor recording of medicines administered had led to the further training and competencies. The management and storage of medicines were safe. The provider had implemented an electronic medicines management solution. Care documentation and associated risk assessments had all been reviewed and a new computerised care planning system was in place. Risks related to fire safety had progressed with additional training and oversight.

Accidents and incident reporting had been completed and there was management overview of audit of falls and incidents to prevent a reoccurrence. This meant measures to ensure learning and preventative measures had been taken.

People were encouraged to express their views and had completed surveys. They also said they felt listened to and any concerns or issues they raised were addressed. Technology was used to assist people’s care provision. P

We carried out an unannounced comprehensive inspection at Green Bank in May 2016 where two breaches of Regulation were found. As a result we undertook an inspection on 6 and 7 July 2017 to follow up on whether the required actions had been taken. Although we found improvements had been made, there remained areas that required improvement.

Green Bank provides accommodation, care and support for up to 20 people. On the day of our inspection 13 older people were living at the service. The service provides care and support to people living with dementia, people at risk of falls and people with long term healthcare needs such as diabetes.

A registered manager was 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.

Although people told us they felt safe living at the service we found the provider had not consistently assured people’s safety in areas related to the management of medicines. Some staff’s training on safety issues associated with fire safety was not current. The registered manager took steps to mitigate these shortfalls during and directly after our inspection. We identified potential risks associated with people using equipment designed for skin pressure areas which was not required and subsequently not being routinely checked.

Staff had an understanding of the Mental Capacity Act 2005 and were seen to act in accordance with its principles whilst supporting people. However the provider had not ensured advocacy documentation was always current so as they could be assured appropriate people were making decisions on behalf of those people who lacked capacity.

The provider had not established a robust induction system which would ensure new staff had access to essential training and learning prior to working independently.

We found an example where the provider was unable to confirm an aspect of a person’s personal care had been completed in line with their care plan. Some people who were new to the service had waited an extended period for comprehensive care plans to be designed. Although we saw activities taking place which people enjoyed the provider was not able to evidence consistency in the provision of this. The relevant staff member was awaiting their hours to be formalised and appear on the rota.

The provider had some effective systems in place to monitor and improve the quality of the service; however we also found shortfalls with areas of quality assurance which meant the provider did not always have clear oversight of areas such as medicines. The registered manager told us the high demand of their workload had begun to impact on their ability to achieve some tasks in a timely manner.

Most staff had an understanding of safeguarding; they were able to identify different types of abuse and told us what actions they would take if they believed someone was at risk. There were sufficient numbers of staff working at Green Bank to respond to people’s support needs.

People and their relatives told us staff were kind and caring and we saw many positive interactions between people and staff. There were regular light hearted exchanges between people and staff that were enjoyed.

People’s health and wellbeing was monitored and the provider and senior staff were seen to regularly liaise with healthcare professionals for advice and guidance.

The provider had a complaints policy; this was displayed in a communal area. People and their relatives told us they knew how to complain.

We found breaches in Regulation. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced comprehensive inspection at Green Bank on the 2 and 4 September 2015 where breaches of Regulation were found. We issued warning notices for these breaches and the service was placed in special measures. A warning notice includes a timescale by when improvements must be achieved. If a registered person has not made the necessary improvements within the timescale, we will consider further enforcement action.

As a result we undertook an inspection on 23 and 24 May 2016 to follow up on whether the required actions had been taken. We found the warning notices had been met. Although we found improvements had been made there remained areas that required improvement. However due to the improvements made the service has now been taken out of special measures.

Green Bank provides accommodation, care and support for up to 20 people. On the day of our inspection 14 older people were living at the home aged between 74 and 91 years. The service provided care and support to people living with dementia, people at risk of falls and people with long term healthcare needs such as diabetes.

A registered manager was 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.

Although people told us they felt safe living at the service we found the provider had not taken adequate steps to ensure people’s safety in relation to medicines and risks related to people requiring special diets. We found kitchen staff had not consistently followed basic food hygiene principles in relation to the storage of food.

Staff received training and had an understanding of the Mental Capacity Act 2005 and were seen to act in accordance with its principles; however care documentation did not clearly identify how people who lacked capacity for specific decision had been supported to reach a decision that was in their best interests.

Staff were kind and caring in their routine interactions with people however we found examples where consideration had not been given to protect people’s choices and dignity.

The provider did not have a consistent approach to managing people’s care and to responding to the needs of people who were being cared for in bed. We found examples where people’s care records were not consistently up-to-date.

The provider had some robust systems in place to monitor and drive improvements in the quality of the service; however we found shortfalls with areas of quality assurance which mean the provider did not have consistent oversight of the service.

People’s support needs had been assessed and personalised care plans developed. Care plans contained risk assessments for a range of daily living needs. However we found examples where routine reviews of care plans had not been undertaken.

Staff had a good understanding of safeguarding; they were able to identify different types of abuse and told us what actions they would take if they believed someone was at risk. There were sufficient numbers of staff working at Green Bank with the appropriate skills and experience.

Care staff were responsive to people’s changing needs. People’s health and wellbeing was monitored and the provider regularly liaised with healthcare professionals for advice and guidance.

The provider had a complaints policy; this was displayed in a communal area. People and their relatives told us they knew how to complain.

We found breaches in Regulations. You can see what action we told the provider to take at the back of the full version of this report.

We used a number of different methods to help us understand the experiences of people using the service. Due to their dementia type illnesses not all of the people who lived at the home were able to tell us about their experiences. We observed care, spoke to staff and people who were visiting the home.

People who were able to told us they were happy living at the home. One person said “it’s okay here.” Another person told us, “It’s good, very good”. One visitor told us, “staff are good” and “people seem to have so much fun.”

We observed staff talking to people. We saw that they knew people well and had a good understanding of their needs. There were care plans in place and these reflected the assessed needs of people. We saw that people received their medication appropriately and safely.

Two visitors told us they were always informed what was happening with their relative. We were told, “they tell me what has happened during the day, I always feel I know what’s going on.”

We saw that people received a choice of suitable and nutritious food and drink throughout the day.

There was a complaints procedure in place and available to people who lived at the home.

We used a number of different methods to help us understand the experiences of people using the service. Some of the people using the service had complex needs which meant they were not able to tell us their experiences. However, those we spoke with told us they were enjoying the entertainment that afternoon.

Visitors we spoke with told us that their relatives received good care. One visitor told us, “there is good continuity of care” and they went on to say their relatives care needs, “were always met.”

We were also told that staff were approachable and people felt able to raise concerns when necessary. One person told us, “if I raise a concern I see that things happen to deal with it, it’s not just left.”

We saw that the care plans were personalised and reflected the assessed need of people who lived at Green Bank.

We saw there were systems in place to monitor the quality of the care provided.

We used a number of different methods to help us understand the experiences of people using the service. Some of the people using the service had complex needs which meant they were not able to tell us their experiences. However, those we spoke with told us they were happy living at Green Bank. Four people that we spoke with told us they were bored and would like something to do. Visitors we spoke with told us that staff were kind and approachable, but they would like their relative to have more to do during the day.

People living in the home have varying degrees of dementia. Many people had significant levels of confusion and their verbal communication was limited. It was therefore difficult to gain meaningful feedback from individuals who we spoke to regarding their experiences of living in the home.

We inspected Green Bank on the 2 and 4 September 2015. This was an unannounced inspection. Green Bank provides accommodation, care and support for up to 20 people. On the day of our inspection 14 older people were living at the home aged between 73 and 90 years. The service provided care and support to people living with dementia, risk of falls and long term healthcare needs.

We last inspected Green Bank on 4 and 7 November 2014 where we found the provider was not meeting all the regulations we inspected against. We found people were not protected against risks associated with medicines. There was a lack of appropriate employment checks and a lack of accurate and appropriate records. The provider submitted an action plan which stated how they would meet the regulations. The service was rated as ‘requires improvement’ and was scheduled a re-inspection within 12 months. However the CQC received information of concern regarding the service in relation to various issues affecting people’s care and welfare and the inspection date was brought forward.

A registered manager was 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.

The provider had not protected people’s safety by ensuring there were sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed.

We found areas of the home were not clean and presented a risk to cross infection. We observed a staff member using poor infection control principles whilst handing soiled laundry.

We found people who used specialist mattress equipment to protect their skin from damage did not have these consistently set at the correct settings.

The provider had not ensured maintenance checks were up to date for aspects of the homes, for example we found portable electrical equipment that had not been tested to check it was safe.

Although there were appropriate systems in place for the safe disposal of medicines we found some concerns with the management of medicines. For example the provider had not followed best practice with regard to the management of storage and recording of medicines.

The provider had not ensured people’s safety with regard to eating and drinking. For example appropriate health care advice had not been sought in a timely manner for a person who required assistance with eating and drinking.

Although people had a choice of meals and told us they liked their food, one person referred to the food as ‘mainly nice’ we found the dining experience was not a pleasurable experience for people.

The registered manager had not met their own target for undertaking staff supervision. In the eight months of 2015 seven of the services 16 staff had undergone one supervision.

We found examples where the provider had not ensured people’s choice and autonomy had not been respected.

We found the provider had not made adequate provision to ensure people’s social needs were met. People told us they would like more to do and be involved in.

There were some quality assurance processes in place however this had not been effective at identifying the areas of concern we found, or at driving improvement in the quality of the service.

Although people and staff generally spoke positively about the registered manager, in their leadership capacity they had not identified the areas of concern we had during this inspection and there were several breaches of Regulations.

However there were several positive areas in the service. The provider ran regular training and refreshers for staff to ensure they had the skills and confidence to support people.

Staff had an understanding of the procedures and their responsibilities to safeguard people from abuse. Staff understood their responsibility in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People had access to on-going healthcare. People told us they were supported to access health professionals such as their GP when required.

People told us staff were kind and we observed positive interactions between people and staff.

People’s friends and family were able to visit freely. One told us, “I can pop in anytime, it’s never a problem.” A complaints procedure was in place and was clearly displayed in a communal corridor.

People’s needs had been assessed and all but one person had a comprehensive individual care plans and risk assessments. Although we identified some inconsistencies for some specific areas care plans in the main provided staff with a detailed picture of the care and support people required.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

There were a number of breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.