This inspection took place on 28 and 29 August 2018 and was unannounced.

Green Heys Care Home is registered to provide nursing and personal care for up to 39 people. At the time of the inspection there were 30 people living at the service. Green Heys is a purpose built single story building set in pleasant grounds and situated in a residential suburb of Liverpool. The service consists of two units and provides care to older people living with dementia. It has a large dining room, two lounges and areas of seating located in both units. There is a large family room equipped with a small kitchenette. People's visitors are able to stay over if so required. There is a pleasant garden area with outdoor seating and a sheltered area.

Green Heys 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.

At the time of our inspection a registered manager was in post. A registered manager is a person who has registered with 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.

At the last inspection in January 2018, the service was found to be in breach of ‘Safe, Care and Treatment’ which was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities Regulations) 2014. This was because systems in place to manage topical medications and controlled drugs were not being properly managed. During this inspection we checked to see if improvements in these areas had been made and found that they had.

At this inspection, we found the service to be in breach of 'Good governance,' which was a breach of Regulation17 of the Health and Social Care Act (Regulated Activities Regulations) 2014. This was because audits did not identify all of the concerns highlighted during this inspection. People’s care records had not always been amended and updated to reflect their current health care requirements. For example, advice from external healthcare professionals had not always been incorporated into the main care plan and people’s care records did not always record consistent information. We also found that people’s personal emergency and evacuation plans (PEEPs) did not contain sufficient information. This meant that people were potentially at risk of exiting a building unsafely in the event of an evacuation or an emergency. We spoke to the registered manager about this and at the time of writing our report, the necessary work had been taken to rectify the information in people’s care records and PEEPs.

We found that the recording of thickened fluids was not managed safely. Thickened fluids are used to reduce the choking risk for people with swallowing difficulties. We found that although Medication Administration Records (MARs) were in place for thickened fluids, the use of thickened fluids were not recorded on people’s input charts. We spoke to the registered manager about this. They amended the fluid input charts so that care staff were able to correctly record the use of thickened fluid. The registered manager implemented this change on the second day of our inspection.

During our inspection we found the environment to be in some need of refurbishment and decoration. Feedback from people living at the service and their relatives, about the cleanliness of the service, was that standards could be improved. We found that improvement was also needed in order to adapt to the needs of people living with dementia. We discussed this with the registered manager who told us about their plans to improve the environment in terms of cleanliness and decoration. You can see what action we asked the provider to take at the b

The focused inspection took place on 8 January, 2018 and was unannounced.

Green Heys Care Home is a large care home, registered to provide general nursing and personal care for up to 47 people. At the time of the inspection there were 36 people living at the 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.

The home is a purpose built facility with all accommodation located on the ground floor. There are two units within the home; Blundell unit and Molyneux unit. Facilities include a large dining room and two large lounges. There are smaller seating areas which can be found on both units as well as a ‘family room’ which requested as and when needed.

At the time of the inspection there was 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 2008 and associated Regulations about how the service is run.

At the previous comprehensive inspection which took place in July 2017 the home was rated as ‘Requires Improvement’. Breaches of legal requirements were found in relation to ‘Safe Care and Treatment’ and ‘Need for Consent’. After the comprehensive inspection, the registered provider submitted an action plan which outlined how they were addressing the breaches in regulation which were identified.

This inspection was carried out to check that improvements to meet legal requirements had been made. The team inspected the service against three of the five questions we ask about services: is the service safe, effective 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.

During this inspection, although we found a number of improvements had been made, the registered provider still remained in breach of ‘Safe Care and Treatment’. To improve the rating from 'Requires Improvement' the service required a longer term track record of consistent safe practice and sustainability of governance. This is the second consecutive time the service has been rated 'Requires Improvement'. We will check this during our next planned comprehensive inspection.

We reviewed systems which were in place in relation to medication management. We found the systems which were in place to manage topical creams (medicated creams) were not being safely managed. We found evidence to suggest that people were not being safely supported to receive topical creams which had been prescribed.

You can see what action we have told the registered provider to take at the back of the full version of the report.

The home had partnered with an external catering company who create healthy and sustainable meals. They offered a wide range of meals which could be tailored to meet the needs and preferences of the individual. We received positive comments about the standard and quality of food which was provided. However, during our observations we did identify that the temperature of the food being provided was too hot for some vulnerable people to determine.

We recommend that the registered provider explores options which are made available to them in relation to food temperatures.

A ‘Short Observational Framework for Inspection tool’ (SOFI) was used during the lunch time period. SOFI tool provides a framework to enhance observations; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at t

The inspection took place on 4 and 5 July, 2017 and was unannounced.

Green Heys Care Home is a large care home, registered to provide general nursing and personal care for people living with dementia. The care home can accommodate up to 47 people, at the time of the inspection there were 36 people living at the home. The home is a purpose built facility with accommodation located on the ground floor. There are two units within the home; Blundell unit and Molyneux unit. Facilities include a large dining room, two large lounges, smaller seating areas which can be found on both units as well as a ‘family room’ which can be used upon request. There is a court yard in the middle of the building, complete with a water fountain as well as other smaller garden areas around the building. A car park is available to the front and side of the building.

At the time of the inspection there was no registered manager in post. There was an interim manager at the care home and a service manager had been newly recruited and was formally applying to the Care Quality Commission (CQC) 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.

At the previous comprehensive inspection which took place in April, 2015 the home was rated ‘Good’ in the safe, effective, responsive and well-led domains and ‘Outstanding’ in the caring domain. During this inspection we found a number of areas which needed to be discussed with the interim manager throughout the inspection as well as two breaches of regulation concerning safe care and treatment and the need for consent. .

The home was not always operating in line with the principles of the Mental Capacity Act, 2005 (MCA). This was because records we viewed did not demonstrate a consistent approach with regards to people’s involvement in decision making. For example, mental capacity assessments were not always completed when consent could not be sought and the records which we reviewed showed that there was a lack of understanding in relation to the MCA principles and how mental capacity assessments needed to be conducted.

We found that topical preparations (medicated creams) and thickened fluids were not safely managed. Thickened fluids are used for people with a disorder of the swallowing function; they are prescribed to help minimise the risk of choking. Staff were not following the medication administration policy which was in place. Medication administration records (MAR) were in place for all topical creams and thickening fluids, MARs were being signed by nursing staff to suggest they were administering the cream and providing the thickened fluids however it was the support staff who were then applying the creams and supporting people with their thickened fluids.

Accidents and incidents were recorded on an internal database system. All staff were able to access the database and record the details of the event which had occurred. The accident/incident report was submitted to the interim manager as well as the regional manager. The report was then reviewed, risks were identified and actions established to mitigate further risk. However there was no evidence to suggest that such accidents/incidents were being communicated with the team in the monthly team meetings. We have made a recommendation regarding this.

From the discussions we had with staff, they demonstrated that they were familiar with the support needs of the people they were caring for. Staff could explain the different levels of support which needed to be provided, specialist dietary needs of some of the people they were caring for, as well as likes, dislikes and preferences.

The day to day support needs of people living in the

On the day of our inspection, we found the home was clean, tidy, well appointed and there were enough staff on duty to meet the needs of the people living there.

We found staff were friendly, warm and respectful toward the people they cared for. In our observations of care, we found staff took every opportunity to promote dignity and choice and involve people fully when providing support. We also found staff focused on the social side of each interaction rather than the task they were performing. People welcomed the company of their carers.

Food and drinks provided met people's nutritional needs. Any person with specific dietary needs was made known to catering staff who planned meals that met those needs. In our observations of the lunch time meal, we saw people had enough time to eat their meal in a relaxed manner. Support was available from staff when needed.

Staff we spoke with told us they were happy in their work and said they felt 'part of a good team'. We particularly noted from comments made to us by staff that they felt valued by their manager. Throughout our visit we saw that all staff took a part in the daily interaction with people living at the home.

A programme of activities was available for all to take part in. Regular family and residents' meeting were held when people could share views, raise any concerns or make a suggestion on an activity or event they felt would be successful. The home had a complaints policy which was accessible to all, as well as a comments and suggestions box which people could use to raise any concern anonymously.

We spoke to people living in the home, their relatives and staff. A member of staff said enjoyed working at the home. "I feel as if I know these people. I want to care properly for them." This member of staff spoke of training they had received very recently, and how they felt supported by management. We observed staff interacting with residents in a friendly, professional and caring manner. When staff had time available, we saw them sitting and talking with the residents, who clearly enjoyed their company.

Relatives said they were happy with the care provided to their family member. A relative we spoke with explained that their family member had been recently admitted. "We were so relieved when XX came here. We visit as often as we want and we are always made welcome. They look well, we don't worry too much. We know they are well looked after here. The staff really do care."

During our inspection we noted that the day rooms and other communal areas were bright, welcoming and in good decorative order. People's bedrooms were personalised with photographs, calendars and ornaments.

Meal times were unhurried and we observed people being supported whilst eating. We asked people if they were happy with their meals, if they had enough time to eat, and if they were offered further drinks. One person said "Yes, I like the food - its actually very good. I also have supper before I go to bed."

People appeared to be supported in meeting their everyday needs.

This unannounced inspection took place on 28 and 29 April 2015.

Green Heys Care Home is a purpose built property on one level that provides accommodation and nursing care for up to 47 people who are living with dementia. Thirty nine people were living there at the time of our inspection. There are two units within the home; Blundell unit and Molyneux unit. Facilities include a large dining room located next to the kitchen and two large lounges. Smaller seating areas are located throughout the building and there is a quiet room that families can use to spend time with their relatives or to stay overnight.

There is court yard in the middle of the building and other smaller garden areas. These secure outdoor areas can be accessed from various points in the building. There is car parking to the front and side of the building. The home is located close to public transport links and local community facilities.

A registered manager was in post. 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.

Families we spoke with during the inspection said their relatives were safe living at the home. They said security of the building was good.

The staff we spoke with could clearly describe how they would recognise abuse and the action they would take to ensure actual or potential abuse was reported. Staff confirmed they had received adult safeguarding training. An adult safeguarding policy was in place for the home and the local area safeguarding procedure was also available for staff to access.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. People living at the home, families and staff told us there was sufficient numbers of staff on duty at all times.

Staff told us they were well supported through the induction process, regular supervision and appraisal. They said they were up-to-date with the training they were required by the organisation to undertake for the job. They told us management provided good quality training.

A range of risk assessments had been completed depending on people’s individual needs. Care plans were well completed and they reflected people’s current needs, in particular people’s physical health care needs. Risk assessments and care plans were reviewed on a monthly basis or more frequently if needed.

Processes were in place to ensure medicines were managed in a safe way. We observed medicines being administered safely in the dining room by two nurses. Audits or checks were in place to check that medicines were managed safely.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment and equipment. The environment had been decorated and organised in accordance with the principles of a dementia-friendly environment.

People’s individual needs and preferences were respected by staff. They were supported to maintain optimum health and could access a range of external health care professionals when they needed to.

Staff were trained and experienced in providing end-of-life care. The home had been assessed and accredited for the Gold Standards Framework (GSF) in March 2014. The GSF is an evidence based approach in end-of-life care and the national GSF centre provides training for all GSF programmes. Green Heys was the first care home in Sefton to achieve this care home quality award.

Staff worked closely with the local palliative care team, the GP and other community health care providers. They had particularly looked at the management of pain in conjunction with other health care providers. Through the use of appropriate pain relief for people who were living at the home, staff have seen a significant reduction in incidents and an improvement in people’s well-being.

People were well supported at meal times. Families were pleased with the quality and choice of food. They said their relative’s dietary needs were being met. People were weighed on a weekly basis and a weight loss of 2kg or more in a month meant the person was referred to the appropriate health professional.

Staff sought people’s consent before providing support or care. The home adhered to the principles of the Mental Capacity Act (2005). Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority.

Staff had a good understanding of people’s needs and their preferred routines. We observed positive and warm engagement between people living at the home and staff throughout the inspection. A full and varied programme of recreational activities was available for people to participate in.

The culture within the service was and open and transparent. Families described the staff as caring, respectful and approachable. They said the service was well led and well managed.

Staff and families said the management was both approachable and supportive. They felt listened to and involved in the running of the home.

Staff were aware of the whistle blowing policy and said they would not hesitate to use it. Opportunities were in place to address lessons learnt from the outcome of incidents, complaints and other investigations.

A procedure was established for managing complaints and people living at the home and their families were aware of what to do should they have a concern or complaint.

Audits or checks to monitor the quality of care provided were in place and these were used to identify developments for the service.