We inspected Greensleeves on 5 and 6 March 2018. The inspection was unannounced. We previously carried out an inspection at Greensleeves in January 2017 where we found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found aspects of the service were not safe due to lack of window restrictors. Sensors and monitors to keep people safe had not always been plugged in to alert staff. Staff had been observed entering the kitchen without appropriate personal protective equipment. The quality assurance system had not ensured that there were robust systems in place to monitor the quality and safety of the service.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had made improvements and confirm that the service now met legal requirements. We found some improvements had been made however not in all areas. In addition we identified further areas that needed improvement and other areas need to be fully embedded into practice. We found there was a continued breach of Regulation’s 12 and 17.

This is the second time the service has been rated Requires Improvement.

Greensleeves 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. Greensleeves provides accommodation and personal care for up to 11 older people living with a learning and/or physical disability. Some people were living with the early stages of a dementia type illness. At the time of the inspection there were 7 people living there.

The manager was aware of Registering the Right Support and other best practice guidance. They were working towards ensuring the service developed in line with these values. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

There was no registered manager at the service. However, there was a manager working at the home and responsible for the day to day running of 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.

Since the previous inspection there had been significant changes at provider level and at the home. There was a new chief executive officer (CEO) at the provider. This person had also become the nominated individual. A nominated individual (NI) is the responsible person within the organisation. The registered manager had also left the company and there was a new manager working at the home. The NI and manager had found quality assurance systems to identify shortfalls had not been in place. They identified many areas that needed to be improved across the home. Both for people and for staff. An audit had been commissioned by an external consultant and identified a large number of improvements were required. However, the audit had not identified all the issues we found. This included a legionella risk assessment had not been undertaken since 2016 and gas and electrical servicing, both required in 2017, had not taken place.

Medicines were not always managed safely because protocols for people who had been prescribed ‘as required’ medicines were not always in place. Cream charts for people who had been prescribed body creams had not always been fully completed.

Record keeping was not always accurate and was not appropriately analysed to assess the quality of care provided. The manager had identified improvements were needed to ensure people were supported to take part in a range of meaningful activiti

The inspection took place on the 4 January 2017 and was unannounced.

Greensleeves provides accommodation and personal care for up to 11 people living with a learning and/or physical disability. At the time of the inspection there were 11 people living at the service.

There was a registered manager in post who had been registered with the CQC since March 2015. 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.

The service was last inspected in April 2014 and was found to be meeting the standards required.

During the inspection we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Window restrictors on the upper floors were not in place which meant that people were at risk of falling from height. This was in contravention of guidance issued by the health and safety executive (HSE). Following the inspection the registered manager confirmed that window restrictors had been put in place.

Appropriate measures were not always taken to keep people safe. Equipment provided was not used appropriately to monitor a person’s safety or health condition. This placed a person at risk of injury or harm.

There were examples where staff entered the kitchen without using the appropriate personal protective equipment (PPE). This presented an infection control risk and placed people at risk of harm.

During the inspection we also identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because quality monitoring audits were not being completed regularly, and had not identified issues relating to the safety of the environment.

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

People were protected from the risk of abuse. Staff had completed training in safeguarding adults and were able to recognise the signs of abuse. The registered provider had a safeguarding adults policy in place which supported staff to take the correct action.

Recruitment practices were safe and helped ensure that people of unsuitable character were not employed. Staff had been subject to a check by the disclosure and barring service (DBS). The DBS inform employers if staff have a criminal history or are barred from working with vulnerable people.

People were supported to take their medicines as prescribed. Staff signed medication administration records (MARs) to show that this had been done. Medicines were stored securely and room temperatures were monitored to ensure that these did not become too hot or too cold.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice Staff had received training in a number of areas including the Mental Capacity Act 2005 (MCA). Staff were aware of their roles of responsibilities in relation to the Act and worked to promote people’s choice and independence. The registered manager had applied for Deprivation of Liberty Safeguards (DoLS) where necessary, to ensure that any restrictions placed upon people were done so within the law.

People had been supported to access input from health and social care professionals such as their GP and social worker. This ensured that people’s health and wellbeing was maintained.

Staff were kind and caring towards people. Positive relationships had developed, and people appeared comfortable in the company of staff. People were treated with dignity and respect and their confidentiality was maintained.

People’s care records contained relevant and up-to-date information around what staff should do to sup

In this report the name of the registered manager is Mrs. Clara Bharmal. This person was not in post and was not managing the regulatory activity at this location at the time of the inspection. Their name appears because they were still registered as the manager on our register at the time.

We carried out this inspection to look at the care and treatment that people living at the home received. At the last inspection on 10 and 15 May 2013 we found that there were inconsistencies in the care plans and associated documentation, and that they did not reflect the care and support provided. We found at this inspection that these issues had been addressed.

We spoke with all of the people living at the home. However, some people were not able to tell us about their experiences of living at Greensleeves, because of their complex needs. People told us they were very comfortable, they liked the food and felt the staff looked after them very well. One person said, “I am really happy here. I can do what I like, and they look after me”.

We spoke with three care staff, the cook, the maintenance person and the manager. We reviewed two care plans and associated documentation; looked at training records and relevant policies and procedures.

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Is the service safe?

We found that during our inspection people were safe; their rights and dignity had been respected. People told us they felt safe.

Systems were in place to ensure the management and staff learned from events, such as incidents and concerns, and the issues identified at the last inspection had been addressed.

The home had appropriate policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, and all staff had attended training. There was evidence that staff had taken action when they had concerns, an application had been made to the local authority for a mental capacity assessment.

Is the service effective?

We found that during our inspection the service was effective. People’s health and social care needs had been assessed, and they had been involved in this process, with the support of relatives or representatives.

People told us the staff supported them to do what they wanted, and staff looked after them very well.

Is the service caring?

We found that during our inspection that the service was caring. We saw that people were supported by kind, patient staff, who encouraged people to make decisions about how they spent their time.

People’s preferences and interests had been recorded, and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

We found that during our inspection that the service was responsive. A range of social and educational activities were available for people to participate in if the wished.

We saw evidence that when people’s needs had changed, the manager had made appropriate referrals to outside agencies.

Is the service well-led?

We found during our inspection that the service was well led. The home worked well with other agencies and services to ensure that people received the support they needed.

A quality assurance system was operated by the provider, which identified and addressed any shortcoming. As a result a good quality of service was maintained.

Staff we spoke with were clear about their roles and responsibilities. They had a good understanding of the needs of people who lived at the home and they said the management were supportive; if they had any concerns they could raise them at any time.

We used a number of different methods to help us understand the experiences of people using the service, because some had complex needs which meant they were not able to tell us their experiences. However those who could told us that their home was lovely, they were very happy living at Greensleeves and that the staff were very good.

People who spoke to us said that they enjoyed the activities and liked the changes that had been made in the garden.

People told us that Greensleeves was “a wonderful place to live” and that the staff were “lovely” and that they “look after me well.” One person said “I’m happy here, it’s nice.” People told us that they liked the food and that they get to spend time doing the things they enjoyed. People informed us that staff support them with their healthcare appointments and ensure “that I am keeping well.”

In this report the name of the registered manager is Mrs. Clara Bharmal. This person was not in post and was not managing the regulatory activity at this location at the time of the inspection. Their name appears because they were still registered as the manager on our system at the time.

We visited Geensleeves and were introduced to the all of the people who lived in the home, and we spoke with nine people. We used a number of different methods to help us understand the experiences of people who used the service. Some people had complex needs, which meant they were not able to tell us their experiences. We looked at a range of documents, spoke with four care workers, the cook and the manager.

People we spoke with told us they were very happy living at Greensleeves. One person said, "They look after us very well".

We reviewed the procedures for protecting vulnerable people. Staff had attended the relevant training.

We examined the systems for the management of medicines. We found that the system had been reviewed and changes made to ensure people were safe.

We looked at staff rotas and training records. Staff told us there were enough staff working in the home and they had received relevant training.

We looked at care plans, handover sheets, medical and incident records and some of the home's policies and procedures. We found that overall the information recorded needed updating and some of the policies did not include current guidance for staff.