Hadrian House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 44 people living with physical and mental health related conditions were using the service.

This unannounced comprehensive inspection took place on 13 and 14 February 2018. This meant that the staff at Hadrian House did not know we would be visiting the home. At the last inspection in November 2017, we identified breaches of regulations which related to safety, person-centred care, complaints, staffing, fit and proper persons employed and governance of the service. We asked the provider to take action to make improvements. We found significant improvements had been made at the service to ensure compliance with all of the statutory requirements.

The registered manager who was in post had been present at our last inspection. They were on annual leave when we arrived to inspect the service but returned to work the following day. 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.

Initially we spoke to the deputy manager about the service as they were in charge of the home when we arrived. They told us that they felt the service was running well and a lot of improvements had been made.

We carried out observations throughout the whole home and found that considerable improvements had been made to the safety, cleanliness and governance of the service. All of the immediate concerns we highlighted at our last inspection had been addressed and consequential actions had been promptly taken and were monitored by senior staff members or the senior management team.

Prior to our inspection, we reviewed an action plan which has been shared with us, the local authority and the Clinical Commissioning Group (CCG). We saw all of the actions had been completed or on-going progress was being made. At this inspection, we found the necessary evidence required to demonstrate all of the progress which had been made.

People told us they felt safe living at Hadrian House and with the staff who supported them. Relatives confirmed this. Staff demonstrated that they were aware of their responsibilities with regards to protecting people from abuse through discussions with us and the completion of suitable training. Policies and procedures had been reviewed by the provider to ensure they were current and reflected best practice in order to effectively support staff in their roles.

Care plans included risks which people faced in their everyday lives. Thorough assessments of these risks and how to reduce them were now properly recorded in the care records which enabled staff to care for people safely.

The registered manager undertook periodic assessments of people’s needs to determine staffing levels. This meant that as people’s needs increased, staffing levels were evaluated and increased if necessary in order to adapt and respond to people’s changing needs. There were enough staff on duty at the service, and the registered manager now ensured they were deployed appropriately throughout the service, particularly at mealtimes when the demand for more one to one support increased. There continued to be a shortage of permanent nursing staff, however the registered manager had ensured the continuity of agency nurses and the provider had rolled out a strategic recruitment plan to attract permanent staff into these roles.

Staff recruitment continued to be safely managed and checks were in place to ensure staff were of good character and suitable to work with vulnerable people. Supervision mee

Hadrian House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 47 people with physical and mental health related conditions were using the service.

This unannounced comprehensive inspection took place on 21 and 22 November 2017. This meant that neither the provider nor the staff at Hadrian House knew we would be visiting them.

At the last inspection in March 2017, we identified breaches of regulations which related to safety, consent, dignity, staffing and governance of the service. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring, responsive and well-led to at least good. We found improvements had been made in some areas but not enough to ensure compliance with all statutory requirements.

This is the second consecutive time that this service has been rated 'Requires Improvement'.

The registered manager had been in post for six months and had recently become registered with the Care Quality Commission on 3 November 2017. 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 registered manager of the service attended most of the inspection. The head of compliance was also present.

We undertook an initial conversation with the registered manager and the head of compliance to ask them about the actions which had been taken to address the previous issues. We also carried out initial observations around the home. Whilst we found some action had been taken to make improvements, we judged that audits and checks on the service were still not robust enough to ensure compliance with all regulations. Several concerns were raised at this inspection which demonstrated that the actions required had either not been wholly addressed or had not been properly implemented and monitored.

During our inspection, the registered manager and the head of compliance were able to take some immediate action to rectify issues which we drew to their attention.

An updated action plan was sent to us by the head of compliance in September 2017 which showed that most actions were completed and that any outstanding actions had a defined target date of 30 October 2017. The head of compliance told us that they “had made tremendous progress in the home.” We did not find sufficient evidence to corroborate this statement. Although the registered manager and the head of compliance had conducted audits, they had not been consistently or comprehensively carried out and they were not robust enough to identify or fully address the continued issues we highlighted during this visit. Audits completed did not always describe the outcomes of the problems identified and most audits did not contain an action plan.

The newly registered manager had not had sight of our warning notices which were issued to the provider in April 2017. They had also been required to cover a significant number of shifts as the ‘nurse on duty’ due to staff shortages. We considered that this had seriously impacted on their ability to carry out their own managerial duties and fully understand the seriousness of the concerns we had.

We found record keeping continued to be poor. Although every care plan had been re-written we noted that this had been done with a clinical slant and staff had not provided a holistic approach to people’s needs. Social, cultural, religious and spiritual needs had either been overlooked or vaguely addressed. Operational records related to act

Hadrian House is a residential care home in Wallsend, North Tyneside. It provides accommodation, personal and nursing care for up to 50 older people who may also have physical and mental health related conditions. At the time of our inspection the home was at full capacity.

This unannounced comprehensive inspection took place on 10, 14 and 15 March 2017. This was the second rated inspection of the service since its registration with the Care Quality Commission (CQC) in May 2011. We previously inspected the service in May 2016 and rated the service as ‘Good’, however at that time we identified one breach of the regulations which related to the management of medicines.

A registered manager was in post and this manager had not changed since our last inspection 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.

We initially looked at how the service managed medicines. We found that the service continued to fall short of expectations and this led us to conduct another fully comprehensive inspection. We saw that PRN and topical medicine protocols were still not in place for each individual person and medicine care plans were not up to date or accurate. We also saw multiple examples of medicine administration records (MARs) which continued to contain gaps in the recording of administration without a corresponding explanation. Therefore, we could not be certain that people had received their medicines appropriately and as prescribed. Additionally we found concerns around the receipt, storage and disposal of medicines.

The governance of the service was not thorough and effective. Following our last inspection in May 2016, the provider and registered manager had not returned an action plan to CQC as requested as part of the requirement notice which was served to them in relation to the breach of regulation 12, safe care and treatment. Neither had they drafted their own action plan to address the shortfalls in the management of medicines which we identified. This meant those shortfalls had not been addressed when we visited on 10 March 2017.

Internal audits and monitoring of the service had taken place however this had not been robust enough to identify the issues we highlighted during our inspection. The provider had recently made changes throughout the senior management team and they told us about the improvements they planned to make regarding governance and oversight of the service. Following this inspection, the senior management team sent us an internal action plan to tell us how they planned to immediately address the shortfalls throughout the service.

Overall staff morale was low and there were differing opinions from staff about the leadership of the service. Some staff told us they felt supported by the management team and had received regular supervision and appraisal. Staff supervision and team meetings had not been held as often as planned however some staff told us they felt able to approach the registered manager whenever necessary. Equally there were some staff who felt undervalued by the management.

A robust induction programme such as the ‘care certificate’ had not been fully implemented at the service and because of this; some staff had not had their competency assessed against the minimum standards which are expected. Formal ‘on-the-job’ competency checks of experienced staff were not conducted. Training which the provider deemed mandatory had not always been refreshed in line with the targets they had set themselves and specific training to meet the needs of the people who used the service such as dementia awareness and challenging behaviour was not routinely arranged. This meant the provider and registered manage

This inspection took place on 11 and 17 May 2016 and was unannounced. A previous inspection undertaken in July 2014 found the home to be fully compliant with legal requirements.

Hadrian House is located in North Tyneside and is registered to accommodate up to 50 older people, some of whom are living with dementia. Accommodation is provided over three floors with the second floor having some adaptation to support people living with dementia. The home was full at the time of the inspection.

The home had a registered manager who had been registered with the Care Quality Commission since January 2016. 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.

Staff were aware of the need to safeguard people from potential abuse and had a good understanding of safeguarding issues. They had received training in relation to this area and were able to describe the action they would take if they had any concerns. There had been 12 recent safeguarding alerts at the home; the majority noting low level concerns. The home had worked with key agencies around these safeguarding events.

Risk assessments were in place both in relation to the wider operation of the home and linked to the individual needs of people using the service. Regular checks were made on fire and safety systems to ensure they worked effectively. Equipment was checked to ensure it was safe to use. Window restrictors were initially found to be noncompliant with the guidance issued by the Health and Safety Executive, but were fully rectified before the inspection had concluded.

People told us they did not have to wait long for support and help and said they felt there were enough staff at the home. The manager told us she had recently introduced a range of new shift patterns to ensure that maximum staffing was available at key times, such as when people were getting up or going to bed. Suitable recruitment and vetting procedures were in place for new staff.

We found some issues with the safe and effective management of medicines at the home. There were gaps in the recording of medicines and some people receiving “as required” medicines did not always have appropriate care plans. The recording of topical medicines (creams and lotions) was not robust, with records not detailed or incomplete. This meant we could not be certain these medicines had always been given correctly.

Staff told us they had access to a range of training and updating. Records showed that a system was in place to monitor training at the home and ensure it was up to date. Additional training was available to further enhance staff skills. Staff told us, and records confirmed regular supervision and annual appraisals took place.

People told us meals at the home were good and they enjoyed them. Alternatives to the planned menu were available. There was good access to a range of drinks. Staff supported people with their meals appropriately and in a dignified manner. Kitchen staff demonstrated knowledge of people’s individual dietary requirements. People’s weight was monitored and there were regular reviews of people’s nutritional needs.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. Where necessary applications had been made to restrict people’s freedom under the MCA. Staff understood the concept of acting in people’s best interests and the need to ensure people made decisions about their care. Records showed people had provided their consent or that best interests decision had been made. The provider had notified the CQC ab

At the time of the inspection there were 48 people living at the home. Due to their health conditions and complex needs not all of the people were able to share their views about the service they received. During our visit we spoke with six people who used the service and observed their experiences. We spoke with the manager, six care staff and two relatives.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five 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?

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, their relatives, staff supporting them and from looking at records.

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

Is the service safe?

Care records contained risk assessments and instructions on how these risks should be managed. For example, moving and handling and preventing falls. They also contained personal evacuation plans in the event of an emergency.

Systems were in place to make sure that management and staff learnt from events such as accidents, complaints, concerns and investigations. This reduced the risks to people and helped the service continually improve.

The CQC monitors the application of the Mental Capacity Act 2005 and operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS is a legal process used to ensure that no one has their freedom restricted without good cause or proper assessment. There was a policy in place related to people's mental capacity and deprivation of liberty safeguards. Records showed, and staff told us, they had received training on this. There was evidence to show that mental capacity assessments and deprivation of liberty checklists had been completed.

Is the service effective?

The staff we spoke with were able to describe the individual needs of the people they cared for and how these needs were met.

People's health and care needs were assessed and the care plans provided staff with information about how each person's care needs should be met.

The service worked well with other agencies and prompt referrals were made to health care professionals which helped ensure people's health care needs were addressed.

People were provided with a choice of suitable and nutritious food and drinks to meet their needs. People told us they enjoyed the food served to them. Comments included, "Very good food, very good indeed" and "The food is good, I enjoy it." The chef was aware of special diets which people required and had completed training in nutrition for older people.

Is the service caring?

We spoke with six people who used the service and their comments included, "I have a lovely room and the staff are very nice," "This is a nice place" and "The staff are very nice to me."

We spoke with six relatives who were visiting the home. They told us they felt their relatives were well looked after. Their comments included, "My mother has been at the home for three years and during that time she has been well looked after and they never hesitate to contact me if there is anything they need to tell me" and "I can't fault the care that my Mam receives.

We observed the interactions between staff and the people they cared for. We saw staff interacted well with people and were attentive and sensitive to their individual needs.

Is the service responsive?

There was a complaints procedure displayed in the home and each person was provided with a copy of this. A complaints book was maintained to record any complaints received in the home and the outcome of the investigation.

We saw prompt referrals were made to health care professionals when required and appropriate training was provided for the staff to help meet individual needs.

Is the service well-led?

The manager of the home was registered with the Commission and there were systems in place to monitor the quality of the service people received. People were asked their opinion of the service and meetings were held every month to discuss day to day issues in the home.

The manager and designated staff carried out regular audits which included medication, care records, infection control and environmental safety and security. The quality assurance manager also carried out audits every month to ensure standards were met and any improvements were implemented.

The people who lived in the home, their visitors and the staff told us the manager was very approachable if they had any concerns or suggestions and she respected their opinions.

Owing to their condition, most people were unable to tell us their experiences of the care and support they receive, but one person who could said, “It’s always nice and clean, I like it here, I settled in very easily.”

The manager told us that following a flood in June 2012, extensive building repairs to the premises had been undertaken and we saw these were almost completed.

Relationships between staff and people were clearly good. People and relatives told us and we saw in practice, staff treated them with respect and helped them to remain as independent as possible.

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke with were positive about the care and support people received. One relative told us, "It's a privilege to see how well people are looked after and cared for."

We found that the provider had suitable arrangements in place to manage medicines.

People were complimentary about the staff. One person told us, "We have found nothing but help from all the staff here. Me and my family haven't any concerns whatsoever." We concluded appropriate checks were undertaken before staff began work and effective recruitment and selection processes were in place.

We saw that people’s personal records, staff records and other records relevant to the management of the home were accurate and fit for purpose.

We spoke with six people and two relatives to find out their opinions of the service. Comments from people included, “It’s lovely here” and “The staff are kind.” One relative told us, “Marks out of ten, they’re fairly well up there.”

Following a flood in June 2012, the basement of the home which included the laundry, kitchen and staff room was being repaired and refurbished. The kitchen had reopened in December 2012. The manager explained that prior to December, meals on wheels were provided. She said that these had proved unpopular with people who lived there. We looked around the kitchen and spent time with people during lunch and tea and concluded that people were provided with a choice of suitable and nutritious food and drink.

We found that people who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We concluded that the provider had secured high standards of care by creating an environment where clinical excellence could do well.

Some of the people using the service were unable to tell us about their experiences of living at Hadrian House. However, some people told us they are happy with the care and support they receive at the home.

We did not speak directly with people living in the home about their medicines.

Although this report confirms that the provider has complied with a compliance action we set in relation to Outcome 9 (Medicines), the outstanding compliance and improvement actions detailed below concerning outcomes 1, 2, 4, 5, 7, 12, 13, 14 and 16, will be checked at a later date.

People using the service, and their families, told us that they were generally satisfied with the quality of care and treatment they received.

People said the following about the care;

"We are very satisfied with the care."

"We are happy with the care but we are worried that having fewer nurses around will affect things."

"We get enough to eat and drink, I sleep well, the staff are nice to me."

People said the following about staffing;

"I worry that the staff will cope, people are very dependent on this floor."

"The staff are very good, I hope they don't get overworked."