This inspection took place on 26 and 28 June 2018 and the first day of inspection was unannounced. At our last inspection in December 2016 we rated the service requires improvement. We carried out this inspection to see if the provider was meeting all legal requirements.

Kara House 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.

Kara House is a large detached home in Sale. Accommodation for people is situated over three floors. A basement area provides storage areas and offices for managers, senior staff and a staff room. There are three large lounges and a large extension provides space used as a dining area or for activities. There is access via steps and a ramp to a fully enclosed garden, with a level paved area with seating. The care home accommodates up to 39 people in one adapted building. At the time of this inspection the home was providing care and support for 32 people.

The home has a registered manager in place. 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.

Person centred care plans and risk assessments were in place. These provided guidance and information about people’s support needs, their likes, dislikes and preferences and how to mitigate any identified risks. Staff we spoke with knew people and their needs well. Care files were reviewed each month. People and their families, where appropriate, were involved in these reviews and felt well informed about care and support provided.

The home had effective systems for ensuring concerns about people’s safety were managed appropriately. A safe recruitment process was in place. Staff completed a thorough induction programme and regular checks were made on their development, knowledge and well-being in the role. Staff received refresher training on an annual basis and for staff who wanted to undertake additional on- line training in subject areas that were of interest to them these were made available.

Improvements had been made to the home. The ground floor décor was neutral in colour with photographs and pictures displayed in corridors and the service was clean and well maintained throughout.

The service was working within the principles of the Mental Capacity Act (2005). A capacity assessment tool was used and applications made for a Deprivation of Liberty Safeguard (DoLS) if a person lacked capacity. The Care Quality Commission were informed of any authorisations granted.

Staff had regular supervisions. Staff meetings were held, which were open discussions. Staff were given the opportunity to make suggestions on how to improve practice. Staff felt supported by and involved with the service.

People we spoke with expressed satisfaction with the food and drink provided in the home. They told us that meals were good and there was always plenty to eat and drink. We saw that people were consulted about the meals on offer and for new menu ideas.

There were policies and procedures in place around respecting equality and diversity, so that people were treated equally. People told us they felt included and not discriminated against.

People we spoke with were complimentary about the service. One visitor explained to us how well care workers knew their relative and how involved their family member had been in the care planning process. Staff had the preferences and wishes of people at the centre when arranging their care and support in conjunction with them.

Kara House had a complaints policy in place. Issues raised verbally had been recorded and responded to.

An activities prog

This inspection took place on the 18 and 19 April 2017 and was unannounced. The service was last inspected in February 2016 when it was rated as Requires Improvement.

Kara House is a care home registered to provide personal care and accommodation to 35 older people. At the time of our inspection there were 32 people living at the service. The home has two shared rooms, one of which two people shared.

One of the directors of the provider (Trinity Merchants Ltd) was managing the service after the registered manager had left in November 2016. They were in the process of being registered with the Care Quality Commission (CQC). 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 manager had previous experience of managing care homes registered with the CQC.

Since January 2017 a senior carer had been given additional responsibilities at the service. They were supernumerary to the shift and completed audits and updated care plans.

People received their tablets as prescribed and the medicines administration records were fully completed. However, we noted two people had been prescribed two creams, one to be applied twice per day and one three times a day, the cream charts indicated they had been both applied three times a day. Guidelines for creams that had been prescribed ‘as required’ were not in place. These were immediately changed and implemented following our inspection.

We found improvements had been made since our last inspection. An activities officer had been employed who organised regular group activities and worked with some people on a 1:1 basis. The home had been re-decorated and was now more homely, with new pictures on the walls and notice boards with reminiscence items in the hallway. Record keeping was more thorough, with the food and fluid charts now being fully completed.

A comprehensive range of audits and monitoring was in place, completed by the senior with extra responsibilities and reviewed by the manager. However these had not identified the issues we found with the cream charts and ‘as required’ guidelines. We saw issues that had been identified in the audits had been recorded and actions put in place.

All the people we spoke with said they felt safe living at Kara House and that the staff were kind, respectful and knew their needs well. We heard and saw positive interactions between people and staff members throughout the inspection.

There were sufficient staff on duty to meet people’s needs, however some people said they had to wait longer for staff to support them at a weekend.

A safe system of recruitment was in place, although the gaps in employment for one new staff member had not been explained. After the inspection the manager told us they had obtained this information. An induction process was in place where new staff shadowed experienced staff so they could get to know people and their needs. Training was arranged and staff who were new to care were enrolled on the Care Certificate. Refresher training was up to date for existing staff. 90% of staff had obtained a recognised qualification in health and social care. The manager completed staff supervisions and regular staff meetings were held. This meant staff had the training and support to undertake their roles.

Care plans and risk assessments were in place for each person. These recorded their health and social care needs and provided staff with guidance on how to support people and mitigate any risks that had been identified. Care plans and risk assessments were evaluated each month by the senior care staff and updated for any changes in people’s needs.

Handovers were held between each shift to update the staff on any changes in people’s needs or healt

This inspection took place on the 24 and 25 February 2016 and was unannounced.

Kara House Residential Care Home was last inspected on the 17 April 2014 and was found to be meeting the regulations reviewed.

Kara House Residential Care Home is registered to provide accommodation with personal care for up to 39 older people. Accommodation is provided in 33 single rooms and 3 double rooms over three floors, accessible by a passenger lift. At the time of our inspection there were 35 people living at Kara House, all in single occupancy rooms. The home is a large detached property located on the outskirts of Sale town centre.

There was a registered manager in place at the home. 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.

During this inspection we found two breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Although the overall system in place for managing oral medicines was safe, the poor information for the administration of prescribed skin creams and the lack of dates when creams had been opened placed people at risk of harm.

We found systems were not in place to demonstrate all areas of the service were monitored and reviewed. Audits completed by the registered manager had identified issues with staff not recording enough detailed information in the challenging behaviour records and that the prescribing instructions for the application of creams were not recorded on the cream charts. However action had not been taken to improve this and staff told us they were unsure of current best practice for recording written notes. The medication audit had not identified the discrepancy between the number of ‘as required’ medication held in stock and the number recorded on the monitoring sheet.

We found that nutrition monitoring charts were not accurately completed. We have made a recommendation that the service looks for a best practice solution to ensure that nutrition charts are completed accurately.

We found that the environment of the home was not following best practice for people living with dementia. We have made a recommendation that the service considers current good practice guidance in relation to planning an environment to help to promote the well-being and independence of people living with dementia.

We found that some activities were arranged with people visiting the home to conduct a chair based exercise class and a singer entertaining people. However we did not observe any activities organised by the staff team at other times of the day. We have made a recommendation that the service considers current good practice guidance and training for the activities officer in relation to the choice of activities offered to help promote the well-being of people with living with dementia, helping to promote their involvement and enable them to retain their independence.

People told us that they felt safe in the service. Staff had received training in safeguarding vulnerable adults and could clearly describe the action they would take if they suspected any abuse had taken place. People told us that the staff were always kind and caring.

The service had a safe system for recruiting suitable staff. However it had not been fully followed for one staff member where two references had not been received as required by the service’s own policy and procedure. We found sufficient numbers of staff were provided to meet people’s needs.

The home was clean and tidy throughout. Plans were in place in the event of an emergency, such as a utility failure. All equipment was found to be maintained to the ma

We considered all the evidence we had gathered under the outcomes 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?

This is a summary of what we found-

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Suitable policies and procedures were in place and staff had been trained to understand their responsibilities under the DoLS Codes of Practice. Care plans and our observation of staff provided evidence of good practice in applying the least restrictive options to promote each person's autonomy.

Staff records contained all the information required by the Health and Social Care Act. This meant the provider could demonstrate that staff employed to work at the home were suitable and had the skills and experience needed to safely support the people accommodated.

Care plans provided evidence of good risk management. For example, information in records provided evidence of staff taking prompt action to prevent a person from becoming malnourished.

Environmental risks had been assessed and the home's equipment had been subject to servicing and maintenance at regular intervals.

Is the service effective?

People living in Kara House received person centred care. This mean that staff understood and respected them as individuals and provided their care and support in line with each person's choices and preferences.

Systems for dealing with complaints, suggestions and compliments made sure that the views of people using the service and their representatives were responded to by making improvements where appropriate.

Changes made to the way care staff were deployed resulted in a reduction of falls experienced by people living in the home.

Is the service caring?

People living in the home were provided with stimulating and interesting activities each day, and care and support was in line with good practice guidelines. This enabled people living with dementia to orientate themselves to their surroundings, maintain meaningful relationships and participate in the home's activities of daily living.

During the midday meal we observed interactions between care staff, nurses and the people they cared for. We saw care staff use good observational skills to provide person-centred and compassionate care. Staff addressed people by their preferred titles and spoke with them in a quiet and calming manner to preserve their privacy and dignity. We saw staff reassuring people if they became distressed.

Three people living in the home and a visiting relative described the care and support provided as good and excellent. The relative said, "This is a really good home and the manager's door is always open."

Is the service responsive?

People living in the home had their needs assessed and their care plans told us how staff would provide care and support to meet their needs. Care plans also contained each person's choices and preferences for how their needs should be met. The people we spoke with during our visit made positive comments about the way the service was provided. They said they were listened to and consulted about the way the service was provided.

The provider had taken proactive action to access the views of people using the service and their representatives. They gave us examples of the changes they had made in response to people's views and suggestions, which demonstrated that the service was being delivered in the best interests of the people accommodated.

Is the service well-led?

The manager had embedded effective quality assurance processes to protect people living and working in the home from accidental injury and to promote their wellbeing.

The people we spoke with during our visit told us the home was managed well. A relative said "This is a really good home and the manager's door is always open." A person accommodated in Kara House told us, "It's the first time I've been here. I've settled alright and that is because the staff have made me feel welcome. They're very obliging you know." A member of the care team at Kara House told us, "The manager is fair, approachable and firm. Things get done and it's a really good home to work in. We work well as a team."

Suitable arrangements had been made to ensure people who used the service were asked to consent to the care and support they received. A person who used the service said, “We are listened to and staff always ask permission before they do anything”

Robust systems had been implemented to support people living in the home to maintain healthy weights. Three people told us they were provided with a range of food choices at mealtimes. One person commented, "We get plenty to eat and you can ask for snacks and drinks at any time."

We found the home to be clean, safe, hygienic and well maintained. At the time of our visit work was underway to redecorate the three lounges and reception area. Three people living in the home said they were satisfied the design and layout of the home was suitable for meeting their accommodation needs. One of the people living in the home said, "I can go to my bedroom when my relatives visit if I want to talk to them privately. My doctor can also see me in my room if they need to examine me."

Following our last visit the provider sent us an action plan telling us what they would do to ensure the chef and care staff received training in nutrition for people who were diagnosed with dementia. During this visit we found that the training had been completed.

Kara House had an effective system in place to monitor the quality of the service provided to people who lived in the home.

Since our last visit, systems had been put in place to develop a person centred service within the home. People living in Kara House had their rights to choice, dignity and decision making respected. One of the people accommodated told us, "Staff listen to me and take me seriously. I have everything I need and I'm happy here."

Care planning had been improved by making sure that the people accommodated had access to the healthcare support they needed, within an effective risk framework. Improvements were still needed in the way care plans were written and to ensure that people had their nutritional needs met appropriately. However, this was determined as a training need, which the provider confirmed would be met.

Improvements had also been made to the way that suspicions and allegations of abuse were identified and reported for investigation by the local authority. Two people living in the home told us that they felt safe. One person said, "I am confident that staff would protect us if anything untoward happened."

We found that appropriate numbers of night care staff had been consistently deployed since our last visit. Staff told us that they felt better supported and this had improved morale among the staff group. A person living in Kara House told us, "Staff come if you call for assistance at night."

Since our last visit action had been taken to make sure that the quality assurance system was effective. Issues found during internal audits had been managed well.

We visited this service in response to concerns that were shared with us by a whistleblower. During our visit we spoke with eight people using the service, two relatives, two managers, five members of the care team and staff from Trafford commissioning and care management.

From observing how staff interacted with the people they cared for and from comments made by two relatives, we found that their rights to privacy and dignity were being maintained. One of the relatives we spoke with on the telephone said, "I visit most days and I am very happy with the service. I have a special admiration for the young carers, who are so kind and loving. Staff are always asking me if I want to ask any questions and they let me know if they have any concerns." Not all of the eight people we spoke with were able to articulate their views on the quality of the service they received. However, several of the people were able to tell us that they felt safe and were happy living in the home.

The provider had systems in place to measure the quality of the service provided. However the systems did not always identify shortfalls, such as a person not having a care plan despite their admission several weeks earlier.

We found further concerns in relation to care planning, staffing levels during the night, incomplete records and omissions in reporting safeguarding concerns to the local authority. The provider gave assurances that remedial action would be taken in these areas.