This inspection took place on 4 September 2018 and was unannounced. The last inspection was carried out in August 2016 when the service was rated as good.

Lever Edge (Lever Edge) Care Home is a residential care home located in the Great Lever area of Bolton. Lever Edge 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.

Lever Edge, Bolton is a purpose built two storey care home. The home is close to Bolton town centre and close to a bus route and the motorway network. The home provides residential and personal care for 81 people. On the day of the inspection there were 76 people living at the home.

There was a registered manager in place. A registered manager is a person who had registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found the overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, medicines, infection control person-centred care good governance.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not, enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found a definite distinction between the ground and first floor with regard to infection prevention and control. The malodour on the first floor was unacceptable.

We found that not all medicines were managed safely and that improvements must be made to ensure people’s health was not placed at risk of harm.

Staff recruitment was satisfactory. Staffing levels needed reviewing to ensure that there were enough staff on duty at all times to ensure people’s need could be met.

There was an appropriate, up to date safeguarding policy and procedure in place. Safeguarding issues had been suitably logged with responses and actions.

The service was working with the legal requirements of the Mental Health Act 200 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Care files included a range of information relating to health and well-being. However, some specific information and monitoring had not been completed.

There was a staff induction and staff training was ongoing. Staff confirmed they received supervision meetings with

This unannounced inspection took place on Thursday 4 August 2016.

Lever Edge Care Home is a residential care home situated in Great Lever, Bolton and is registered with the Care Quality Commission to provide residential care for up to 81 people. At the time of the inspection there were 57 people living at the home. The home is divided into three areas; part of the ground floor provides residential care and support. There were 17 people living in that area. The area known as The Bungalow is also on the ground floor and cared for people living with dementia. There were 19 people being supported in The Bungalow. The upstairs floor had 21 people living with dementia being supported. The home is located on a main road and is close to local shops and transport routes.

At our previous inspection on 12 November 2015 and 09 February 2016, we found a total of 11 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found four breaches in relation to safe care and treatment, two breaches in relation to staffing and training, one breach in relation in safeguarding, two breaches in relation to person-centred care, one breach in relation to receiving and acting on complaints and one breach in relation to good governance.

The home was also placed into special measures meaning significant improvements were required, or further enforcement action could be taken. Following this inspection, the home sent us an action plan, detailing the improvements they intended to make. Until the home could demonstrate improvement and sustainability the local authority suspended placing people at the home.

At the time of our inspection of 04 August 2016, the service had an acting manager who was in the process of applying 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 inspections we identified concerns in relation to medication, staffing levels, staff training, safeguarding, responding to complaints and monitoring. During this inspection, we saw improvements across all areas had been made.

We found there were enough staff available meet people's needs in a timely manner and we saw lounge areas were not left unattended when in use.

We undertook a tour of the building and found it to be clean and tidy, with domestic staff carrying out their duties during the day.

We saw people who used the service were transferred safely into their chairs by staff, with appropriate moving and handling assessments having been undertaken.

People who lived at the home told us they felt safe. The relatives we spoke with also said they felt their family members were safe living at the home as a result of the care provided.

Staff had a good understanding of safeguarding procedures and how to report concerns.

We found appropriate recruitment checks were undertaken before staff started working at the home. These included ensuring references from previous employers were sought and either a Disclosure Barring Service (DBS) or a Criminal Records Bureau (CRB) check was undertaken.

Medication was given to people by staff that had completed relevant training. Regular audits of medication were also undertaken to ensure this was being done safely.

At our previous inspection, we had concerns in relation to staffing levels and staff training. During this inspection we saw staff had now received appropriate training to support them in their roles and staff told us they felt well supported.

We saw people received appropriate support at meal times and saw that staff encouraged and prompted people with eating as well as possible to ensure a good nutritional intake.

We saw areas of the home included adeq

We visited Lever Edge Care Home on 15 October 2013. On arrival at the home we saw breakfast being served in the dining room. We were told some people were still in bed having a lie in.

We found the home to be warm, clean and tidy. We looked on all three units and found the home to be sufficiently staffed. Staff we spoke with told us it was important to maintain good staffing levels to ensure continuity of care for people who used the service.

We saw people who used the service were well presented and we observed staff interacting with them in a friendly, polite manner and respecting their dignity and privacy.

We spoke with four people who used the service and two relatives. One person told us, “I never thought I would have to move in to a home, but it’s very nice here”. Another said, “The staff are good”. We spoke with two relatives, one told us, “I am happy with the care my X receives” another said, “It’s great, no complaints at all”.

We saw staff had access to relevant policies and procedures including safeguarding procedures and contact details. We spoke with four members of staff who told us they had undertaken lots of training which was relevant to their role.

We saw a number of compliment cards from relatives displayed on the units. Comments included: ‘As a family we can’t thank you enough for all the love, care and support you gave our X’. Another read, ‘To all the staff at Lever Edge we wish to express our heartfelt gratitude’ and ‘Thank you, our X felt loved and cared for by your delightful team’.

People said their care had been discussed and agreed with them. They said staff were kind, supportive and respectful. One person said, “The staff are always good and helpful.” Another person told us, “There isn’t a bad member of staff among them here.”

Care plans were in place and of a satisfactory standard. The care records seen were person centred and informative. They showed how the person wanted their care delivered.

Lever Edge care home was comfortable and homely and safe. People said they were encouraged to bring their personal mementoes from home. Old photographs decorated the corridors with nostalgic images. LP covers from the fifties and sixties and interactive items were placed on the walls along with other items of interest to encourage discussions. Seats were placed strategically along the corridors for people to rest on. One person said about the pictures, “They are great aren’t they; they bring back so many memories.”

Staff had regular training to keep their skills up to date. They had all completed national qualifications in care. They felt this provided them with the skills and knowledge to support people well.

People said they were happy and had no complaints. They knew they could tell the manager if they had any worries. One person told us “I would just tell the manager and she would sort it for me, no problem.” Another person said, “What would we have to complain about here? They couldn’t do more for you.”

We spoke with several people who use the service some of their comments included:

“It’s lovely here and the food is really good”.

“The staff are very kind and they look after us really well”.

One visitor was very complementary about the staff saying, “The home is very well run and all the staff make you welcome. It’s always clean and it never smells, they look after people well, they really care”.

A visiting health professional was also pleased with the way the home was managed and with the care given to her client.

The staff said the manager of the home was very supportive and approachable. In turn the manager said, “There is a good staff team that work well together”.

We spoke with the relatives of a person who had only been at the home for a few days, they said, “So far we are very pleased with what we have seen. We were provided with information about the home before accepting a place here”.

This inspection took place on 12 November 2015 and an inspection report was initially published with a ‘good rating’. This report was suppressed following an incident involving a police investigation that raised concerns about documentation falsification. This meant the information relied upon on the previous inspection day was inaccurate. We therefore returned to the home on 09 February 2016.

This report includes information from the inspection in November 2015 and a further inspection day in February 2016, at which we reviewed certain aspects of the care provided in detail in response to the information that had been brought to our attention. We had previously carried out an inspection on 15 October 2013 when we found the service had complied with all the regulations reviewed at that time.

Lever Edge Care Home is a two storey purpose built care home. It is situated in the Great Lever area of Bolton and is close to local amenities and public transport. There is car parking to the front of the building and parking on the road is permissible. The home is registered to provide care for 81 adults. On the first day of our inspection there were 75 people using the service. On the 2nd day of the inspection there were 72 people using the service.

The home is divided into three areas; part of the ground floor provides residential care and support. The area known as The Bungalow also on the ground floor provides care for people living with dementia as does the first floor.

The home had 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. The registered manager was present on the first inspection day. On the second inspection day there was an acting manager overseeing the service.

We found that regulations had been breached in eleven instances with regard to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the safe administration of medicines, having sufficient numbers of suitably qualified staff, staff receiving the appropriate level of training and support to ensure they had the skills to care for people effectively, person centred care, complaints and good governance.

The environment was spacious to allow people to move safely around the home with the use of walking aids and wheelchair. The home was well maintained, clean, warm and well lit. There was an internal courtyard with appropriate seating for people to sit outside.

The service had a robust recruitment and selection process to protect vulnerable people from staff who were unsuitable.

There were a significant number of occasions when there were not sufficient numbers of experienced and suitably trained staff on duty to support people safely and effectively.

A significant number of training records had been falsified, meaning that many staff did not have the correct skills and knowledge to carry out their duties effectively.

Systems were in place in relation to the medication practices, but people did not always receive their medicines in a correct and timely way.

We saw how staff worked in cooperation with other health and social care professionals. However some issues were not followed up to ensure that people received appropriate care and support. This placed people’s health and well-being at risk.

We saw risk assessments were in place for the safety of the premises and procedures were in place to prevent and control the spread of infection.

Contingency plans were in place in the event of any emergency that could affect the running of the service and the provision of care.

We found that people’s care records contained detailed information to guide staff on the care and support people required. The records showed that risks to people’s health and wellbeing had been identified, but some records were incomplete and did not demonstrate a commitment to person-centred care.

We saw that people who used the service and/or their family (where appropriate) had been consulted about the care plan. This helped to ensure that people’s preferences were considered.

We found that the provider was not meeting the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. In some cases applications should have been made for DoLS authorisations and these had not been done.

Appropriate arrangements were in place to assess whether people could consent to their care and treatment.

People were offered a variety of nutritious food and adequate hydration. We saw the food was home cooked and the presentation of food was appealing.

We observed that the relationship between people who used the service and staff was respectful, kind and friendly. However, staff at the home did not have the specialist training and skills required to help ensure people who were poorly and needed end of life care were supported appropriately.

The home had an activities coordinator. On the first day of the inspection we discussed with the registered manager that people who used the service may benefit from a more varied programme of activities.

Systems were in place to monitor the quality of the service provided and regular checks were undertaken on all aspects of running the home. However, evidence found during the process of the inspection indicated that records were not always complete and accurate.

There were opportunities, such as residents/relative meetings, satisfaction questionnaires for people to comment on the facilities and the quality of the care provided. It came to light following the first day of inspection that people’s concerns were not always addressed in a satisfactory way.

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.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We are considering our enforcement actions in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded.