About the service: Mabbs Hall provides accommodation for older people, some of whom may have nursing needs or live with dementia. The service can accommodate up to 29 people. On the day of our inspection visit there were 27 people resided.

People’s experience of using this service:

• People at this service were well cared for by dedicated staff.

• People using the service were relaxed with staff and the way staff interacted with people had a positive effect on their well-being.

• People’s feedback was consistently positive about the care, support and staff. One person told us, “They are caring and friendly. If you have got a problem you can go and talk to anyone.” A relative told us, “We are very happy, my relative is settled, everyone is welcoming, they are well looked after.”

• People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

• The newly registered manager was making positive changes within the service.

• These changes would benefit people living at the service because they linked directly to enhancing the skills of staff. Face to face training had just been completed in relation to supporting people living with dementia and end of life care from the local hospice was being rolled out. The clinical competencies of the nurses were being updated and a variety of courses had been sourced and booked.

• The environment had received a cosmetic freshen up with lighter paint being applied to communal areas. All stair wells were now safe with an audit being completed of the environment to ensure it was safe for people living with dementia.

• We fed back to the registered manager areas for further development. How people spent their day in relation to meaningful activities needed further development. People needed to be consulted and truly involved in identifying their aspirations and developing a quality of life. People needed to be consulted and processes put in place in relation to people sharing double rooms. This should be a positive choice, based upon people’s relationships.

Rating at last inspection: We rated Mabbs Hall as good and published our report on 29 November 2016.

Why we inspected: This was a scheduled inspection based on previous rating.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for those services rated good.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection was carried out on 8 November 2016 and was unannounced. At their last inspection on 28 August 2014, they were found to be meeting the standards we inspected. At this inspection we found that they had continued to meet the standards.

Mabbs Hall Care Home is registered to provide accommodation for up to 29 people. The home provides support with personal care and nursing care for older people, some of whom live with dementia. At the time of the inspection there were 28 people living there as one of the double rooms was occupied by one person.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

People received care that met their needs from staff who knew them well. Staff were seem to be attentive and kind and worked in a respectful way that promoted people`s dignity.

People had care plans in place that gave clear guidance to staff and there were reviewed regularly. People were involved in the planning and review of their care.

People’s medicines were managed safely and any individual risks to their welfare were assessed. We observed staff were aware of these risks. Staff knew how to recognise and report any concerns of abuse and people told us they felt safe.

People were supported by sufficient numbers of trained staff who had been recruited safely. Staff felt they were well supported.

People had access to a range of healthy foods and their health was monitored appropriately. People’s consent to care was sought and the service worked in accordance with the Mental Capacity Act 2005.

The feedback about the registered manager and leadership at the home was positive. There were quality assurance systems in place that were effective and addressed any shortfalls in the home.

We carried out our inspection on 28 August 2014 after we received concerns regarding the care and welfare of the people who used the service. We also received concerns about the amount of staff employed by the service and that these numbers may be insufficient.

We gathered evidence of people's experiences of the service by observing how they spent their time and we noted how they interacted with other people who used the service and with staff. We looked at six people's care records. Other records viewed included staff rotas and training records and policies and procedures. We spoke with five staff members, the registered manager and people who used the service.

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?

Below is a summary of what we found during our inspection. The summary is based on our observations during the inspection.

Is the service safe?

When we arrived at the service we were asked for our identification and asked to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service was aware of new changes in the law with regard to DoLS. Where applications had needed to be submitted, appropriate policies and procedures were in place and had been followed. Relevant staff had been trained to understand when an application should be made and how to submit one.

People told us they felt safe living in the service. People did not have concerns about the staffing levels. We saw that there were enough staff to ensure that people received the care they needed in a timely way. We saw staff were not rushed in their work so their time with people was as meaningful as it could have been.

The provider considered how staffing levels were calculated to ensure that staffing levels were aligned with the dependency and needs of people who used the service.

Staff told us that they felt they were part of a good team and received a good level of training and were supported. Records detailing staff training showed us that regular updates were attended by staff.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure their safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

We saw that the service had effective systems in place for monitoring the quality of care.

We found that there were enough trained, skilled and experienced staff to meet people's needs. Staff received the training they needed to provide care and support safely and were able to demonstrate that they understood the specific needs of the people who used the service and how those needs were to be met.

Is the service caring?

We saw that the staff interacted with people who used the service in a caring and respectful manner.

Staff had a good knowledge and understanding of people's care and support needs, including recognising and supporting them as an individual. Where people required assistance, staff provided this in a timely manner and at a relaxed pace. This ensured people received care and support consistently and in ways that they preferred.

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised, these were addressed.

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

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken into account and listened to.

People told us that they knew how to make a complaint if they were unhappy. We saw that where people had raised concerns, appropriate action had been taken to address them. People could therefore be assured that complaints were investigated and action was taken as necessary.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the service and quality assurance processes were in place. This helped to ensure that people received a good service at all times.

The service had a quality assurance system in place and records seen by us showed that identified shortfalls were addressed promptly. The service had processes in place to collate the information they had gathered, identify the service's strengths and weaknesses, and plan the actions required to improve the experiences of people who used the service. This ensured continued improvement in the areas identified.

Is the service safe?

When we arrived at the service the registered manager greeted us and noted our identification and we signed in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

We saw the staff rota and dependency levels assessment which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs. Two staff spoken with said there were sufficient numbers of staff on duty and a relative and a person who used the service also felt the staffing levels were sufficient to meet people’s needs. There was always a qualified nurse on duty 24 hours a day.

There have been no applications made under the Mental Capacity Act (MCA) 2005 in relation to a Deprivation of Liberty Safeguards (DoLS).We saw that there was a policy and procedure in place and that staff had received training. This demonstrated that staff at the service were aware of the legislation and how to protect people and uphold their rights by appropriately using this legislation if and when needed.

We examined the medication systems in use and found that these protected people as they were being followed and staff were trained to use them.

Is the service effective?

Care at Mabbs Hall Care Home was effective because we did not see any pressure sore that had developed within the care home and those sores people had upon admission were healing well. Systems in place to audit medication, infections and the kitchen made for effective organisation in the delivery of care.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People using the service told us staff were caring and met their needs.

People using the service were asked how they would like to spend their day and this was recorded. Relatives completed satisfaction questionnaires. There were regular meetings that were well attended for people at the service, their relatives and separate staff meetings. This meant people had regular opportunities to express their views.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. This included regular trips out to the local shops and the on-site day centre.

The service had a complaints procedure and whistle blowing procedure in place. No concerns had been raised, but there were processes in place if needed. People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to regularly review care plans. This included seeking support and guidance from health care professionals, including a doctor and nurse specialists.

Is the service well-led?

The service worked well with other agencies and services such as health and social care professionals to make sure people received their care in a joined up way.

The service had quality assurance systems, audits and records seen by us that showed identified shortfalls were addressed promptly. As a result the quality of the service was improving.

We did however find evidence to show that the service was not adhering to the conditions of registration set by the Care Standards Tribunal in August 2013. Regulation 33, 'Failure to comply to conditions', had not been met because admission of more than one person to the service in any period of 14 days had been breached. Therefore CQC is currently considering what action it must take to ensure compliance to maintain the safety and well-being of all at Mabbs Hall Care Home

At our previous inspection visit on 6 June 2013 we found concerns about; cleanliness and infection control, supporting staff and effective monitoring of the quality of service.

At this inspection we found the service had made improvements. Care records were accurate and updated regularly to reflect people's needs. People were cared for according to their assessed needs. The premises and equipment were clean and there was a routine for ensuring cleanliness and reducing the risk or spread of infection.

We found that staff were trained and had support to care for people appropriately. Managers were able to confirm that staff were competent in specific nursing duties.

We found that audits of the quality of care were effective in monitoring that safe and effective care was being provided.

We spoke with three people who used the service, and two relatives. One person told us, “I am doing well now.” A relative told us, “It is better than it was here, the managers keep us updated.”

The service had made improvement in some areas including ensuring there were enough staff to meet people’s needs and ensuring medicines were managed safely. We found that actions put in place to protect people were not always followed. This included people at risk of falls and systems to reduce opportunities for cross infection.

We saw clinical areas and equipment was not cleaned to an appropriate standard. We also found that cushions used by people were stained, had an unpleasant odour.

The service was in the process of implementing assurance systems including audits to effectively manage and review the service provided. They were not sufficiently robust in order to protect people using the service from the risk of receiving poor quality care.

Our visit was to follow up on previous non compliances found at the last four inspections of Mabbs Hall Care Home. We spoke with three people who used the service, who were able to speak with us, and one relative. One person told us, “Staff have more time to talk to me now.” A relative told us, “They are trying to put it right.”

We found that people were not protected from the risks of developing an infection. We identified that five people who used the service had developed a urinary tract infection within the two weeks prior to our inspection. Whilst the service had not achieved compliance with the enforcement action taken in relation to care and welfare the care received by the ten people, on the day of our inspection had improved.

Records of the amount of food and drink people were offered and received had improved and were recorded accurately. However we found that some records remained inaccurate. These included people’s care plans and risk assessments.

We found some dependency risk assessments (assessments used to determine the level of care people required,) involvement of family in care planning documents and reviews of care plans were not accurate. This therefore meant that some plans of care were not correct.

We inspected to follow up on previous non compliance we found at the last three inspections of Mabbs Hall. There were 18 people accommodated at the service at the time of our visit. We spoke with six people who used the service and five relatives. People told us, “The food is better.” A relative told us, “They are trying but they have a way to go. We know they are trying hard.”

We found that people were still at risk from falls resulting in injury. We identified people who had newly developed pressure ulcers that had not been reported to the management team.

We found that, where required, records of the amount of food and drink people had was not recorded accurately. In addition we found that records for those who needed to be turned regularly (to lower the risk of pressure areas developing) were also not accurate.

We found malnutrition screening tools (MUST) and Waterlow risk Assessments (assessments used to manage the risks to people’s skin integrity) were incorrectly calculated. The assessment is used to plan people’s care; therefore the plans were not correct.

We found that the quality and accuracy of records had not improved since our last inspection. We found that entries did not define the care provided, we also found that records were not accurate.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

On the day of our inspection we spoke with ten people who used the service and three relatives.

Two relatives we spoke to expressed concern about the care provided within the service. However one relative told us they were very happy with the care their family member received.

We spoke with two people who we spoke at our last inspection in October 2012. We asked both about the care and if it had improved. One person told us, “Not much has changed. It is the same, it is not good.” The other told us, “The care is good, I have no complaints.”

We found that improvements required by the previous enforcement action had not been achieved. This meant that people who used the service were still at risk from unsafe or inappropriate care and malnutrition or dehydration. The service continued to fail to ensure the safety and welfare of people using the service.

We undertook formal observations in the lounge area during the morning and during the lunch hour. We generally observed care and treatment of people who used the service throughout the day. We found that although staff were kind, people were not receiving adequate care at all times.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

During this inspection our pharmacist inspector looked at how information in medication administration records and care notes for people living in the service supported the safe handling of their medicines. We found that not all medicines could be accounted for numerically and so could not be assured people’s medicines were being administered as intended by their prescribers. We found that improvements in the availability of information are needed for staff to refer to about people’s medicines.

On the day of our inspection we spoke with six people who use the service, three people and three relatives. They told us that they found the staff kind and caring. One person told us, “The staff do care.”

We asked two people about the food. We asked them if they get to eat their favourite or preferred meals at the service one person told us, “I get my favourite treats when my family brings them in for me.”

Relatives we spoke with expressed concern about staffing in the service. One told us things had improved after recent changes in staffing. Other comments included, “The staff here are so busy and do the best they can.” And, “There is not enough staff, the ones here are nice and they work so hard but they are run ragged and cannot get to people quick enough.”

During our inspection we found concerns in relation to the management of peoples care and welfare, meeting people’s nutritional needs, safeguarding vulnerable people from abuse, staffing, support for workers, management of workers and records.

The people living in Mabbs Hall Care Home and their family members told us that they liked living there, that the care staff showed them respect and worked hard to look after them. They also told us that they were comfortable in the home. One person told us that they were glad to be in the home, saying, “The carers can not be more helpful.”

We saw that shortfalls in staffing levels were having a major impact on people using the service. We observed that the staff found it difficult to meet the people’s individual needs during meal times and during the night. This was because there were not sufficient numbers of staff to meet the dependency levels of the people using the service.

We found that the service was not meeting the requirements of the Mental Capacity Act 2005. People were being provided with personal care without appropriate mental capacity and consent processes being considered. These actions are important to ensure people’s wishes and views are taken into account when providing their care.

We saw that people were not provided with a choice of foods. One person had been given beans and told us, “I don’t like beans, I won’t eat them.” We had to request for alternatives to be provided for this person.

We found that, where required, records of the amount of food and drink people had was not recorded accurately. In addition we found that records for those who needed to be turned regularly (to lower the risk of pressure areas developing) were also not accurate.

During our inspection we identified failings relating to the quality of the service provision. We saw that there were shortfalls due to the lack of quality management.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.