We inspected Mais House on the 28 August 2017 and the 3 September 2018. The inspection was unannounced.

Mais 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.

Mais House provides accommodation, personal and nursing care for up to 54 older people living with a range of physical health problems, such as Parkinson’s disease, diabetes, strokes and cancer. There were also people who were now living with early stages of dementia and those who were receiving end of life care. There were 46 people living at the home at the time of our inspection.

At a comprehensive inspection in 28 and 30 October and 02 November 2015, the overall rating for this service was Inadequate and it was placed into special measures by the Care Quality Commission (CQC). Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by May 2016. During our inspection on 22 and 24 June 2016, we looked to see if improvements had been made. We found that the breaches of regulation had been met but needed time to be embedded in to everyday care delivery and Mais House therefore was rated as requires improvement. We inspected Mais House in August 2017 to see if the improvements had been sustained. We found that whilst the necessary improvements had been sustained, it was identified that whilst people’s health needs were monitored but not all were effectively managed and monitored.

We undertook this comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan and confirm that the service had sustained the improvements. We found improvements had been made and sustained and the overall rating for Mais House has been changed to good.

The service had a 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 legal requirements in the Health and Social Care Act 2008 and the associated regulations on how the service is run.

People felt safe living at Mais House. We were told, “I am safe and very happy,” and “I am looked after and still as independent as I can be.” Risks associated with people's care had been appropriately

assessed. Medicines were managed and administered in a safe manner. There were sufficient staff available to ensure people received person centred care. Staff were safely recruited. Systems and processes were in place to ensure people were protected from abuse.

Staff had received regular training, supervision and an annual appraisal to support them to provide effective care. People were supported to have maximum 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. People had choice around what they ate and were supported to maintain good health.

We observed kind and caring interaction between people and staff. People living in the home and their

relatives praised the caring nature of the care staff and registered manager. People were supported to

increase their independence and maintain strong links with their families. People were involved in planning their care.

Care plans were person centred, detailed and updated as and when people's care needs changed. People were supported to lead active and fulfilling lives and went on regular daytrips. Systems were in place to manage complaints. People and relatives told us they were happy with ‘Everything about Mais House.’ Quality assurance processes were in place to monitor the quality of care delivered. The registered manager worked in partnership with external health and social care professio

We inspected Mais House on the 10 and 15 August 2017. We also visited on the 22 August 2017 to feedback about the inspection and its findings to the registered manager as she was on annual leave during the second day of the inspection.

Mais House provides accommodation, personal and nursing care for up to 54 older people living with a range of physical health problems, such as Parkinson’s disease, diabetes, strokes and cancer. There were also people who were now living with early stages of dementia and those who were receiving end of life care. There were 46 people living at the home at the time of our inspection. Accommodation is arranged over two floors on the residential wing and three floors on the nursing wing. Each person had their own bedroom. The home is divided into two units, nursing and residential with communal areas shared by both units. Access to each floor is gained by a lift, making all areas of the home accessible to people. The outside areas are safe and attractive with areas for people to enjoy. The garden areas were accessible for those who required assistance.

This service had a registered manager in post. A registered manager is a person who is 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 a comprehensive inspection in 28 and 30 October and 02 November 2015, the overall rating for this service was Inadequate and it was placed into special measures by the Care Quality Commission (CQC). Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by May 2016. During our inspection on 22 and 24 June 2016, we looked to see if improvements had been made. We found that the breaches of regulation had been met but needed time to be embedded in to everyday care delivery and Mais House therefore was rated as requires improvement.

This unannounced comprehensive inspection was carried out on 10 and 15 August 2017 to see if the improvements had been sustained. We found that whilst improvements had been sustained there were areas that still required further improvement.

People’s health needs were monitored but not all were effectively managed and followed up in timely manner. When peoples’ blood sugars were higher than the normal range, action had not been taken. There was also no recorded timely follow up to see if the blood sugar level had reduced to the normal range. A quality assurance system was in place. However some areas of documentation such as wound care and medicines administration records needed more oversight to ensure they were completed consistently, correctly and information was appropriately recorded.

Care plans were reflective of people’s assessed level of care needs. Risk assessments included those for falls, skin damage, nutritional risks and moving and handling risks. For example, cushions were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. Staff had received training in end of life care supported by the local hospice team. There were systems in place for the management of medicines and people received their medicines in a safe way.

Nurses were involved in writing the care plans and all staff were expected to record the care and support provided and any changes in people's needs. The manager said care staff were being supported to do this and additional training was on-going. Food and fluid charts were completed and showed people were supported to have a nutritious diet.

Staff had a good understanding of people's needs

Mais House provides accommodation, personal and nursing care for up to 54 older people living with a range of physical health problems, such as Parkinson’s disease, diabetes, strokes and cancer. There were also people who were now living with early stages of dementia and those who were receiving end of life care. There were 41 people living at the home at the time of our inspection. Accommodation is arranged over three floors and each person had their own bedroom. The home is divided into two units, nursing and residential with communal areas shared by both units. Access to each floor is gained by a lift, making all areas of the home accessible to people. The outside areas are safe and attractive with areas for people to sit with wheelchair access for those who require assistance.

We undertook an unannounced inspection of this service on the 22 and 24 June 2016.

This service did not have a registered manager in post. The registered manager resigned at the end of 2014. A registered manager is a person who is 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 met the new manager who had been in post for 6 weeks and who confirmed that they would be registering as the manager of Mais House.

At a comprehensive inspection in 28 and 30 October and 02 November 2015, the overall rating for this service was Inadequate and it was placed into special measures by the Care Quality Commission (CQC). Seven breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found significant risks to people due to the poor management of medicines and people not receiving appropriate person centred care. This was because where people’s health needs had changed considerably, care plans had not been updated. Staff therefore did not have the most up to date information about people’s health. This meant there was a risk that people’s health could deteriorate and go unnoticed. Risk assessments did not reflect people’s changing needs in respect of wounds and pressure damage and pressure relieving equipment was not set correctly. The meal delivery had not ensured peoples nutritional and hydration had been met. Accidents and incidents had not been recorded appropriately and steps had not been taken by the staff to minimise the risk of similar events happening in the future. Risks associated with the cleanliness of the environment and equipment had been not been identified and managed effectively. People had not been protected against unsafe treatment by the quality assurance systems.

Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by May 2016.

During our inspection on 22 and 24 June 2016, we looked to see if improvements had been made.

At this inspection we found that many improvements had taken place since the last inspection and the breaches of regulations had been met. At the next inspection we will check to make sure the improvements are embedded and sustained. This is because we will need to see that as people are admitted the improvements are continued, which is why the rating is requires improvement despite no breaches having been identified.’

This inspection found that the staffing numbers and the deployment of staff ensured that people were safe and supported to spend their day as they wished. There had been a high usage of agency staff as many permanent staff have left and there were people who told us that this had unsettled them because “ There needs to be a more regular structure” and “The agency staff sometimes just stand and watch it would be better if we had permanent staff.” New staff were being recruited and the organisation were committed to furt

People told us they were generally happy living at the home. However, most people we spoke with had concerns about staffing levels. One person said, “There is not enough staff here, they are kind but just not enough of them.”

A visitor told us that they were impressed with level of care, “You can bring things up and know they will be addressed.” They said that they were always kept informed about their relatives care and changes in health. They said, “The only problem is the staffing issues, there are not enough of them.”

Staff ensured that consent was obtained prior to providing support. Where appropriate, specialist advice and support was obtained to meet people’s individual needs.

We found that care plans were reviewed but that information from reviews or advice from specialists was not used to change the original care plan. Staff were clear about what they should do if they suspected abuse.

There was a high use of agency staff and the home was taking appropriate steps to recruit new staff. There was no tool in place to assess staffing levels in line with people’s needs and the layout of the building. We assessed that there were insufficient staff to meet the needs of people.

There were appropriate systems in place to monitor the quality of care provided.

We spoke with eight people, all of whom spoke very positively about the staff team. Comments included, “Staff do a good job.” “I join in some activities and others I don’t, I’ve been here a long time, staff are good.” “It’s my home now, I enjoy it.” “Staff are good and helpful.”

We spoke with one visitor to the home who was very happy with the care their relative received. They said that staff were very good and kept them fully informed of their relative’s changing needs.

We observed that staff spoke with people in a respectful and caring way. Staff were clear about what they should do if they suspected abuse. There was a high use of agency staff but the home was ensuring there was consistency of workers.

We undertook an unannounced inspection of this service on the 28 and 30 October and 02 November 2015.

Mais House provides accommodation, personal and nursing care for up to 54 older people living with a range of physical health problems, such as Parkinson’s disease, diabetes, strokes and cancer. There were also people who were now living with early stages of dementia and those who were receiving end of life care. There were 51 people living at the home at the time of our inspection. Accommodation is arranged over two floors and each person had their own bedroom. The home is divided into two units nursing and residential with communal areas shared by both units. Access to the each floor is gained by a lift, making all areas of the home accessible to people.

This service did not have a registered manager in post. The registered manager resigned at the end of 2014. A registered manager is a person who is 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 met the manager who had been in post for ten months and had submitted their application to the CQC to become the registered manager.

We last inspected the home 30 April 2014 and no concerns were identified.

People and visitors spoke positively of the home and commented they felt safe. Our own observations and the records we looked at did not always reflect the positive comments some people had made.

People’s safety was being compromised in a number of areas.

Care plans did not all reflect people’s assessed level of care needs and care delivery was not person specific or holistic. We found that people with specific health problems such as end of life care did not have sufficient guidance in place for staff to deliver safe care. Not everyone had risk assessments that guided staff to promote people’s comfort, nutrition, skin integrity and the prevention of pressure damage. Equipment used to prevent pressure damage was not set correctly. This had resulted in potential risks to their safety and well-being. Staffing deployment had impacted on people receiving the support required to ensure their nutritional needs were met.

People were not protected against the risks of unsafe medicines management. The staff were not following current and relevant medicines guidance. We found issues with how medicines were managed and recorded.

Risks associated with the cleanliness of the environment and equipment had been not been identified and managed effectively. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff, however the evacuation plans did not reflect the decrease in staff in the afternoon and night.

Staffing levels were not sufficient and staff were under pressure to deliver care in a timely fashion. The delegation of staff placed people at risk from accidents and incidents due to lack of supervision in communal areas.

The delivery of care suited staff routine rather than individual choice. Care plans contained information on people’s likes, dislikes, what time they wanted to get up in the morning or go to bed. However these were not always followed. We saw staff make decisions about where people spent their day without consulting the individual. For example, remaining in a communal area whilst requesting to go to their room. The lack of meaningful activities for people in their rooms impacted negatively on people’s well-being.

Whilst people were mostly complimentary about the food at Mais House, the dining experience was not an enjoyable experience for people who remained in their room. People were not always supported to eat and drink in a safe and dignified manner. The meal delivery was not efficient and we were told by people who were assisted in their room that they didn’t often get a hot meal at lunchtime. We also observed food left in front of people without being offered the support they needed to eat. We also could not be assured that people had sufficient amount of fluids to drink.

Quality assurance systems were in place. However the quality assurance systems had not identified the shortfalls we found in the care delivery and documentation.

There were arrangements for the supervision and appraisal of staff. Although staff supervision took place to discuss specific concerns, regular supervision and appraisals had not ensured good practice was embedded into care delivery.

Mental capacity assessments did not always meet with the principles of the Mental Capacity Act 2005, as they are required to do so. We saw that not all peoples’ documentation reflected people’s mental capacity correctly and that “do not attempt cardiopulmonary resuscitation” were not accurate. Care plan records did not always reflect that people were involved or had agreed to decisions and changes made about the care and treatment they received.

People we spoke with were complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Some staff interactions demonstrated they had built a rapport with people and people responded to staff with smiles. However we also saw that many people were supported with little verbal interaction and many people spent time isolated in their room. We saw some interactions from staff that were not respectful to the person they were supporting.

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people’s health.

People were protected, as far as possible, by a safe recruitment system. Each personnel file had a completed application form listing their work history as wells as their skills and qualifications. Nurses employed by Mais house all had registration with the nursing midwifery council (NMC) which was up to date.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

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