We carried out this unannounced comprehensive inspection on 25 January 2017. This inspection was undertaken to ensure improvements that were required to meet legal requirements had been implemented by the service following our last inspection on 29 July 2015.

At the previous inspection the home was found to be meeting regulations, however the service was given an overall rating of Requires Improvement because further improvements were required to ensure newly recruited staff accessed safeguarding training; chemicals needed to be stored securely and more improvements were required to the general environment to ensure it was suitable for people living with a dementia. At this comprehensive inspection on 25 January 2017 we found improvements had been made to meet the relevant requirements previously identified at the inspection on 29 July 2015.

Norfolk House is a privately owned care home that offers personal care and support for up to 18 older people. The house is a large converted property situated in the Springfield area of Wigan close to local amenities. At the time of the inspection there were 14 people using the service.

There was a registered manager 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.

People who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise risk. We observed good interactions between staff and people who used the service during the day. People felt staff were kind and considerate.

Recruitment of staff was robust and there were sufficient staff to attend to people’s needs.

Medication policies were appropriate, comprehensive and medicines were administered, stored, ordered and disposed of safely. Safeguarding policies were in place and staff had an understanding of the issues and procedures.

People’s nutrition and hydration needs were met appropriately and they were given choices with regard to food and drinks. Staff responded and supported people with dementia care needs appropriately. Care plans included appropriate personal and health information and were up to date. We saw evidence within the records of appropriate assessments being carried out.

People’s health needs were responded to promptly and professionals contacted appropriately. Records included information about people’s likes and dislikes and we observed that people had choices, for example, about when to get up, what to do and when and where to eat.

There was an appropriate complaints procedure and complaints were followed up appropriately.

People who used the service and their relatives spoke positively about how the service was managed.

Staff told us the registered manager was always available and approachable. Staff told us they attended regular meetings with the manager and we saw evidence of recent staff meetings.

Meetings with residents and relatives were conducted approximately every three months and relatives we spoke with confirmed they were aware of these meetings and received notification in advance.

Annual questionnaires were sent to people’s relatives. Resident’s questionnaires were also completed and we saw an evaluation of the two most recent questionnaires done in 2016.

Staff supervisions were undertaken regularly and we saw that these were used to discuss issues on a one to one basis.

The manager carried out a comprehensive range of audits and we saw historical audit records were in place.

Throughout the course of the inspection we saw the registered manager walking around and observing and supporting staff.

The service worked alongside other professionals and agencies in order to meet people’s care

We carried out this unannounced comprehensive inspection on 29 July 2015. This inspection was undertaken to ensure that improvements that were required to meet legal requirements had been implemented by the service following our last inspection on 08 January 2015.

At the previous inspection on 08 January 2015 the home was found to have five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to safety and suitability of premises, meeting nutritional needs, cleanliness and infection control, respecting and involving people who use services and receiving and acting on complaints.

At the comprehensive inspection on 29 July 2015 we found that improvements had been made to meet the relevant requirements previously identified at the inspection on 08 January 2015.

Norfolk House is a privately owned care home that offers personal care and support for up to 18 older people. The house is a large converted property situated in the Springfield area of Wigan close to local amenities. At the time of the inspection there were 11 people using the service.

There was a registered manager 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.

People who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise the risks. We observed good interactions between staff and people who used the service during the day. People felt staff were kind and considerate.

Safeguarding policies were in place and staff had an understanding of the issues and procedures.

Recruitment of staff was robust and there were sufficient staff to attend to people’s needs. Rotas were flexible and could be adjusted according to changing need.

Medication policies were appropriate and comprehensive and medicines were administered, stored, ordered and disposed of safely.

We saw that people’s nutrition and hydration needs were met appropriately and they were given choices with regard to food and drinks.

Care plans included appropriate personal and health information and were up to date. We saw evidence within the records of appropriate assessments, carried out by the manager or owner within the files and these were regularly reviewed and updated.

The environment was not consistently effective for people living with dementia and provided little stimulation. There was insufficient signage to aid people’s orientation and help them to be as independent as possible. The environment was in need of some refurbishment.

Staff responded and supported people with dementia care needs appropriately.

People’s health needs were responded to promptly and professionals contacted appropriately. Records included information about people’s likes and dislikes and we observed that people had choices, for example, about when to get up and when and where to eat.

There was an appropriate complaints procedure and complaints were followed up appropriately.

We carried out this unannounced inspection on 08 January 2015. Norfolk House is a privately owned care home that offers personal care and support for up to18 older people. At the time of the inspection there were 16 people using the service. The last inspection and follow up took place in April and June 2014 and the home was found to be meeting all the regulatory requirements.

There was an acting manager at the home who was in the process of registering with the Care Quality Commission. 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 found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which correspond to breaches of the Health and Social Care Act 2008 (Regulated Activities)Regulations 2014. These breaches related to safety and suitability of premises, meeting nutritional needs, cleanliness and infection control, respecting and involving people who use services and receiving and acting on complaints. You can see what action we told the provider to take at the back of the full version of the report.

We found that there was good security at the front of the building, but the back was not secure and people who used the service may be able to leave the building, unseen by staff, by that route. This could put people at risk of harm. People who used the service were also able to walk into the kitchen and office and at risk of harming themselves on objects they may pick up.

The main meal was provided from outside caterers and nutritionally balanced, but the other meals, supplied by the home were of poor quality and we saw little food on the premises on the day of the inspection.

Three of the toilets, for people who used the service, did not contain any liquid soap or paper towels, putting people at risk of infection. There was also no liquid soap in the staff toilet. We asked the acting manager if they had supplies of these, which she said they did. We asked why they had not been refilled when supplies ran out, but she could not give an answer to this question.

We observed a member of staff take a person to the toilet and leave the toilet door open whilst they went to get continence products, affording them no dignity or privacy. The staff member returned, and then closed the door.

Staff meetings were held on a regular basis, but the minutes depicted a list of directions from the owner and the manager, with little opportunity for staff to participate and voice their opinions. We were told residents’ meetings were held on a six monthly basis but no minutes were produced for these. We were told that complaints and concerns were not responded to well, and we saw some evidence of this. People felt they were not listened to.

Staff were recruited safely and there were adequate staffing levels on the day of the inspection. However, there was a high turnover of staff and people who used the service could be put at risk due to staff possibly being unfamiliar with people’s needs.

We observed good interactions between staff and people who used the service during the day. People generally felt staff were kind and considerate.

The environment was in need of some refurbishment and provided little stimulation for people living with dementia. Some areas, for example the conservatory, were not fit for purpose.

People’s health needs were responded to promptly and professionals contacted appropriately. Records included information about people’s likes and dislikes and we observed that people had choices, for example, about when to get up and when and where to eat.

We saw evidence within the records of appropriate assessments, carried out by the acting manager or owner. There were appropriate risk assessments within the files and these were regularly reviewed and updated.

Staff members told us the acting manager was approachable but staff and other people felt the owners were difficult to speak to.

We saw that audits were undertaken regularly to help ensure quality. However, the results were not analysed and follow up was inconsistent.

Medicines were handled safely. Medicines were administered by suitably trained staff and medicines records were clearly presented to support and evidence the safe administration of medicines. Some of the photographs used to support positive identification of residents when administering medicines were missing; we have prompted the manager about this.

During this inspection the Inspector gathered evidence to help answer our five key questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

During the inspection we looked at respect and dignity, care and welfare, suitability of staff, staffing levels and quality assurance.

This is a summary of what we found, using evidence obtained via observations, speaking with staff, speaking with people who used the service and their families, speaking with visiting professionals and looking at records:

Is the service caring?

We saw staff interacting with people who used the service in a caring and respectful way. There was evidence, from speaking with staff and within records that people’s privacy and dignity was respected and preserved at all times.

We saw evidence within the care records of people’s individual choices being noted and followed.

Is the service responsive?

People received an assessment prior to being admitted to the home. The care records included a large amount of information about the person’s needs, wishes and preferences. We spoke with a professional visitor to the home who told us they felt the staff responded to individual needs, making appropriate referrals, seeking advice when needed and following instructions correctly.

People’s mental capacity was taken into consideration with regard to decision making and families and professionals were consulted to help ensure decisions were made in the person’s best interests.

Is the service safe?

Risk assessments were in place in the care records, along with clear guidance for staff to follow. These risk assessments were reviewed and updated regularly to ensure people’s needs were met safely.

Staff were recruited safely and their induction was thorough, so staff were suitably qualified for their roles. There were enough staff on duty at the time of the visit, although staff rotas indicated that this may not always have been the case in the past. This had been addressed recently and an extra staff member now covered peak times in the mornings and evenings.

We were told by staff there was a good mix of experienced and less experienced workers on each shift. This helped ensure the safety of the people who used the service.

Is the service effective?

We spoke with three care staff who demonstrated a good understanding of people’s individual needs. People were well presented and looked well cared for.

Staff were aware of the importance of care plans, understood how and when care plans should be consulted and were alerted to changes to people’s care needs.

There were a number of activities on offer within the home and people were encouraged to join in at a level which was within their own capabilities and skills.

Is the service well-led?

Although there was no registered manager on site at the time of the visit, the providers were in the process of recruiting a new manager. In the meantime there was an acting manager, or a provider on site to oversee the running of the home.

There was evidence that communication between management and staff was good and effective. Handovers were clear and staff had knowledge of their roles and responsibilities.

There were quality assurance systems in place to ensure any issues were identified and addressed in a timely and appropriate manner.

This inspection was conducted to check that the provider had taken actions to address the issues of concern previously raised at our last inspection in October 2013.

When we visited we found that the people living at the service were settled within the lounge areas and were suitably dressed and well presented. The atmosphere was calm and settled and the people that we spoke with chatted to us and did not raise any concerns.

The provider had introduced a number of new documents and ways of working. An example of this was a communication book for staff to write in to ensure that relevant information such as hospital appointments was transferred to the relevant staff, relatives and other professionals so that people living at the service did not miss important appointments.

We looked at another document, the fault recording book. The purpose of this was to record the date that a fault had been found in the environment and when it had been repaired. We saw that although this had been completed correctly a systematic approach had not been taken as we also found areas in the home that required attention that had not been recorded. Examples included aluminium door thresholds that had lifted from the floor causing potential trip hazards and some windows that had broken catches, no opening restrictors or were sealed and not allowing any fresh air in to the room. We discussed this with the provider who told us that they would attend to the issues urgently and would inform us within one month.

The care manager informed us on the 20th January 2014 that these actions were now completed.

The care manager was continuing to act in the role of manager and had made an application to C.Q.C. to become the registered manager of the service. The registered manager continues to be on leave from the service.

At this visit we found that action was being taken to improve medicines handling at the home. The home’s medicines policy had been reviewed and updated to provide clearer guidance to staff about the handling of medicines in the home. Regular medicines audits and assessments of staff competency were completed to help ensure medicines were safely handled. We found that appropriate arrangements were in place in relation to the recording and administration of medicines. However, we found that action advised by the hospital was not correctly carried out on one person’s return to the home. This resulted in two medicines being restarted without the requested GP treatment review.

We also found at the inspection that the registered manager remains on long term leave and the care manager continues to manage the service in her absence.

This inspection was to check that compliance actions issued in August 2013 had now been achieved. We were also acting in response to concerns that had been raised in relation to the care and welfare of people living at Norfolk House some of which have been referred to safeguarding.

We spoke to members of staff, a visiting health professional, a visitor and people who lived at Norfolk House and received a variety of responses. A relative told us that they were happy with the care provided and a thank you letter received in to the home thanked the staff for the exceptional care that their relative had been given.

One person told us that they felt that concerns previously raised by CQC (Care Quality Commission) had been an accurate account but that the support staff were kind and hardworking. Another person had concerns in relation to the assessment of individuals needs prior to being cared for at Norfolk House and of the dignity afforded to some of the people who lived there.

We found that the care manager was continuing to act in the role of manager and he told us that he had made an application to CQC to become a registered manager at the service.

There had been an improvement in documentation but this was an area that would still benefit from additional attention.

We saw that the provider had worked to address the issues that had been raised in the previous report and had received support from an infection control specialist.

However, we continued to have concerns in relation to the care and welfare of people using the service at Norfolk House, particularly in relation to supporting people who were approaching the end of their life and we have outlined these in the report.

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Some people living at the home were less able to directly discuss the management of their medicines but the person we spoke with did not raise any concerns. However, we found that the home’s policies did not provide clear guidance to care workers about the homes arrangements for handling medicines and that current good practice guidance was not adhered to, increasing the risk of mistakes.

We conducted this inspection in response to concerns that had been raised with us.

When we arrived at the home the staff on duty were unable to tell us who was in charge of the building. We found that a lot of people living at the home were up and about and having their breakfast. They were dressed and well presented.

We noted several areas of concern in relation to infection control and safety and spoke with staff on duty, a contractor, four relatives and several people living at the home.

People we spoke with told us that they thought the '' care was good. Comments such as '' ''My relative is fine and the carers are lovely.'' were made. One visitor told us that ''the service could possibly have more staff,'' but that their relative was kept clean.

A person living at the home told us that they enjoyed the food and there was plenty of it.

During the inspection the providers told us that the absence of the registered manager continued and the person who had been assuming the role on a temporary basis had now left the service. They told us that they had recruited another person who would take charge during the managers continued absence.

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We visited Norfolk House as we had received concerning information about the food provided and staffing issues. We were told that people did not always have enough food and that the food purchased consisted of cheaper products rather than branded food products. During our visit we did not find any evidence to support these allegations.

We were also told that some staff members listed on the rota were not always working on that day and that students were listed on the rota as if they were staff members. We were told that at night there were two staff on duty and at times this meant that medication could not be given as some staff were not trained to give medication. We were also informed that there were some staff members working at the home from other countries who were not entitled to work in the UK and may not have gone through the required checks. We found that students were listed on the rota and on two occasions they were included in staff numbers for that day. We did not find any evidence to support the other allegations about staffing that had been made.

We spoke with four staff members, a relative, five service users and a visiting health professional during our inspection.

The relative told us that ''the staff are fantastic'' and that the family were 'kept in the loop' in relation to their relatives care. They told us that the relatives had been informed of new measures that had been implemented in relation to the fire doors in the home. They also thought that the service had improved in recent weeks.

One service user who we spoke to told us that the food was O.K. and they could choose off the menu. They had also been able to take a bath.

A visiting health professional told of their concerns in relation to staffing levels in the home, particularly in the morning.

Staff members told us of their concerns in relation to staffing levels and leaving service users unsupervised at times when they were elsewhere in the building.

We found that improvements had taken place since our last visit in relation to communications within the home between the provider and service users and relatives. A notice board was displaying relevant information and agendas for meetings. We saw evidence of service users involvement in the home and that some issues raised by them had been addressed.

A jubilee party had taken place and a trip to Blackpool lights and a Christmas Fayre were planned.

The manager was still absent from the service.The acting deputy was taking charge in her absence alongside the provider.

We spoke with two people who were living at the service and one relative during our visit.

Their comments overall were positive and they all agreed they liked living at Norfolk House.

The people we met told us they were happy and comfortable with the staff supporting them.

We spoke to one relative and they were positive and happy with the staff and had no concerns. This relative told us they were happy with the service provided and said that the Doctor was always called if needed.

Due to concerns raised about the management of fire safety we have referred these issues to the local fire brigade for their review.

The local authority contracts and monitoring team carried out a contractual visit in May 2012 and produced a detailed report that identified a lot of topics including staffing levels that needed to be reviewed, especially for supporting people with dementia.

“The staff have looked after me very well since I arrived here”.

“The staff try their best but they are busy all the time”.

“I would like to go out more once the weather gets better”.