We undertook an unannounced inspection of Northway House Residential Home on 3 and 5 December 2018. When the service last received a comprehensive inspection in November 2017 we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches included the following failures; Statutory notifications had not been made as required. The care and treatment of people was not always person centred and met their needs and preferences. People risked being deprived of the liberty without legal authority. Systems and processes to investigate allegations of abuse were not effective. The premises were not appropriately maintained. The provider had not ensured systems to assess, monitor and mitigate the risks to people were effective. Following this inspection we rated the service Requires Improvement

Following the inspection in November 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Responsive and Well-Led to at least a good rating.

On 31 March 2018 we undertook an unannounced focused inspection of the home to check the most significant issues from the last inspection. The team inspected the service against one of the five questions we ask about services: is the service Safe? This is because at the last inspection the service was not meeting some legal requirements; we had significant concerns about a choking risk which had not been managed appropriately. During the focussed inspection, we found the registered manager had made the required improvements. Following this inspection, the rating of Requires Improvement did not change.

During this inspection, we found the required improvements from the last two inspections had been made and we rated the service good.

Northway House Residential Home 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. The service did not provide nursing care. Northway House Residential Home is able to accommodate up to 29 people in one adapted building. At the time of the inspection there were 23 people living in the home and another six people staying there for respite (short term) care.

There was a registered manager in post at the time of this inspection. 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.

Staff received regular training and were knowledgeable about their roles and responsibilities. They had the skills, knowledge and experience required to support people with their care and support needs.

Systems, processes and standard operating procedures around medicines were reliable and appropriate to keep people safe. Monitoring the safety of these systems were robust.

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.

There were suitable recruitment procedures and required employment checks were undertaken before staff began to work at the home. Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times.

Assessments were undertaken to assess any risks to the person using the service and to the staff supporting them. This included environmental risks and any risks due to the health and support needs of the person. The risk assessments we read included information about action to be taken to minimise the chance of harm occurring.

Staff knew the people they supported and provided

During the inspection in November 2017, we found one person had a choking risk. The service had failed in assessing the relevant risks to the health and safety of this person and had failed to do all that was reasonably practicable to mitigate the identified risk. This was because the person had not been referred to a speech and language therapist for an assessment, support or guidance in a timely manner. The person’s nutritional plan had not been updated with information about the risks. The person’s diet had not been modified to make it easier for them to swallow.

During this inspection, we found the registered manager had made the required improvements. The registered manager had referred the person to a speech and language therapist for assessments and guidance. This information had been used to inform risk assessments and care plans. The assessments we looked at were clear. They provided details of how to reduce risks by following the guidelines or the person's care plan. Both the care plans and risk assessments we looked at had been reviewed regularly.

All staff we spoke with were aware of the person’s nutritional needs and preferences. Staff said, “We’re aware of [name’s] needs and the risks of choking”, “All staff have been trained what to do and there’s an emergency bell on the wall” and, “Since we’ve been reminding [name] not to eat too fast and drink, they’ve been fine.” Staff who worked in the kitchen were aware of the person’s needs and said, “We know how to prepare food for [name] and staff observe.”

We observed lunch. Staff discreetly observed the person and reminded them to take drinks regularly. After lunch we spoke with the person who told us, “I can eat what I want, I have choices what I eat and staff help me.”

The registered manager told us, “Learning from this has led to the initial assessment form being updated. We also get more information from professionals.”

We undertook an unannounced inspection of Northway House Residential Home on 7 November 2017. When the service was last inspected in October 2015 no breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Northway House Residential Home 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. The service do not provide nursing care. The service is able to accommodate up to 29 people. At the time of the inspection there were 26 people living at the service.

There was a registered manager in post at the time of this inspection. 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 identified that improvements were needed in ensuring people were cared for safely. We identified concerns around risk management in relation to choking and requested the registered manager take immediate action to reduce this identified risk. We also noted that risks associated with people being permanently cared for in bed were not well managed. Where people had risks associated with fluid intake and monitoring this was not consistently safe. Where risks were identified in relation to people’s weight, actions to monitor their weight increase or decrease had not been completed as required.

Safeguarding systems to ensure people were not safe as referrals had not been made as required and current policies required updating to be in accordance with current legislation and regulations. Medicines management required improving, as we found medicines specific for the use at the end of a person’s life were out of date and there was a risk they may have been used. Improvements in relation to infection control practice was required.

The service had not met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). The registered manager had not made any applications for people living at the service and it was not evident they understood current legislation around DoLS applications.

People were not fully supported by the design and decoration of the service. We found that repairs to different areas of the service were needed, for example there was water damage on some ceilings and when it began to rain during the inspection staff used a bucket to catch dripping water. Staff understood the Mental Capacity Act 2005 (MCA) and had been trained in it, however improvements were needed to ensure that legal records relating to a person’s authority to make decisions on behalf of another had been obtained. Improvements were needed to ensure staff received frequent supervision and appraisal.

We found that some practices at the service were not person centred or in line with people’s preferences. For example, the service had set ‘Bath days’ for people and people that wished for more frequent bathing were being told it wasn’t possible. Care records did not always evidence how people’s physical needs would be met and personalised information about people was not consistent. We received mixed feedback on how involved people and their relatives felt in relation to care planning.

The service had failed to send legal statutory notifications to the Care Quality Commission as

We had received information that people might not be receiving a safe service.

On the day of our inspection there were 27 people using the service. The summary is based on conversations with three people using the service, eight staff supporting them, a visiting health care professional and the provider. We looked at records and observed what happened at the home throughout our visit.

The service is currently without a manager but the provider is actively recruiting.

We saw that people were treated as individuals and with respect. We saw staff supporting a person who was upset and people being asked what they wanted and how they could be helped. One person told us “It is quite pleasant. I’m happy here”. There was a homely, accepting atmosphere.

We found that the service was safe because people’s needs were assessed and how those needs were to be delivered was planned in detail. This took into account people’s individuality; strengths and vulnerabilities. Where risks was identified these were reduced without unnecessary restriction.

We found that the servicing of equipment and the review of fire safety risk was not fully up to date but otherwise there were no concerns with regard to the premises or safety, availability and suitability of equipment.

We found that medicines management did not ensure that mistakes or mishandling could not occur although there were some risk reducing systems in place.

We found the changes in the level of people’s needs, management and staff sickness had raised the risk to people using the service. Despite many changes at the home staff were supported to provide a good service and promote people’s wellbeing.

We found that the home had extended its registration and had accepted four people with nursing needs in the last month.

We spoke with twelve people who lived at the home. Some had lived at the home for many years, while others had moved in during the past year. Several people said they had not noticed any change in the care they received, although some people thought they were given less attention as a result. We discussed the situation with the provider and the manager, who gave us assurance that lots of meetings were held to discuss proposed changes and to give reassurance that individual needs continued to be a priority in the care delivered.

We saw there was a full activity programme in place which people enjoyed. One person told us the 'flexercise' session had helped their back 'enormously'. Another said ‘we didn’t half enjoy yesterday’s visit out’. The activity coordinator encouraged people to join in group sessions, and supported people individually, if preferred.

Suitable equipment had been purchased to support people who had specialist needs.

We spoke with the provider, registered manager and clinical lead nurse who assisted with the inspection. We also spoke with three care staff and two newly appointed nursing staff. Two relatives we spoke with told us their relatives were comfortable and that the ‘personal care was excellent’.

There were 27 people living at the home on the day of the inspection. Of these four people had nursing needs.

When we visited 21 people were using the service and two people were receiving day care. We spoke with 18 people, the manager and five members of staff. We also spent time observing how staff interacted with the people who lived at the home.

People told us that they were fully involved in life at the home. They said “If we are not happy about something or if we want something changed, we only have to say and they sort it straight away” and “they encourage us to make comments. They are always telling us that this is our home and I certainly feel that we are in charge.” One person said “I feel completely in control of my life.”

Each person had a care plan which provided staff with up to date information about people’s needs, abilities and preferences. We saw that people’s healthcare needs were monitored and responded to.

The people we spoke with told us that they felt safe and well cared for. They made the following comments “I feel really well looked after here and very safe” and “all the staff are so kind. It’s so reassuring knowing that someone is there when you need them.”

Formal systems for staff supervision were in the process of being implemented. Staff told us that they felt “very well supported” and that the manager and deputy manager were “very approachable.”

No concerns were raised with us during our visit to the home. The people we spoke with told us that they would feel confident in raising concerns if they had any.

During this inspection we were invited to join a group of people who lived at the home for their ‘resident’s representatives meeting’. The meeting was chaired by the manager of the home. A company director and an activity coordinator were also present. People were encouraged to speak freely about any aspect of life at the home and to offer suggestions and improvements. Notes of the meeting were taken and people were informed that these would be displayed on the notice board along with any action points.

People spoken with were positive about the care and support they received. Comments included “It’s improved so much here and I am very happy with everything”. People confirmed that they were able to see a health care professional when needed. Comments included “they got the doctor straight away when I wasn’t feeling well and they told me what was going on”.

People who lived at the home told us that they were involved in the development and review of their plan of care. Comments included “my key worker went through my care plan with me to make sure that I was happy with everything” and “they know all the things I like and don’t like”.

People told us that the staff were “very kind” and all confirmed that they were supported to make choices about their lives. We found the atmosphere in the home to be relaxed and inclusive. People appeared relaxed in the presence of staff and communication was noted to be kind and respectful. People were observed moving freely around the home and we did not observe any restrictive practice.

People told us that they were now much more involved in their plan of care. Each person spoken with during our visit told us that staff had spent time discussing their needs and preferences with them. People said “the staff went through my care plan with me to make sure that I was happy with everything”, “the staff did a new care plan with me and talked to me about my preferences”, “they checked that I was still alright with the support I get”. One person said “the staff never make you do anything that you don’t want to do” and “they explain things before they help you”, “My choices were discussed with me and I can do my own thing”. People spoken with were much more positive about the care and support they received. Each person was very complementary about the acting manager who commenced employment in September of this year. People said “Things are good here now and I am so much happier than I was”, “all the staff are kind and they have improved as they seem to know how to help me now”. One person said of the manager, “he has employed more staff and he seems to make sure we get the right staff”. People told us that they were treated with respect and that assistance with personal care was offered in a sensitive and respectful manner; “the staff help me with a bath and they are so good, they make sure I am alright and always respect my privacy”. The home had introduced a ‘key worker’ system and each person spoken with was able to name their allocated carer. They said “my key worker went through my care plan with me and they make sure that I am happy with everything”.

We asked people about the meals offered by the home and views were mixed. The majority of people told us that choices available at teatime had improved and that there was now a ‘hot option’. People were not so positive about the ‘homemade’ soup and we were informed by the manager that this had now been addressed. A number of people told us that lunch was “often late”, meaning that they had to wait. On the day of our inspection lunch was served 10 minutes late. The manager informed us that he was aware of this and would continue to monitor. People were keen to tell us about the improvements made to the range of activities offered by the home. They told us that they enjoyed a firework display at the home, visiting entertainers which included a singer and an accordion player and arts and crafts. One person told us that they had recently enjoyed a shopping trip out with staff. An activity programme had been displayed in the home and this offered a selection of activities which included visiting entertainers, Christmas carols, communion and church services, hairdressing, crafts and bingo.

Each person told us that they “felt safe” at the home and that “the staff were never unkind”. People confirmed that they would feel confident in raising any concerns and that the manager would “make sure things were put right”.

People told us that the acting manager kept them up to date about events and life at the home. They said “things have really improved”, “the manager is always keeping us up to date with what is going on, he is marvellous”. They said the manager “has kept us up to date about what they are doing to improve following your last inspection”, “he tells us about staffing levels and any changes in the staff”, “I feel like I know what is going on now”. People confirmed that they had the opportunity to attend regular meetings where their views were encouraged. One person said “I choose not to attend the meeting but John (the manager), always fills me in afterwards and it is all written down”.

People told us; "the staff are alright, they don't make you do anything you don't want to do". We asked people about the care they received and whether they had been involved in planning the care they received. They said; "no, nobody has discussed it with me but it's alright here", "I don't know about care plans but I suppose the staff know about that sort of thing". Each person spoken with during our visit told us that their medicines are administered by a member of staff. One person said; 'I get my medication when I need it'. Staff members spoken with were clear about people's rights to make decisions, they said; "we make sure people can make choices, they don't have to do anything they don't want to do". Staff spoken with told us that whilst they had not yet received training in the Mental Capacity Act or deprivation of liberty safeguards, they had been informed that this would be arranged.

People spoken with during our visit told us; "they look after me but they are always so

busy". They also told us "there doesn't seem to be much going on at the moment". Staff

told us that "with the staffing levels we have we can meet people's basic needs". They told us they felt people were "safe" but "things were a bit rushed".

We asked people about the meals offered by the home, they said; "the food is quite nice really", "I get enough to eat but get a bit fed up with jam sandwiches" and "I like the food very much". We were told that hot drinks are served at 'set times' during the day and we saw in the minutes of a recent 'resident meeting', that people had requested 'jugs of squash' to be left out in communal areas so that they could help themselves. We did not observe any drinks in communal areas during our visit.

People spoken with during our visit told us that they would "talk to the manager" if they had any concerns. They said; "I'm pretty sure they would do something about it if I had any worries".

Staff spoken with during our visit were positive about the improvements in staff training

and support. They said; "there is much more training now and I feel more supported". One staff member told us that since our last visit they had been supported to complete a National Vocational Qualification (NVQ) level 2 in care. When asked, staff confirmed that they felt they had the skills and training needed to meet the needs of people living at the home. They also confirmed that they were never asked to do anything they had not received training to undertake.

People told us that they received care in line with their assessed needs and preferences. People told us that the staff team were kind and that their privacy was respected.

People said, “The staff are very kind and will always help you”, “Yes I am treated with respect”, “The new management team have spoken to us about what activities we would like”.

Most people told us that they were 'happy' with the care they received. They told us that staff were aware of their preferences, “they know I don't like to go to bed too early”.

Care planning procedures do not ensure that all staff are fully aware of people’s assessed needs or preferences.

One person told us that they felt that staff “did not understand” their physical condition and how this affected them.

We found that care plans did not always contain up to date and detailed information about peoples' assessed needs.

We found that staff had not received the training necessary to enable them to meet people’s assessed needs.

Some care plans examined contained the individual's signature though we could not confirm whether people had fully understood what they had signed. We spoke with one person who had signed their care plan and they said; “sorry I don't remember, I am not sure what you are talking about”.

Care plans did not contain evidence that people using the service and/or their representatives were provided with opportunities to be involved in the care planning and review process.

We were unable to ascertain how the home assessed people in relation to their ability to give consent.

We were unable to confirm that newly appointed staff followed an appropriate induction programme on commencement of employment.

It was confirmed that no systems were currently in place to ensure that staff were appropriately supervised or supported.

People told us that the food was “generally good” and that there was “plenty to eat”.

They told us that choices were available and that staff would ask them about their meal choices each morning.

During our visit we observed the lunch time experience to be a relaxed and sociable occasion.

People told us that hot drinks were served at set times during the day. People said that they “wouldn't ask for drinks at other times as the staff were very busy”.

Care planning procedures with regard to nutrition and hydration do not ensure that peoples assessed needs and preferences can be fully met by staff.

People told us that “staff arrange for the doctor to visit when needed”. During our visit we heard a carer informing an individual that a doctors appointment had been made for them as requested.

The home were unable to demonstrate that effective pre-admission procedures were in place.

People do not currently benefit from a staff team who are appropriately trained in safeguarding adults from abuse.

During our visit we looked at all communal areas and a selection of bedrooms and communal bathrooms. We found the standard of cleanliness to be good and no malodours were apparent.

People live in a comfortable and well maintained home. People have their own bedroom which they can personalise.

People told us that they were “happy and comfortable” at the home.

People are able to access their bedrooms throughout the day as they choose.

We observed staff knocking on bedroom doors before entering.

The acting manager informed us that domestic staff were employed covering a 7 day period. We were informed that night staff currently undertake laundry duties.

Appropriate staff hand washing facilities and protective clothing were seen to be sited throughout the home.

The acting manager has developed an action plan which identifies action required to further improve the home's infection control procedures and training for staff.

People do not currently benefit from safe systems for the management and administration of their prescribed medication. Staff have not been appropriately trained in this area.

People spoken with were positive about the staff team and of their kindness. People did tell us that the “staff are always very busy”.

We observed a staff presence during the day though the majority of their time was spent with 'tasks' rather than spending 'quality time' with people.

People told us that the acting manager and deputy manager “ask how we are” and “if everything is alright”.

Staff told us that “staff meetings are being arranged”.

The home does not have any formal systems in place to seek peoples' views or to monitor and improve the quality of the service provided.

The home has a complaints procedure though this does not provide the contact details of the Commission or other outside agencies. People spoken with and staff did not know how to contact the Commission.

People can be confident that their records are securely stored but they cannot be confident that their records are up to date or are reflective of their current needs or preferences.

This inspection was unannounced and took place on 19 and 21 October 2015. The inspection was carried out by an inspector and a pharmacy inspector. The last inspection of the home was carried out on 29 and 30 October 2014. At that time we found the service was not meeting the regulations in relation to the management of medicines, consent to care and treatment, and assessing and monitoring the quality of the service.

The service provides accommodation and personal care for up to 29 older people. At the time of the inspection there were 29 people living there. The home does not provide nursing care. This is provided by the local community nursing team. When vacancies allow, the home also offers a respite care service for older people who need a short period of care. They also provide a day care service for a small number of people. This service is not registered and therefore was not covered in this inspection.

There was a manager in post who was not yet registered. An application for registration has been received by the Care Quality Commission and was being processed at the time of this inspection. 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.

Since the last inspection the home had gone through a period of change. A new manager and head of care had been appointed. The number of people living in the home had doubled in recent months. A core group of loyal staff have remained along with some recently recruited new staff. Most people we spoke with were positive about the changes and told us they were very happy living there, although a few people had found the changes a little challenging to cope with. Overall the comments were positive, for example, “I enjoy it here”, “I am happy here” and “It’s alright here”. A few people were a little less positive, and one person told us, “Staff are caring but they are short of time.” We saw the manager and staff team were working hard to help new people settle into the home and also supporting new staff settle into their jobs.

Relatives and professionals were very positive about the home and told us the changes had been positive. Comments included “I am delighted with the home – very good”, “The care is always OK”, “It’s a nice home” and “There are some amazing staff here.”

There were enough staff to meet people’s needs safely. Staff appeared busy on the second day of our inspection but we saw people’s needs were being met. Call bells were answered promptly. Staff told us they were confident that when the new staff had completed their induction and settled in they would be more effective in meeting people’s needs without feeling rushed. Training had been given a high priority in the last six months and we found the staff team were knowledgeable, competent and positive.

People were protected from the risk of abuse and avoidable harm through appropriate policies, procedures and staff training. Staff understood how to recognise signs of abuse and how to report any concerns. They were confident any concerns or complaints they might raise with the manager or provider would be listened to, taken seriously and acted upon promptly and appropriately.

People who lived at Northway House had been involved and consulted in drawing up and agreeing a plan of their care and support needs. Risks to their health and safety had been assessed and people had been consulted and involved in drawing up measures to reduce the risks where possible. The care plans contained basic information on all areas of need. However, there were some areas that would benefit from greater detail. During the inspection the manager showed us new care planning documents they were going to introduce that will enable them to provide better information to staff on key areas of need

Overall the home was maintained to a good standard and appeared comfortable and homely. An improvement plan was in place. Equipment such as gas, electrics, water and fire alarms were regularly serviced and checked. The maintenance records showed repairs were carried out promptly and there was a plan in place to redecorate and improve some areas of the home where decorations were beginning to show signs of wear.

Medicines were securely stored and administered safely by staff who had been trained and were competent.

People participated in a variety of social activities within the home and in the community. Two activities organisers were employed, providing a wide range of activities to suit all individual and group interests. During our inspection we saw staff sitting and talking to people, giving nail care and hand massage, and providing group activities such as quizzes, singing, and arts and crafts. Some people went out for walks or to the shops. We also heard about parties and fetes held in the home. A regular newsletter kept people updated with news about past, present and future events.

People were supported to maintain good health. People had regular health checks and the service received good support from a wide range of healthcare professionals. Local health professionals visited the home when this was requested. Staff from the service supported people to attend hospital and community appointments when needed.

The provider had a range of monitoring systems in place to ensure the home ran smoothly and to identify where improvements were needed. People were encouraged to speak out and raise concerns, complaints or suggestions in a variety of ways. Regular resident’s meetings were held and people told us they could speak out in these meetings. People were also asked to complete survey forms seeking their views on all aspects of the service. We saw evidence of formal complaints raised with the manager and these had been investigated and responded to.