This inspection visit took place on 23 May 2017 and was unannounced. At the last inspection on 6 July 2016, the service was rated as requires improvement overall with specific concerns about the management of people’s medicines and to ensure people who needed help with decision making were appropriately supported.. The provider sent us an action plan on 8 September 2016 which stated how and when they would make improvements to meet the legal requirements. At this inspection, we found that some improvements had been made but further action was still required.

The Old Rectory, Bramshall is registered to provide accommodation, personal and nursing care for up to 30 people some of whom are living with dementia. At the time of the inspection, 20 people were living at the home. There was a registered manager at the service. 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 that improvements had been made and people’s medicines were administered, recorded and stored safely, in accordance with legislation and good practice.

We found that people’s capacity to make decisions was being considered. Staff sought people’s consent before providing care and supported people to make choices over their daily routine. Where people were being restricted to the home’s environment in their best interests to keep them safe, the appropriate approvals had been sought. However, the provider still needed to make improvements where people lacked the capacity to make certain decisions for themselves to fully demonstrate that their rights were being upheld. We have recommended the provider seeks advice on best practice in this area.

People felt safe living at the home and their relatives were confident they were well cared for. If they had any concerns, they felt able to raise them with the staff and registered manager. Risks to people’s health and wellbeing were assessed and managed and staff understood their responsibilities to protect people from the risk of abuse. People’s care was regularly reviewed to ensure it continued to meet their needs. There were sufficient, suitably recruited staff to keep people safe and promote their wellbeing. Staff received training so they had the skills and knowledge to provide the support people needed.

Staff knew people well and encouraged them to have choice over how they spent their day. Staff had caring relationships with people and promoted people’s privacy and dignity and encouraged them to maintain their independence. People were supported and encouraged to eat and drink enough to maintain a healthy diet. People were able to access the support of other health professionals to maintain their day to day health needs.

People received personalised care and were offered opportunities to join in social and leisure activities. People were supported to maintain important relationships with friends and family and staff kept them informed of any changes.

There was an open and inclusive atmosphere at the home. People and their relatives were asked for their views on the service and this was acted on where possible. Staff felt supported and valued by the registered manager.

The registered manager and provider carried out a range of checks and audits to continually assess monitor and improve the quality and safety of the service.

This inspection visit took place on 6 July 2016 and was unannounced. At the last inspection on 30 September 2015, the service was rated as Requires Improvement. We asked the provider

to make improvements to ensure that the rights of people who did not have the capacity to make their own decisions about their care were being protected. We also asked them to make improvements to the systems used to improve the quality and safety of the service. At this inspection, we found that some improvements had been made but further action was still required. We also found improvements were needed in relation to medicines management.

Old Rectory, Bramshall provides accommodation, personal and nursing care for up to 30 people some of whom are living with dementia. At the time of our inspection, 27 people were using the service. There was a registered manager at the service. 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. On the day of our inspection visit, the manager was not working at the service and we were only able to speak with them briefly. However, the provider was at the service for most of the day.

People’s medicines were not always managed safely. Further improvements were needed to the provider’s quality monitoring systems to ensure shortfalls were consistently identified and the necessary changes made.

The manager and staff understood the principles of the Mental Capacity Act 2005 (MCA) but further improvements were needed to ensure people were being assessed in line with the legislation as required. Where people were restricted of their liberty in their best interests, for example to keep them safe, applications had been made in accordance with the legal requirements. Staff gained people’s consent before providing care and support.

People felt safe living at the home and their relatives were confident they were well cared for. If they had any concerns, they felt able to raise them with the staff and management team. Risks to people’s health and wellbeing were assessed and managed and staff understood their responsibilities to protect people from the risk of abuse. People’s care was regularly reviewed to ensure it continued to meet their needs. There were sufficient, suitably recruited staff to keep people safe and promote their wellbeing. Staff received training so they had the skills and knowledge to provide the support people needed.

Staff knew people well and encouraged them to have choice over how they spent their day. Staff had caring relationships with people and promoted people’s privacy and dignity and encouraged them to maintain their independence. People were supported and encouraged to eat and drink enough to maintain a healthy diet. People were able to access the support of other health professionals to maintain their day to day health needs.

People received personalised care and were offered opportunities to join in social and leisure activities. People were supported to maintain important relationships with friends and family and staff kept them informed of any changes. People’s care was reviewed to ensure it remained relevant.

There was an open and inclusive atmosphere at the home. People and their relatives were asked for their views on the service and this was acted on where possible. Staff felt valued and supported by the manager.

We found a breach 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 the report.

We inspected this service on 30 September 2015, it was an unannounced inspection. The Old Rectory (Bramshall) provides accommodation and nursing care for up to 30 people. At the time of our inspection 24 people were using the service. Most of the people living at the home had physical health needs and some people were living with dementia.

There was no registered manager in post at the time of our 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. An acting manager was working at the service at the time of our inspection and was about to start the process of registering with us. We refer to them as the acting manager in the body of the report.

At our last unannounced inspection on 8 May 2015, multiple regulatory breaches were identified and the service was judged to be ‘Inadequate’ and placed into ‘Special Measures’ by us. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

This meant the service would be kept under review and inspected again within six months. We told the provider they needed to make significant improvements in this time frame to ensure there were enough staff to support people, that people received safe care and treatment and were protected from abuse and not unlawfully restricted. We also told them that they needed to demonstrate there was good leadership, management and governance.

At this inspection, we made the judgement that the provider had made sufficient improvements in the provision of safe and responsive care to take the service out of special measures. However, further improvements were needed to demonstrate that the service was consistently effective and well led.

We found the provider was not consistently meeting the legal requirements of the Mental Capacity Act 2005. The legislation sets out the actions needed to ensure that where appropriate, decisions are made in people’s best interest when they are unable to do this for themselves. Some improvements had been made and the acting manager had made referrals for approval to ensure people were being lawfully deprived of their liberty. However, the acting manager had not reviewed the mental capacity assessments in place for people to ensure they met the requirements of the Act.

The acting manager carried out some checks and had taken action to improve the service as required. However, further improvements were needed to ensure the quality and safety of the service was reviewed and monitored on a regular basis to drive continuous improvements in the service.

The provider had taken action to ensure there were enough staff on duty to keep people safe and provide care at the right time. The provider had a planned programme of checks, servicing and maintenance arrangements to ensure people were cared for in a safe environment. Staff were recruited in a safe way because the provider completed appropriate checks before they started work. Staff received an induction and ongoing training and support to equip them with the skills they needed to care for the people.

We found the provider had taken action to ensure risks to people’s health and nutritional needs were met. People had assessments of their needs and care was planned and delivered in a person centred way. People were supported to maintain good health and accessed the services of health professionals when needed.

People told us the staff were good and treated them with kindness. Staff knew people’s needs well and encouraged them to maximise their independence. Staff supported people to make choices about their daily routine and promoted their privacy and dignity. People were offered opportunities to participate in social activities and were supported to follow their religious and spiritual preferences.

There was a procedure for people and their relatives to raise complaints and the provider acted on feedback received.

We inspected this service on 8 May 2015. This was an unannounced inspection.

The service was registered to provide accommodation and nursing care for up to 30 people. At the time of our inspection 28 people were using the service. People who used the service had physical health needs and/or were living with dementia.

Our last inspection took place on 17 September 2014. During that inspection two Regulatory breaches were identified. We told the provider that improvements were required to ensure people received care that was safe and effective. At this inspection we found that the required improvements had not been made.

The service did not have 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 requirements in the Health and Social Care Act and associated Regulations about how the service is run. The provider told us that a new manager had been recruited and they would be registering with us after their induction.

At this inspection we identified areas of unsafe, ineffective and unresponsive care. This was because the service was not well led. 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 the report.

There were insufficient numbers of staff to keep people safe and provide the right care at the right time. This also meant that people’s individual care needs and preferences were not always met.

Some people who used the service were unable to make certain decisions about their care. In these circumstances the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were not being followed. The Mental Capacity Act 2005 and the DoLS set out the requirements that ensure where appropriate, decisions are made in people’s best interests when they are unable to do this for themselves. This meant people could not be assured that decisions were being made in their best interests when they were unable to make decisions for themselves.

The provider did not have effective systems in place to assess, monitor and improve the quality of care. This meant that poor care was not being identified and rectified by the provider.

Risks to people’s health and wellbeing were not consistently managed and reviewed which meant people did not always receive safe care.

Staff did not know how to report alleged abuse to the local authority and records relating to people’s medicines needs were not always accurate. This meant that effective systems were not in place to ensure people’s safety and wellbeing needs were met.

There were gaps in the staffs’ knowledge and skills that meant some people’s specialist needs were not met effectively.

People were not always supported to eat at the right time and the staff could not always show that people’s risk of malnutrition were being managed safely.

People’s feedback about care was not sought which meant the registered manager and provider could not use people’s feedback to make improvements to the quality of care.

When staff had the time they supported people with care, compassion and respect. However, we saw that the staff did not always have the time to consistently support people in this manner.

Systems were in place that enabled people to receive end of life care that met their preferences and people were protected from the risk of infection.

People were involved in the planning of their care and they were able to participate in social and leisure based activities of their choice.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We completed this inspection because we received information of concern that related to how people were supported to move around the home and how new staff were recruited to work for the provider.

In this report the name of a registered manager, Ms Sarah Janet Galer appears, who was not in post at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

At the time of our inspection 26 people were using the service, although one of these people was in hospital. During our inspection we spoke with three people who used the service and two relatives. People and their relatives told us they were happy with the care and shared no concerns with us.

We also spoke with one nurse, five care staff and the new manager. The manager was in the process of applying to become a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We looked at three people’s care records and four staff records to see if they were accurate and up to date.

Below is a summary of what we found. The summary describes what we observed, the records we looked and what the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Based on the information we received we asked if this service was safe?

Is the service safe?

The service was not consistently safe. Equipment to help people to move around the home was not consistently used correctly.

People’s care records did not contain all the information the staff needed to protect people from harm.

The provider could not show us that people were consistently protected from the risks of receiving care from unsuitable staff.

People’s personal and confidential information was not kept safe and secure. This meant there was a risk it could be lost, damaged or accessed without their consent.

In this report the name of the registered manager, Ms. Sarah Janet Galer appears, who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still identified as the registered manager on our register at the time.

We observed interactions and saw that people were relaxed with staff. Staff had a good knowledge of people’s support needs and we saw the staff were respectful when providing this support. One person told us, “The staff are wonderful, so polite and helpful.”

Where people were not able to make decisions, capacity assessments were completed and information about why others had made decisions on their behalf had been recorded. This meant people could be confident decisions had been made in their best interest.

People had care records which recorded how they wanted to be supported. The information we read in the care records matched the care, support and treatment we saw being delivered to people.

We saw people were dressed in their own style. People told us if they needed support the staff would help them to continue to take a pride in their appearance.

Family and friends we spoke with told us they could visit whenever they wanted to. People using the service told us family members were able to continue to provide care for them and were involved in providing support. One person told us. “It’s a home away from home, my family is always made to feel welcome.”

We inspected this service in October 2012, and found the service was not compliant with how people were supported to make decisions and seeking their views. Improvements were also needed with care provision and the environment. We carried out this inspection to check the improvements in these areas.

Where people were not able to make decisions, capacity assessments had been completed. Information about why others had made decisions on their behalf had been recorded to demonstrate why decisions had been made. This meant people could be confident these had been made in their best interest.

We saw the staff provided sensitive support to people, and people were treated with respect. Personal care issues were discussed discreetly and people using the service could choose who they wanted to help them with their personal care requirements.

The registered provider was upgrading the facilities in the building including the kitchen and bathroom areas. The registered person told us this would mean they improved facilities to meet people’s on-going needs.

We saw that people were protected from the risks of abuse because the staff had received the necessary training to identify and report safety concerns.

We saw that there was now a system in place to regularly assess and monitor the service which focussed on service improvement and included the views of people using the service.

We carried out this inspection as part of our schedule of inspections to check on the care and welfare of people using this service. The visit was unannounced, which meant that the registered provider and the staff didn’t know we were coming.

We spoke with four people using this service, four visitors and seven members of staff. People told us they were happy with the care provided and visitors reported that they were made to feel welcome. People said, “The staff here are very caring and I have everything I need.” “I’m very happy here.”

During our inspection, we observed staff treat people with care and respect. We found that care records were informative. We saw that some care practices were not always followed, as we saw care which placed people at risk of falling and choking.

We found that people’s views were taken into consideration when planning their care; however the records were not always in place when people were unable to make decisions for themselves. This meant that we could not be sure that decisions were being made in peoples best interests.

We found that views of relatives about the quality of the service were gained, however people using the service or professionals were not consulted. The provider had not evaluated or developed the service from any information they had received. This meant that valuable feedback which could improve the service was potentially being missed, and people could not be confident their views were being listened to.