About the service: Otterburn is residential care home that is purpose built and, provides personal care and nursing for up to 30 people across three separate units, each supporting 10 people. These units are called Otter, Fox and Squirrel. Care and support is provided to people with complex health needs including rare forms of dementia, physical disabilities, mental health needs and brain injury and neurological disorders. At the time of the inspection 29 people were living at the home.

People’s experience of using this service:

¿ People received safe care. Medicines were managed safely; infection control arrangements were effective in reducing cross infections and there were enough staff to support people and keep them safe.

¿ People were supported by skilled staff with the right knowledge and training. This was important as people had complex and multiple needs.

¿ Staff involved people in decisions about their care and obtained the necessary consent for the care and support provided.

¿ Staff ensured people had access to healthcare services by making appropriate and timely referrals and following their recommendations and advice.

¿ Staff had respectful, caring relationships with people they supported. They respected people's dignity and privacy and promoted their independence.

¿ People's care and support met their needs and reflected their preferences. The provider upheld people's human rights.

¿ People were involved when their care plans were reviewed and were actively involved in decision making in relation to their care and support.

¿ People felt supported and it was apparent from our discussions with staff and what we saw throughout the inspection, that staff cared about people and their well-being.

¿ Effective quality assurance processes were in place to monitor and improve the quality of the service. There was a positive, open and empowering culture.

Rating at last inspection: The rating at the comprehensive last inspection undertaken on 23 and 24 November 2017 was Requires Improvement and the report was published on 22 February 2018. After this inspection we undertook a focused inspection on 20 June 2018 and the report was published on 10 August 2018. At the focused inspection we looked at how the provider had progressed areas of improvement to meet legal requirements.

Why we inspected: This was a planned inspection based on the ratings at the last comprehensive and focused inspection. The rating has improved to Good overall.

Follow up: We will continue to monitor the service through the information we receive until we return, as part of the inspection programme. If any concerning information is received we may inspect sooner.

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

We undertook an unannounced focused inspection of Otterburn on 4 June 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our November 2017 inspection had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At our inspection in November 2017 we identified that Otterburn was in breach of regulation in relation to medicines management and we asked the provider to take action to make improvements. This action has been completed. At this inspection we found that Otterburn had improved and was now meeting the regulation, but remained as requires improvement in the key area of safe.

Otterburn 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.

Otterburn accommodates up to 30 people across three separate units, each supporting 10 people. These units are called Otter, Fox and Squirrel. The home provides care and support to people with complex health needs including rare forms of dementia, physical disabilities, mental health needs and brain injury and neurological disorders. At the time of our inspection there were 27 people living at the home.

The provider is required to have a registered manager at Otterburn. 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. At the time of our inspection. Otterburn did not have a registered manager but we are aware the acting manager had applied to register with us.

People were not always safe at Otterburn. We found that in some cases staff were not following nationally recognised guidance in relation to how they monitored people’s skin conditions or how they recorded the risks associated with weight loss.

Medicine management had improved but there remained some concerns relating to how ‘as required’ or PRN medicines were given and the information available to staff to give these medicines safely. We also found staff were not always following the manufacturer’s guidelines in relation to how they applied medicinal skin patches.

People were safeguarded from potential abuse, and staff knew what to do to report any concerns. Staff had received training and understood their role in relation to safeguarding people.

Staff were recruited safely and the acting manager had processes in place to support staff well. There were good infection control measures in place at Otterburn, and the management had systems in place that meant that they were able to learn from accidents and incidents to help make sure they did not happen again.

The acting manager understood their roles and responsibilities in relation to the law and was applying to become the registered manager. The quality of the care people received was monitored by the acting manager, and over seen by the provider to make sure there were on going improvements.

The co-ordination between staff and other agencies was effective. People had support from staff who communicated well.

We carried out this unannounced inspection on the 23 and 24 November 2017..

Otterburn is a care home with nursing. 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. Otterburn provides care and support for up to 30 people with complex health care needs including rare forms of dementia, physical disabilities, mental health needs, brain injury and neurological disorders. The home is divided into three ten bed units called Otter, Fox and Squirrel. 27 people were living at the home at the time of our inspection visit.

We undertook a comprehensive inspection of this home in November 2016 when we identified that improvements were needed throughout the service. We judged the home to require improvements in all five of our key question and identified three breaches of regulation. We issued a warning notice in regard to the legal breach about Governance. We undertook a focussed inspection in April 2017 to look specifically at the key questions of 'safe’ and ‘well-led’ to check legal requirements had been met. This identified that the warning notice had been met.

This inspection identified that significant effort and improvements had been made in many areas of the home’s operation, however these had not been fully effective in ensuring people received a consistently good service.

The home had not had a registered manager since February 2017. 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. Failure to ensure a registered manager was in place is a breach of regulation. You can see what action we told the provider to take at the back of the full version of the report. The registered provider has recruited a new manager who has commenced the process of applying for registration.

Improvements were needed so that people could be confident they would receive their medicines safely and we found a breach of regulation. You can see what action we told the provider to take at the back of the full version of the report.

People told us, using words and gestures, that they felt safe living at the home. Staff demonstrated a good awareness of their role and responsibilities regarding protecting people and were confident a member of the management team would deal with any concerns reported. People had risks relating to their care and treatment assessed and staff had guidance to refer to about how these should be managed.

Sufficient staff were on duty to meet people's needs and recruitment was on-going to reduce the use of agency staff. Staff were employed through safe recruitment practices.

Staff told us they had received induction, sufficient training and on-going support. Some refresher training and training in specialist areas was needed for some staff. This had been identified by the provider and was in progress.

We saw staff seek consent from people before providing personal care and respected their wishes. People were supported in line with the Mental Capacity Act 2005. Staff demonstrated a knowledge of legislation which promoted people’s right to make decisions about how they lived their lives. Relevant applications had been made and kept under review for people whose liberty was deprived.

Improvements had been made to the choice and quality of food served and people had been appropriately supported with their specific dietary needs. People were supported to access a range of healthcare services.

Relatives were happy with the care provided by individual staff and told us that staff were kind and caring. Staff enjoyed working at the home and many knew the people they supported w

We carried out this unannounced inspection on the 06 April 2017. Otterburn provides nursing care and support for up to 30 people who may be living with a range of neurological conditions. At the time of our inspection 30 people were residing at the home. The home is divided into three separate units, that accommodate ten people each.

We undertook a comprehensive inspection of this home in November 2016 when we identified that improvements were needed throughout the service. We judged the home to require improvement in all five of the key questions we inspect. [Is the service safe, effective, caring, responsive and well led?] The registered provider had breached three of the legal regulations. This was because the systems in place to monitor the safety and quality of the service had not been effective, people could not be confident they would receive safe care and treatment and people could not be certain their needs relating to nutrition and hydration would be well met. We issued a warning notice in regard to the legal breach about Governance. Warning notices are one of our enforcement powers. This inspection was planned and undertaken to look at the key questions of safe and well-led, to check that the action required in the warning notice had been taken, and to provide assurance that people using this service were now safe and receiving a good quality service.

This most recent inspection identified that the requirements of the warning notice had been met in full, and that people could be more confident that their needs would be met and their safety maintained. We received positive feedback about the difference this had made to people's quality of life and safety. We did not look at the action taken to meet the requirement about nutrition and hydration. The registered provider had produced an action plan informing us that improvement had been made. We will look at this in detail at our next inspection.

We undertook this focused inspection to check and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Otterburn) on our website at www.cqc.org.uk.

The home 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 2008 and associated Regulations about how the service is run. The registered provider had recruited a new manager and we were informed that they had commenced the process of applying for registration. Throughout the time the home has been without a registered manager, the registered provider had arranged for another senior member of staff to be in day to day control of the home.

We looked at risks people were exposed to that were related to their health care needs and lifestyle choices. These had been assessed using professionally recognised tools, and had been kept up to date. The checks we made confirmed that people's needs in relation to falls, choking, malnutrition and dehydration, and the risks relating to them developing sore skin had been well managed. We observed staff providing care consistent with the written plans, and staff we spoke with had a good knowledge about how to keep people safe.

Everyone told us that the management team had made a positive impact on the quality of care, environment and atmosphere of the home. People, their relatives and staff told us they felt able to approach the management team with concerns or feedback. People had been supported to provide feedback about their experience of using the service.

The systems in place to monitor the quality and safety of the service had been mainly effective. The management team and systems in place had driven im

We carried out this unannounced inspection on the 08,10 and 16 November 2016. Otterburn provides care and support for up to 30 people with complex health care needs including rare forms of dementia, physical disabilities, mental health needs, brain injury and neurological disorders. The home is divided into three ten bed units called Otter, Fox and Squirrel.

We undertook a comprehensive inspection of this home in November 2015 when we identified that improvements were needed throughout the service. We judged the home to require improvements in all five of our key questions. We undertook a focussed inspection in May 2016 to look specifically at the key question of 'safe.' We looked in detail at the risk management processes for people who were at an increased risk of falls.

This inspection identified that significant effort and improvements had been made in all areas of the homes operation, however these had not been fully effective. The registered provider was not meeting all the legal requirements and people could not be certain their needs would consistently be met.

The home has a registered manager who was present throughout 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.

People told us using words and gestures that they felt safe living at the home. Staff had knowledge of possible signs of abuse and could describe action they would take in reporting any concerns. Action had been taken to improve the number of staff available. However there were not always enough staff available to meet people’s requests for support.

The provider had identified risks to people and had put measures in place to minimise the risk for the person. The systems in place to reduce these risks to people had not all been used accurately and were not being used consistently to be effective.

People received their medicines safely and there were systems in place to monitor medicines administration.

Staff told us they had received induction, sufficient training and on-going support. Feedback we received during our inspection indicated that staff did not always have the specialist knowledge they needed or benefitted from robust and effective handovers between shifts.

Staff had some knowledge of the Mental Capacity Act (MCA) (2005) and described how they supported people with making choices. Our observations showed that staff did not work consistently in line with the principles of the MCA when supporting people. Relevant applications had been made and kept under review for people whose liberty was deprived.

People had access to regular healthcare and specialist advice. It was not always evident that people were always supported to attend healthcare appointments or to take the action advised by healthcare professionals.

Significant improvements had been made to the choice and quality of food served, however people had not always been appropriately supported with their specific dietary needs. You can see what action we required the provider to take at the back of this report.

Relatives were happy with the care provided by individual staff and told us that staff were kind and caring. Staff enjoyed working at the home and many knew the people they supported well. During our observations we saw some good staff practice but we also observed that people were not consistently treated with dignity and respect.

People had some opportunities to be involved in planning their care to meet their individual needs and care was reviewed with people to ensure people were still happy with the care they were receiving.

People had the opportunity to join in with activities in the home and out in the community. These were not as often as some people wi

We carried out an unannounced comprehensive inspection of this service on 4,5 and 18 October 2015. During that inspection we identified breaches of two legal requirements. This was because people were not consistently receiving safe care and because adequate numbers of staff were not always available to meet people's support needs. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We also met with them to discuss our concerns and to hear about the improvements they planned to make.

We undertook a focused inspection on the 18 May 2015 to check that they were following their plan, and continuing to make improvements to ensure they would meet people's needs and the requirements of the law. We also focussed on following up on issues that had been raised indicating that aspects of the premises were not safe and could present a risk to people using the service.

CQC receives information about people's experience of care from a wide range of sources. We received information about incidents that occurred at Otterburn that suggested people had come to harm, and that potentially this could have been avoided. During this focussed visit we looked at the risk to people who were at a high risk of falling to determine if the registered manager had done all that was reasonably practicable to manage these risks, to determine if there were any on-going risks, and to decide whether any enforcement action should arise from any breach of Regulations identified.

This report only covers our findings in relation to the key question, 'Safe'. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Otterburn’ on our website at www.cqc.org.uk’

Otterburn provides accommodation for up to 30 people who require nursing care and support with their personal care. The home supports people who are living with a wide range of neurological disorders. There were 29 people living at the home at the time of our inspection.

The home had a registered manager. They were present throughout the 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 and associated Regulations about how the service is run.

People told us, or indicated with gestures that they felt safe. Staff we spoke with confirmed this, and were able to describe a range of developments that had occurred across the service recently, which in their opinion improved people's safety even further.

People who were at a high risk of falls could not be certain their care would always be planned or provided in ways that would reduce as far as possible the likelihood of them falling and sustaining a injury.

The provider had identified prior to our visit that action was required to ensure the environment and equipment provided was in good order, and that repairs took place swiftly when things broke. We found some improvements had been made, but that further work on this was required.

We found that the number of staff had increased and that the number of staff on duty now reflected the assessed needs of people more accurately. Staff had received additional training, and we observed staff working safely, and demonstrating greater, more in depth knowledge about people's needs.

Work had been undertaken to improve the management of medicines. Nursing staff had received training about medicines. An external audit undertaken by a pharmacist working for the Clinical Commissioning Group (CCG) shortly before our visit provided evidence that the required improvements had taken place.

Summary

This inspection was carried out by two inspectors and a specialist advisor. We spent a day at the home, talking to and observing people who lived in the home, visitors and staff at all levels. We sampled the records. After the visit we spoke to several relatives and professional visitors to the home on the telephone to find out their views.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

We spoke to several people who lived in the home and several relatives/visitors. People told us they felt safe. One relative told us, “I am happy that (person’s name) is safe there.”

People were safe and their health and welfare needs were being met because staff were supported to gain appropriate skills and experience.

We found that the home’s safeguarding procedures were robust and staff understood their role in safeguarding the people they supported. We checked staff training records and saw that staff had received recent training in safeguarding vulnerable adults.

CQC monitors the operation of the Deprivation of Liberty Safeguards, (DoLS), which applies to care homes. We found that the manager understood her responsibilities in relation to the law and had planned further training for staff so that they would be made aware of new developments in this respect..

We checked people’s care plans and found them to be detailed, relevant and up to date. This meant that staff had appropriate information for them to provide safe and appropriate care.

We found that there was a need for some records of the review of the plans to be more detailed and the manager showed us that she had planned to provide more training for staff in this respect.

We found that care was provided in an environment that was accessible, clean and adequately maintained.

Is the service effective?

People told us that they were happy with the care they received. One person told us, “It’s nice here...it looks nice and we all get on.”

We found that care staff knew the people they supported very well.

Staff training records showed that staff had received appropriate training in a number of relevant areas, including food hygiene, Huntington’s disease, moving and handling and infection control. This meant that staff had the appropriate skills and knowledge to ensure that people received safe, appropriate and effective care.

People’s needs were assessed and care and support was planned and delivered in line with their individual care plans. We saw that people had regular access to a range of health and social care professionals which included general practitioners, dentists, chiropodists and opticians.

People had access to activities inside the home and in the community. Some people told us that they were pleased with the activities and others said that they would like there to be more activities and outings outside the home.

Is the service caring?

Staff demonstrated on the day of our visit that they treated people with respect and they sought consent before providing care and support.

We saw that care staff being patient with the people they were supporting.

Relatives and visitors told us that the manager and staff were supportive towards them when they had concerns or worries.

Is the service responsive?

Records showed that meetings were held between staff, people using the service and people’s relatives/visitors to discuss on-going concerns and improvements at the home including meals, activities and laundry.

We found that care staff had regular one to one supervision meetings. This meant that care staff had the opportunity to discuss their training and development needs, welfare and any concerns they might have about the people they were caring for.

People living at the care home, their relatives and visitors told us that they would have no hesitation in telling the manager and staff if they were unhappy or had any complaints about the service they received. We were told that the manager and staff had listened when people had raised concerns.

Is the service well-led?

The manager whose name appears on this report no longer works at the home. Her name appears because it has not yet been removed from our register. The present manager has applied for registration.

We found that the manager had implemented changes which meant that the home now complied with the requirements of the relevant legislation. These included improvements in relation to the care, staff training and records. The manager told us about the measures she had planned to make sure that there were further improvements in relation to the records and staff training.

We saw that the manager was well known to the people who lived in the home and the relatives to whom we spoke. People told us that they had no difficulty in contacting the manager when they needed to do so.

We undertook this inspection after receiving concerning information about the home. This included concerns about the care of people with tracheotomies and autism. There were also concerns raised in relation to delays in responding to incidents that occurred at the home.

Many of the people who used the service had complex health needs and were not able to tell us about the care they received. We spoke with six people who used the service who were able to tell us a little about their experiences of the home and the relatives of two people who used the service. The people we spoke with told us that they were happy living at the home and described the home as, “great”, “excellent” and “alright.”

We found that in most cases care provided was good and that people received the day to day care and support that met their needs. We found that there were areas for improvement for example around the care of people with incontinence, support for people at risk of falling and staff support to help people with oral health care.

We found that there was a high proportion of newly recruited nursing staff from a variety of nursing backgrounds at the home. Induction training did not however routinely include the typical health conditions of people who used the service. Whilst staff were supported to deliver safe care and treatment to some people who used the service this was not consistent for all living in the home. We found that on occasion the home admitted a small number of people for whom there was an insufficient skill base among staff to provide care and support to adequately meet their needs.

During our visit we spoke with four people who used the service. Many of the people who used the service had complex health needs and were not able to tell us about the care they received. We therefore used a number of other methods to help us understand their experiences. This included speaking to four relatives of people who used the service, six members of staff and observing care on Fox and Squirrel units.

The people we spoke with told us that they were involved in discussions about their care and that staff respected their wishes and choices.

People were complimentary about the care and support that they or their relative received at the home. Comments we received about the service included: “It is really good, I would never move, I like it here” and “It’s the best possible place [my relative] could have been in.”

People told us that they felt safe at the home and safeguarding procedures in place helped to minimise the risk of harm to people who used the service.

Processes for the recruitment of staff helped to ensure that people were cared for by suitably skilled and experience staff.

Systems were in place to monitor how the service was run and ensure people received a quality service. Although we did find that monitoring information to keep people safe and well was not consistently maintained.

The report refers to two managers. Mrs. Gaynor Dingley-Smith is the current registered manager. The previous manager has not yet applied to be de-registered.

We used a number of different methods to help us understand the experiences of people using the service. This included the support from an expert by experience who has personal experience of using or caring for someone who uses similar types of services. The expert by experience spent time talking to people and observing the care provided.

People at Otterburn had complex needs and many were not able to speak with us. We spoke with six people who used the service and the relatives of three people who could not communicate with us directly. We also spoke with three members of staff and the registered manager. We spent most of our time on two of the units, Otter and Fox which are located on the ground and first floors of the home.

Most people we spoke with were satisfied with the service they received. One person told us: “I think the care is excellent” and added that “the staff are kind and understanding”. A relative we spoke with told us “It’s a good place; they (the staff) are very good”. Another relative expressed some concerns about the care provided and had made a formal complaint. We were advised that a multi-disciplinary team meeting had been arranged to discuss the concerns about this persons care needs.

During our visit we observed care being given and people appeared comfortable. We saw that staff patiently supported people who needed assistance and responded quickly and calmly to emergencies when a person experienced an epileptic fit. We saw people using the in house sensory room but were told by people who used the service that since the activities co-ordinator had left involvement in social activities had reduced. The manager informed us that this post would be replaced.

We carried out this review to check on the systems in place to monitor and improve the quality of services being provided to people living in Otterburn.

We did not speak with people living in the home whilst reviewing the monitoring of the quality of service provision at Otterburn. However, during our short visit we observed that people were relaxed and at ease with staff and within their home environment. We saw people were taking part in small group craft activities. Others were following their own preferences in being alone, doing a jigsaw or in the room where computers can be used. The atmosphere was generally calm, relaxed and homely.

Following our visit we spoke with six relatives who told us that they were satisfied with the care and support their family members received. When we asked relatives if they knew how to make a complaint they told us that they knew how to do this. Some of the comments received included:-

‘’Always being consulted.’’

’’Safe environment.’’

‘’Perfectly happy with the care X (person’s name) is receiving.’’

‘’Staff are very nice, friendly people and the home is very clean.’’

‘’Do trust them, have X’s (person’s name) best interests at heart.’’

‘’All staff very good.’’

‘’Everybody’s well cared for and staff are there for all.’’

We saw that the experiences of people who were living in this home and their representatives were sought through meetings and satisfaction surveys. We found these practices assisted people in sharing their views to shape the standard of care, support and treatment they received whilst living in Otterburn.

We found that there were checking and monitoring procedures in place to ensure the quality of the services people living in this home received were improved, for the benefit of those who were living in Otterburn.

This inspection took place on 04, 05 and 18 November 2015 and was unannounced. At our last inspection in July 2014 the provider was complying with all the regulations we looked at.

Otterburn provides care and support for up to 30 people with complex health care needs including dementia, physical disabilities, mental health needs, brain injury and neurological disorders. The home is divided into three ten bed units called Otter, Fox and Squirrel.

Otterburn is required to have a registered manager in post. A manager had been recruited to the home and had been in post since February 2015, but at the time of our inspection the manager had not applied for registration. This meant that the registered provider was in breach of their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like the registered provider they are a 'registered person.' Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. 

People were not consistently kept safe from the risk of harm associated with their health care conditions. People's healthcare needs had not all been well assessed, planned or delivered. Some essential parts of people's healthcare had been omitted, and ways of reducing risks to people were not being managed well. 

People were not always being supported by enough staff, or by staff with the required skills, experiences or training to meet their specialist needs.

People were not always getting the nursing and healthcare they required to maintain good health, or achieve the best possible health outcomes.

People were not always getting the support they required to eat and drink enough. Where people were at risk of malnutrition or dehydration inadequate records were being maintained to enable staff to monitor the person's food and fluid intake to help them determine what further action or support people needed.

We found that staff usually sought people's consent before offering care and that the required applications had been made to the local authority in line with legislation to protect their legal rights.

People could be confident that the staff supporting them would always work with kindness and compassion. People's dignity and privacy was consistently maintained.

Some people had enjoyed specific activities and had been supported to go on holiday this year. However on a day to day basis most people did not have access to activities that they would find interesting, stimulating or helpful in reducing the risk of social isolation.

The provider had a complaints procedure and records showed complaints had been identified, investigated and reported. People we spoke with did not always find that their complaint had resulted in the desired changes taking place.

The service was not consistently well led. Our observations showed that the nurses did not always  provide clear leadership or that they always had the clinical skills required to lead a shift. The providers own audits used to monitor safety and quality had not all been effective at identifying areas for improvement or driving forward improvements.