About the service: Overdene is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home accommodates up to 70 people and 57 people were living at the home at the time of our inspection.

People’s experience of using this service: People were protected from the risk of abuse and harm. All staff had completed training about safeguarding and they understood their responsibilities for keeping people safe and reporting any concerns about people's safety. The risks people faced in their lives were fully assessed in order to keep them safe. Robust recruitment and matching procedures were followed for staff. Staff were always visible during our visit to assist people. Medicines were safely managed. Accidents and incidents were reported in an open and transparent way and an analysis undertaken to prevent further occurrences and learn from them.

An holistic approach had been followed in the assessing, planning and delivery of people’s care and support. Care plans were detailed and person-centred and reflected people’s personal preferences. Staff provided care and support that was met in a way people preferred and provided positive outcomes. Staff worked to provide a better quality of life for people by supporting them to develop in areas of daily living. People spoke positively of the support provided.

People and family members confirmed how kind and caring staff and the management team were. They considered they had a good relationship with the staff team. Staff and management sought to provide good, person-centred care. People told us they felt listened to. Staff and managers had the skills available to support people and their relatives if they were reaching the end of their lives.

The management staff at the service demonstrated experience and capability to deliver good care. Managers and leaders had knowledge and a person-centred approach which directed staff to provide a good standard of care. Managers sought to gain the views of people in a meaningful way which informed the development of the service. The management team sought to work closely in partnership with other agencies who were stakeholders involved in people’s lives.

Rating at last inspection: The service was rated as requires improvement overall at our last inspection in March 2018. This was because we wanted to see a period of sustained improvements and good practice following the issues we identified in June 2017. The service had now demonstrated sustained good care and has been rated good overall

Why we inspected: This was a planned inspection based on the rating on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-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

This inspection took place on the 12 and 13 March 2018. The inspection was unannounced on the first day with the registered provider aware we intended to visit on the second day.

We previously carried out an unannounced comprehensive inspection of this service on 21 April and 9 June 2017. Breaches of legal requirements were found in relation to Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As a result of this rating, the service was placed into special measures. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safety, effectiveness, caring, responsiveness and well led to at least good

At this inspection we identified that the required improvements had been made.

While no breaches were identified at this visit, we have rated the location as requiring improvement overall. This is because the registered provider needs to demonstrate a period of sustained good practice.

Overdene House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Overdene House is situated within a residential area of Winsford, Cheshire. On the first floor nursing care for older people is provided. On the ground floor residential and respite care is provided for older people as well as adults with physical disabilities. There were 45 people residing in the home on the day of the inspection.

There was a registered manager. This 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 manager had come to work at Overdene House since our last inspection.

Our last inspection identified that people were not being provided with a safe service. People were not being supported to take their medication as prescribed. We had found that prescription pain relief had not been re-ordered in a timely manner which meant that people did not receive pain relief for more than a week. Medication audits were not effective as the actual stock of medication did not tally with stock recorded on audits. This had meant that the registered provider could not be sure that people had received their medication as required.

This visit found that the registered provider had introduced a more regular and robust audit of medications. Systems of re-ordering medicines had been improved. As a result, people who used the service were appropriately provided with their prescribed medication.

Our last inspection also identified that effective action had not been taken following serious incidents. For example one person had managed to leave the building placing them at risk. The premises had not been secured following this incident. Other risks at that time involved people given food that presented a choking hazard to them despite dietary advice and an incident involving a person falling down the side of their bed. In these instances, no subsequent action had been taken to prevent reoccurrence.

This visit found that the premises were secure and that no further incidents had occurred. There was evidence that the registered provider had made arrangements to prevent adverse incidents occurring. This had been achieved by prompt action being taken to ensure that any incidents were investigated and analysed to prevent future re-occurrence. In addition to this, information for both kitchen and care staff was robust meaning that people could not be at risk of choking if given inappropriate food.

At our previous inspection we identified that the registered provider did not have effe

Overdene House is registered to provide support for up to 70 older people, or people living with a physical disability who require nursing and personal care. At the time of the inspection there were 50 people living within the service.

We previously carried out an unannounced comprehensive inspection of this service on 15 February 2017. Breaches of legal requirements were found. After the comprehensive inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we identified that the required improvements had not been made and there were continuing breaches of Regulations 12 and 17.

This inspection was unannounced and took place on the 21 April 2017 and the 9 June 2017. The inspection initially started as a focussed inspection to look at concerns that had been raised in relation to the ‘safe’ and ‘well led’ domains. However, following the first day of the inspection we received concerns that were being investigated by the police and the local authority safeguarding team. This resulted in us revisiting the service on the 9 June 2017 to carry out a full comprehensive inspection. The report cannot comment on the concerns being investigated by the police, as the investigation is still underway.

The service did not have a registered manager in post. The previous registered manager had left shortly before the inspection in April 2017. At the time of the inspection visit the deputy manager was running the service with support from the area director. 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 last inspection we identified a breach of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because systems were not effective at ensuring the safety and quality of the service being provided, the premises were not always safe and secure, the call bell system was not functioning and people were not always being protected from the risk of malnutrition. At this inspection we found that not all the required improvements had been made. This has resulted in a repeated breach of Regulations 12 and 17. In addition to this we have also identified a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 due to issues around staff training and supervision.

People were not always protected from the risk of harm. For example, during the inspection we identified that one person had managed to abscond from the service on two separate occasions over a period of four days without the required level of support. In another example staff did not have a good knowledge around people’s dietary needs which had resulted in two people being given an inappropriate diet, and one person choking. In both examples effective measures had not been put in place following initial incidents which had enabled the incidents to reoccur. This showed poor risk management and placed people at ongoing risk of harm.

Parts of the environment were not always safe. The lift motor room door was left unlocked, and a cupboard containing electricals which displayed hazards signs was also left open. This placed people at risk of injury should they access these. On the second day of the inspection we found these to be secure.

Audit systems were not always robust. For example, medicines audits showed that an analysis of information relating to variances in stock levels had not been carried out, which meant that the registered provider could not be sure that people had received their medication as prescribed. In thre

The inspection took place on the 24 November 2016 and was unannounced.

Overdene House provides support to up to 70 people who require nursing and personal care. At the time of the inspection there were 44 people living within the service.

There was a manager in post within the service, however they were not yet registered with the CQC. 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 last inspection in February 2016 we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered provider sent us an action plan which showed that these issues would be rectified by the 31 May 2016. At this inspection we found that sufficient action had not been taken to rectify the issues identified. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At the last inspection in February 2016 we identified that doors were not always kept locked to prevent people from leaving without the required support. During this inspection one fire door had the exit code written on a piece of paper and stuck to the door. In June 2016 Healthwatch also identified that one of the fire doors had been left open. This compromised the safety and security of people using the service.

Risk assessments were not always accurate. Two people had not been referred to the dietician in a timely manner despite being at high risk of malnutrition. In both examples the risk assessment tool had been completed incorrectly. This place these people at risk of weight-loss and declining physical health.

The call bell system was not fit for purpose. In one example staff had not been aware that one person had pressed their call bell to ask for help. This call had failed to register on their handheld call monitors because previous calls had not been deleted, and the device was full. This meant that staff were not always aware that people were in distress or needed help.

Audit systems were not robust. An analysis of falls and care records had not consistently been completed, and weight monitoring audits had failed to identify that appropriate action had not been taken to refer two people to the dietician. Environmental checks had failed to identify that the safety of the premises was compromised by having the exit code written on the fire door.

You can see what action we told the provider to take at the back of the full version of the report

The registered provider had a system in place to gather people’s views on the service. The report from this showed that only one person had used this system since June 2016. This showed that this was not an effective method of gathering information. We have made a recommendation to the registered provider around ascertaining people's views about the service they receive.

Staff had received training however the registered provider’s records showed that this was not always up-to-date. For example almost 25% of staff did not have up-to-date training in safeguarding vulnerable people and 27% of staff did not have up-to-date training in infection control. However staff had a good understanding of safeguarding procedures, and we did not observe any poor practice in relation to infection control. The manager confirmed that training in these areas would be provided.

At the last inspection in February 2016 the registered provider was not complying with the Mental Capacity Act 2005 (MCA). During this inspection we found that action had been taken to rectify this. Staff had received training in the MCA and were aware of their roles and responsibilities in relation to the Act. Mental capacity a

The inspection took place on the 16 February 2016 and was unannounced.

Overdene House provides nursing care for up to 70 people. The service is situated in the Winsford area of Cheshire. Respite support is also offered to people who are referred into the service via their GP or social services. At the time of the inspection there were 56 people living within the service.

The service has a manager who was registered with the CQC in January 2015. 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’s safety was put at risk because the safety and the security of the premises were not always maintained. One of the fire escapes was unlocked which meant that people who were at risk could leave the premises without the required support and supervision. A door leading up to the attic was unlocked which placed people at risk of injuring themselves on the stairs. Also sluice rooms remained unlocked throughout the day which placed people at risk of infection. These issues were remedied prior to us leaving the premises.

The registered manager had failed to remedy issues around the safety and security of the premises after we raised them with her, which placed people at continued risk of harm. You can see what action we told the provider to take at the back of the full version of the report.

Care records contained information around people’s mental capacity, however we found examples where this had not always appropriately been assessed in line with the principles of the Mental Capacity Act 2005 (MCA). Staff did not always understand the principles of the MCA or how to incorporate these into their work. We have made a recommendation about staff training on the subject of the MCA.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). The registered provider had made applications to the local authority for those people who required deprivation of liberty safeguards (DoLS) as required by law.

People were protected from the risk of abuse. Staff had completed safeguarding training and they understood the different types of abuse, along with the signs and indicators that may accompany them. Staff were aware of how to report their concerns.

People told us that there were enough staff to meet their needs and that they did not have to wait long for support if they pressed their call bell. Rotas indicated that staffing numbers were consistent, and we observed sufficient numbers of staff on duty.

Recruitment processes were sufficient to ensure that people’s safety was maintained. New staff were required to provide two references and had been subject to a check by the disclosure and barring service (DBS). A DBS check helps employers decide whether applicants are suitable to work with vulnerable people.

People told us that they enjoyed the food that was provided and that there was a variety of choices on offer. People were able to have a different option if they did not like what was on offer, and staff had a good knowledge of those people who required a special diet.

There was a good rapport between people and staff and we saw examples where staff were kind to people and treated them with dignity. Staff were respectful of people’s privacy and effective measures were in place to ensure people’s confidentiality was maintained.

People told us that they had choice and control over the support that was provided, and care records contained information around people’s like, dislikes and preferred routines.

Staff meetings were held on a daily bas

This inspection helped us answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was safe.

People were treated with respect and dignity by the staff and people told us they felt safe.

Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards and the required authorisations had been applied for. Relevant staff had been trained to understand when an application should be made, which meant that people's rights were upheld.

The manager set the staff rotas, making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were met.

Is the service effective?

The service was effective, providing appropriate care and support.

People's health and care needs were assessed with them. People who used the service and their relatives were involved in writing their care plans and they reflected people's current needs.

Visitors were able to see people in private and visiting times were flexible.

Staff were well trained to carry out their role.

Is the service caring?

People told us that they were happy with the service and well cared for. Comments from people who used the service included: "I am glad to be here, it feels like home"; "I am happy here and well looked after"; "All the staff are very nice". A relative commented "I would recommend Overdene to others for the caring approach and dedication to making its residents feel they do matter".

People were supported by kind and attentive staff. We saw that nurses and care workers showed patience and gave encouragement when supporting people.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The service responded to people's care needs.

People said that staff responded to call bells and supported them to meet their needs, but some people said they would like more activities and outings.

People knew how to make a complaint if they were unhappy. We looked at how complaints had been dealt with, and found that the responses had been open, thorough, and timely.

Is the service well-led?

The service was well-led.

Staff told us they were clear about their roles and responsibilities and had a good understanding of the ethos of the home. They said they felt well supported by the temporary manager.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We spoke with five people that used the service. They told us they were happy at the home and had no concerns with the care and treatment they received. Comments from them included: “The staff are lovely. I’m certainly looked after” and “They (the staff) are wonderful. I can’t fault them.”

We found that care plans demonstrated people's weight was monitored on a regular basis. We saw that nutritional assessments to identify if people were at risk from malnutrition also formed part of people's care plans. Where a risk had been identified additional care plans were in place.

We found that staff felt well supported and they had the information they needed for their roles. From discussions with staff and examination of training records we saw that staff were supported by the company to gain National Vocational Qualifications (NVQ) levels 2 and 3 in social care. Comments from staff included: “Hand on heart I have not worked anywhere else as good as here” and “We are going in the right direction under Steve (the manager). We are well supported.”

From discussions with staff and people who used the service we found that there were enough qualified, skilled and experienced staff to meet people’s needs.

We contacted the Local Authority prior to our inspection who confirmed they had no concerns about the care provided at Overdene House.

For the purposes of this visit, we were accompanied by an expert by experience who had personal experience of using or caring for someone who uses this type of service. The expert spent time talking to individuals who live at Overdene as well as observation of staff practice. Comments made to the expert included:

“I really like this place, I think of it as my first home”.

“The staff are great people who always make you welcome”.

“Of course we can do what we want it’s our home isn’t it?”

“I am very happy here and the girls look after you well.”

“They know what you like and get it for you.”

“We are encouraged to be self reliant but they will still do anything for you if you ask”

“Staff ask me regularly how I am.”

“The staff know all my likes and dislikes.”