Park House is registered to provide accommodation and personal care for up to 21 older people living with dementia and other physical health needs.

The home had 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out a previous unannounced comprehensive inspection of this service on 13 May 2015. The service was rated as requires improvement overall. Breaches of legal requirements were found and improvements were required in relation to risk assessments, care plans and the storage of medicines.

The provider sent us an action plan which detailed how they were planning to make improvements and they sent us an updated action plan in February 2016 telling us all actions had been completed. At this inspection we found action had been taken to respond to our concerns and improvements had been made.

This inspection took place on 17 and 18 October 2016 and the first day was unannounced. At the time of our inspection there were 18 people living in Park House. People had a range of needs, with some people being more independent and others requiring more support with their mobility and health needs.

Following our previous inspection in May 2015 a new manager had started at the home and had registered with the CQC. Since the registered manager had started in the service they had made a number of improvements. New care plans had been created for each person, new risk assessments had been implemented, improvements had been made to the environment and new staff training had been delivered.

People were protected from risks relating to their health, their mobility, their medicines, their nutrition and their behaviours. Staff had assessed individual risks to people and had taken action to seek guidance and minimise identified risks. Where accidents and incidents had taken place, the registered manager had reviewed these, had learned from them and had taken action to reduce the risks of reoccurrence.

Although we found some people’s risk assessments lacking within their care plans, verbal risk assessments had taken place and staff knew what actions needed to be taken to protect people. As soon as the missing risk assessments were highlighted to the registered manager they took action to rectify this. The registered manager also put in place a new auditing system to ensure risk assessments were created and updated as soon as people’s needs changed.

People were protected by staff who knew how to recognise possible signs of abuse. Staff knew what signs they would look for and the procedures they would follow to report these. Safeguarding information and contact numbers were accessible to staff who told us they felt comfortable and confident reporting concerns. Recruitment procedures were in place to ensure only people of good character were employed by the home. Potential staff underwent Disclosure and Barring Service (police record) checks before they started work in order to ensure they were suitable to work with vulnerable people.

Staffing numbers at the home were sufficient to meet people’s needs. Staff spent time chatting to people and dedicated one to one time with each person. Staff responded to people without delay and cared for people in an unrushed manner. Staff supported people to take their medicines safely. Changes had been made following our previous inspection to increase the suitability of the medicine cupboard and during our inspection we saw staff following best practice when administering medicines.

Improvements had been made to the environment following our previous inspection in May 2015. Some people’s bedrooms had been renovated and some signage had been added to the home. We found that further im

This inspection was unannounced and took place on 13 May 2015.

Park House is a care home without nursing, which provides care for up to 21 people. People who live at the home are older people who may be living with a dementia or have mental health needs.

There is a registered manager in post. 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 home was not always safe. People were not always protected from risks presented by other people who lived at the home, or from risks associated with the building. This was because risk assessments lacked necessary detail, did not contain sufficient guidance for staff, sufficient control measures or had not been updated to reflect changes.

Systems to assess and review the quality of care provided had not always been successful in identifying shortfalls in practice or inappropriate care. Some areas of the building were looking tired and some rooms had an odour problem.

People were not always protected by the home’s understanding of legislation in place to protect their rights. A recent safeguarding concern had indicated that staff had carried out actions that had not been in line with the Mental Capacity Act 2005. However, staff on the inspection demonstrated an understanding of the Mental Capacity Act 2005 and the principles of consent.

People did not all have clear care plans detailing their needs or how they were to be met. One person did not have a completed care plan despite being at the home for nearly four weeks and other supporting information about their needs could not be located. Other people’s plans did not all include sufficient detail to determine how their care was to be provided or their needs met consistently.

People were able to take part in organised activities, but these would benefit from development. We have made a recommendation in respect of activities to meet the needs of people living with dementia.

People were protected from the risks associated with medicines, but we have made a recommendation about the medicine storage facilities.

Staff were creative in encouraging people to eat well. The home’s chef had suggested new themed menus that involved serving meals from different countries throughout the world, with a different country each day. Menu plans offered a choice of three main dishes, three side dishes and two dessert options for the main meal for people to select from. People were offered choices just prior to the meals being served, and the meals served were hot and appetising. People really enjoyed the meals they ate and extra helpings were available. The registered manager told us that they had monitored the meals taken and found that not only had waste been reduced but people were enjoying the meals more and putting on weight.

Risks of abuse to people were minimised because staff had received training in recognising and reporting abuse, and staff had a clear understanding of what constituted abuse. Where concerns had been identified the home had taken appropriate action to support people and safeguard their well-being.

People were protected by the home’s staff recruitment procedures, and there were sufficient staff on duty to meet people’s needs both by day and night. People benefitted from good visual clues and information available to support them to retain their independence and navigate themselves around the building.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provides a process by which a person can be deprived of their liberty when they do not have the capacity to make certain decisions and there is no other way to look after the person safely. Applications had been made for deprivation of liberty safeguards authorisations where people were considered to be deprived of their liberty.

People received care and support from staff who had the skills and knowledge to meet their needs, and had access to community healthcare services.

Staff knew people well and were positive about their care. Staff spoke about people with concern for their well-being. Care was given to preserve people’s dignity, and staff were respectful of people’s choices for example with regard to dress.

People benefitted from an effective system to manage complaints or concerns about the home. The registered manger and staff learned from events or incidents and were creative about putting learning into practice.

We found a number of breaches of regulations and you can see what action we told the provider to take at the back of the full version of the report.

We carried out this inspection to follow up on concerns we had identified at our last inspection of the home on 2 April 2014. These concerns related to the management of the home, care and welfare of people and the premises. On this inspection we saw that improvements had been made.

This inspection was carried out by an adult social care inspector and an expert by experience. During the inspection we looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

We carried out this inspection to follow up on concerns we had identified at an inspection on 2 April 2014. On this inspection we found that improvements had been made.

Park House is a care home for up to twenty one older people, many but not all of whom were living with dementia or mental health needs. On the inspection we spoke with seven people who lived at the home about their experiences there. We also spoke with two relatives, three members of staff and the team leader on duty. We reviewed records relating to the management of the home which included four care plans in detail and observed the care and support people received.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

We observed staff delivering care to people. We saw that they were relaxed, confident and supportive towards people even when they presented challenges or hard to manage behaviours.

People told us that the staff were kind, caring and supportive. One person told us “The staff are good…they’re kind and make me comfortable… they do everything for me”. A visitor told us their relative was “contented here. I appreciate the place and how well she’s looked after”.

Staff we spoke with understood people’s needs, personalities and aspects of their lives before entering the home. People told us staff took their wishes into account when delivering care. One staff member told us they “go with the flow” of people’s day.

Is the service responsive?

We saw that the home responded to changes in people’s needs. For example at the last inspection we had concerns that where people had lost weight, and this had been identified on their care plans and risk assessments, action had not been taken to refer the person to their GP or dietician for investigations. On this inspection we found that this had been done.

In another instance we saw that one person had been increasingly agitated and presented increased risks to others around them in the days prior to our inspection. We saw that action had been taken to contact the responsible clinicians and review the person’s mental and physical health as well as trialling medication to manage their agitation. This told us the home responded well to support changes in people’s well-being or mental health.

We also saw that when the questionnaires sent to relatives and people living at the home had been analysed the home had altered the menus. They had been made more seasonal and provided two hot options and a lighter cold option for each meal. This had led to greater choice for people and showed the home responded to comments made to improve the service.

Is the service safe?

People told us they had full confidence in the staff to support them and their care safely.

We saw that risk assessments had been improved since the last inspection, and where concerns were identified action plans were put in place to reduce risks. Some personal risk assessments were being improved to make them more person centred for the individual. However, some care plans we saw did not have detailed strategies for staff to support them in managing behaviours that were challenging in a consistent manner.

We saw that where improvements had been made following the last inspection to improve the control of infection these had been maintained.

Work was planned to improve the safety of the grounds so that people could spend more time outside.

Is the service effective?

We saw that the home had taken steps to help make the environment more dementia friendly for people. We saw for example that the home had put up signs to help people orientate themselves better around the home. We heard one person following the signs and saying to themselves “This way to the toilet. That’s what I want.” Staff told us the signs had been particularly effective for this person. This told us that these actions had helped increase this person’s independence and sense of well-being.

We saw other instances where changes had been made that had improved the effectiveness of people’s care. We saw for example that one person’s nutritional risk assessment had indicated they were at high risk on admission due to a low Body Mass Index (BMI). We saw that the person had gained weight since admission and was now at lower risk. This had been achieved through a higher calorie diet and monitoring of their food intake. We looked at another person’s file and saw that they had continued to lose weight despite having a higher calorie diet. We saw the person had been referred to their GP for a health evaluation as a result. This told us that the systems for monitoring people’s care needs were effective in identifying risks to the person’s health.

Is the service well led?

On this inspection the provider and manager were not available so the inspection was conducted with the team leader. We saw that they had a clear understanding of their role and the ethos of the home. They were able to explain management systems to us and locate records needed. This told us that information about the management of the home was understood by the staff who worked there.

A relative we had spoken with told us “I wanted (my relative) to move from the previous home and I was given a choice of three. This was the best…It’s clean and tidy and the staff are obliging and helpful.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. We saw that since the last inspection the home had increased the number of audits that were being carried out. We also saw a new audit system for incidents, accidents and near misses. Falls were being audited every three months as an example. We saw evidence that people had been referred to the falls team for specialist advice as a result of this analysis.

We also saw the home had adopted targets for improvement on a monthly basis for staff to focus on. The team leader told us that the recent target had been for staff to have an increased awareness of the use of protective infection control equipment, such as gloves and aprons and improved hand washing techniques. There had been spot checks on staff including the use of ultra violet gels and lights to assess how well hands had been washed. This told us the home thought about ways of ensuring that staff were involved in understanding the need for improvement and quality at all levels.

We saw a new audit system was in place to assess complaints and concerns raised and identify actions required to prevent a re-occurrence. We saw that there had been a number of concerns or complaints raised about the home in 2014, many of which had been managed through safeguarding processes from the local authority. We saw that the home had acted quickly to protect people where concerns had been identified.

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?

On our last inspection of the home in January 2014 we had concerns over the cleanliness and infection control practices at the home. Following that inspection the provider had sent us an action plan telling us what they were going to do to put things right. On this inspection we saw cleanliness and infection control practices had improved.

We found that there were enough staff on duty to support people. Staff knew the people living at the home and could tell us about how they liked their care to be delivered.

We saw actions had been taken to reduce risks to people, for example through assessments of security of the premises and risks from hot surfaces or water. However we identified some other risks presented by the premises, such a trip hazards from some carpets.

CQC monitors the operation of the Deprivation of Liberty safeguards which applies to care homes. We discussed the deprivation of liberty safeguards (DOLS) of the Mental Capacity Act 2005 with the team leader. We found she was aware of the legislation and did not feel that there were people at the home who may be subject to the safeguards. No applications had been made to deprive people of their liberty.

Is the service effective?

We saw that people’s healthcare needs were assessed and they had been involved in compiling their plans of care where they were able. Where they were not able the plans had been contributed to and signed by their relatives. This had included giving information about people’s pre-existing life histories, hobbies and interests. People’s plans were being reviewed regularly. However we saw instances in the care plans where assessments identifying care needs had not led to action by the home. This gave us concerns that people were not having care delivered effectively or in accordance with their assessed needs.

One person we spoke with told us they were “under the hospital” for a number of health problems. They told us they received the support they needed to manage their condition and were always asked about what they wanted to happen.

Is the service caring?

We saw that people were spoken to respectfully by the staff. We saw one person being supported to eat by a staff member. We saw this was done at a suitable pace for the individual and with good verbal and eye contact. This helped calm and reassure the individual. People had their hair styled and cut by a hairdresser during the day and one person told us they had a new apron to wear which they really liked.

People we spoke with told us that their needs were met. One person said “We are all like family here” and another said “They look after me well enough. They help me with the things I need and I do what I can for myself”.

Staff we spoke with wanted to do a good job and work well to support people. We saw they understood the needs of the people they were caring for and were thoughtful when discussing their care and how it was delivered. We saw people were given choices for example with regard to getting up in the mornings and meals. Individuality and personality traits were celebrated.

Is the service responsive?

We did not find that the service was always responsive to people’s assessed needs. As an example we found that the environment had not been adapted to the needs of people with dementia. We also found that activities were not personalised to meet individual’s needs or planned in a person centred way. However staff did tell us about strategies they used to support people who were distressed or agitated and this reflected an understanding of individual needs.

One person told us “They know when I like things done and they try to make sure they are here at the right time to help me”.

Is the service well led?

We found that there was a lack of robust management, quality assurance, quality monitoring and strategy at the home. This meant that the service could not demonstrate to us how they ensured the people that lived there were protected against the risks of inappropriate or unsafe care. As an example the home had not completed auditing themselves against the regulations, and although questionnaires had been completed last year to allow people living at the home their relatives and staff to comment on the quality of experiences they received the results had not been collated or analysed. This had meant it was not possible to identify trends or address any concerns identified.

Although there had been three safeguarding concerns since January 2014 robust overall management systems were not in place to audit complaints and learn from incidents or accidents.

We saw that the home had not assessed themselves against best practice in relation to dementia care or made changes to the environment to support people with dementia or visual impairments where these had been identified.

We also found a lack of management oversight of systems for care planning and review meant that deterioration in people’s needs was not consistently being identified for action. This put people at risk.

We inspected Park House as we had received concerns about the cleanliness and infection control practices in operation there.

We found that the home had already made improvements to their own practice since an internal audit in November 2013, including the provision of new systems, and purchasing of equipment.

A person living at the home who we spoke with told us that they were happy with the way their room was kept clean. Staff we spoke with understood the principles of good infection control. We saw equipment such as aprons, anti-bacterial gels and gloves were in use across the home.

However some cleaning checklists were not being completed regularly and a risk assessment in relation to a specific infection risk had not been completed. We found that some areas of the home still required cleaning to ensure they could be kept clean and reduce the risks of infection. The laundry was in need of significant cleaning and renovation to reduce risks of cross infection. We also found some concerns in relation to cleaning of equipment such as bath hoists and commodes inside of the home.

We saw that the home had a current action plan with targets and dates to achieve improvements.

On inspection visits we, the Care Quality Commission (CQC), had made to the home in July and August 2013 we had identified concerns over the way that medication was managed at the home.

Following the inspections the home had sent us an action plan to tell us what changes they had made. This inspection was made to follow up on the action plans and see that the systems for the management of medication were safe. We found that improvements had been made. The home had taken appropriate professional advice and made changes to the systems in use.

We saw that the systems for recording of medication administration were more robust, and there were no unaccounted for gaps. We saw that medication was dated and that changes had been made to ensure that where medication was being refused people's rights or best interests were being protected.

Additional arrangements had been made to transport medication safely around the home and changes had been made to improve the main storage cupboard. An improved system for auditing of the home's systems had identified where errors had occurred and could demonstrate that the changes had led to reduced errors and risks. Care workers had received and were due to receive additional training in the systems in use.

On an inspection of Park House on the 16 July 2013 we had identified concerns in relation to the management of medication. Following the inspection the provider sent us an action plan telling us how they were going to put things right. On this inspection we looked at what changes had been made.

We found that although the provider had made some improvements the medication was still not being managed safely. The medication cupboard was not clean and administration instructions were not clear. We were not satisfied that the arrangements for transporting medication around the home were safe. We found that eye drops or creams did not have their opening dates recorded which could lead people to receive out of date medication.

We saw that records regarding medication administered had not always been completed properly. This meant it was not always possible to see who had given out medication.

We did not identify that anyone had been harmed by these concerns.

We saw that risk assessments had been undertaken for people dealing with their own medication. One person we spoke with told us the staff member who did this with them was “Very good. Excellent. They look after my nebuliser and oxygen and I deal with my inhalers. I know how to use them and tell them if I am running out.”

People living at Park House on our inspection were older people, many of whom had dementia or mental illness. We observed the care being delivered to people who were not able to share their experiences with us verbally, and spoke with two people who could discuss their care. One person we spoke with told us “You get looked after here well. If anyone complains they are round the bend, it’s very good indeed.”

We saw that people were treated with kindness and good humour. We saw the home was flexible to cater to differing needs. The home had a programme of entertainment and activities for people, and on the day of the inspection a harpist was playing in the lounge. One person was helping staff to pod peas for the next meal and other people were in their rooms or with visitors.

Care records were up to date, but did not include much information on people's life histories. Life histories would help staff understand the person with dementia and their choices in the context of the life they had lived. This would mean they could be supported in the most appropriate way for that individual.

We found that people's nutritional needs were met well. One person told us the home served “Good home cooked food – not bought in like some places. We get lots of choice -two choices for lunch and I don’t know how many for tea”.

However we found that the medication systems in use were not safe and did not protect people's rights.

This inspection was a follow up from an inspection undertaken on 17 October 2012 at which we found two areas of non compliance. These were in relation to respecting and involving people who used the service and consent to care and treatment. At this inspection we found that the home had made improvements.

There were 20 people living at the home on the day of the inspection. We spent time observing people. Observation was used to assess the interaction and engagement between staff and people living at the home. We talked with two people that lived at the home, one relative and two staff. We looked at three care records.

People living at the home told us that they were happy living there and staff were very good. We observed positive interactions between staff and people living at Park House. Records that people were involved in their care. One relative told us “They are very good here, we are very happy with the care they give.”

We found that the home had communicated with people’s families and GPs to make best interest decisions for significant issues involving their care. For example giving covert medication. This is when medication is not given openly for instance within a drink or food.

We found that all of the staff had received training in dementia care. We were told all staff were to have further training in the Mental Capacity Act 2005. Staff were able to describe when and how they obtained consent from people living at the home.

Because of the complexities of people's illnesses, for example memory loss and dementia, most people at the home were unable to express their views about what is was like to live there. We spoke with eight people that lived at the home and observed the care that was being delivered to them. We also spoke with two of their relatives and five staff.

We found that people who used the service were not fully involved in the decisions made about their care. Best Interest meetings had yet to be held for people with deteriorating health needs.

We saw that people's dignity was not always protected. For example on the day of this inspection we saw a bag full of underwear in a bathroom which was used for everyone. We were told it was for when people “needed changing quickly”.

We saw people looked well cared for. We asked a relative about their experience of care at the home and they described it as “good”. They said “Mum always looks clean and tidy with her hair well brushed.".

People spoke well of the food and were aware that if the menu was not to their liking ”something else” would be offered.

We saw all areas were clean. Some parts of the home had been redecorated and had new carpets. Others appeared tired and in need of modernisation.

Staff were receiving appropriate support in the form of supervision and training.

The home had a satisfactory quality assurance system in place.