This inspection was undertaken on the 9 and 10 March 2017 and the first day was unannounced.

Pinetum is registered to provide accommodation for up to 45 people who require nursing or personal care. At the time of the inspection there were 38 people using the service.

The service is located on the Countess of Chester Health Park on the outskirts of Chester city centre and adjacent to the local hospital.

Pinetum had a registered manager in place. 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.

At the last inspection in March 2016 we found that a number of improvements were needed in relation to dignity in care, planning people's care and support, understanding capacity and consent and resolving concerns with the quality and safety of the service. We found the service in breach of Regulation 10,11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered provider informed us they would be compliant with the regulations by 31 July 2016.

This inspection took place to establish what improvements had been made. We found that the registered provider had made the required improvements.

We observed at all times that people received personalised and appropriate care. People were treated with kindness, dignity and respect. Staff ensured that all reasonable steps had been taken to ensure the confidentiality of personal information.

Care plan documentation reflected a person's preferences as to how they would like their care and support to be delivered. Up to date information about people’s needs was readily available. Records reflected that appropriate care was delivered consistently. Checks on people's diet and fluid intake and repositioning were completed. Accurate information meant that the risk of inappropriate care and treatment was minimised.

People were supported to take their medications and the level of support people needed was assessed and documented. Medicines prescribed to people on an "as required basis" were given in a consistent manner and thickening agents were appropriately recorded and stored.

People's capacity was assessed under the Mental Capacity Act 2005 (MCA). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The registered provider had a system in place to monitor the quality, safety and effectiveness of the service. This highlighted where improvements were required and remedial actions were taken in a timely manner so that risks to people were minimised quickly.

People told us that they felt safe and cared for and their relatives echoed this. People lived in an environment that was clean and maintained. People and their relatives said that the registered manager was approachable and had made some improvements. Appropriate action had been taken in response to complaints made.

Staff were recruited in line with the registered provider’s procedure which was safe and thorough. This helped to ensure that people received care from staff that were suitable to do the job. New staff undertook an induction programme that included shadowing more experienced staff.

Staff received training and support appropriate to their roles. Staff also met on a regular basis to discuss issues of relevance, good practice, as well as wider developments in the service.

The views of people who used the service and their relatives were sought. Meetings were held where they could discuss issues with the management team. People also had the opportunity to participate in a wider survey conducted by the registered provider. This was to seek their opinion as to the quality of the service provided a

This inspection was undertaken on the 9 and 10 May 2016 and the first day was unannounced. The last inspection of the service was carried out on the 2 February 2015 and at the time the service met all the requirements of the outcomes assessed.

Pinetum is registered to provide accommodation for up to 45 people who require nursing or personal care. It is located on the Countess of Chester Health Park on the outskirts of Chester city centre and adjacent to the local hospital.

Pinetum had a registered manager in place. 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 whilst some aspects of the care and support were satisfactory, there were areas which required improvement and did not meet the regulations. You can see what action we told the provider to take at the end of the full version of this report.

Whilst we observed, at times, people received appropriate care, we also saw occasions where people were not treated with kindness, dignity or respect. There were occasions when staff did not ensure that all reasonable steps had been taken to ensure the confidentiality of personal information. This we deemed to be a breach of Regulation 10 of the Health and Social Care Act 2008.

Care plan documentation did not always reflect a person’s preferences as to how they would like their care to be delivered. Up to date information was not always readily available. Records did not reflect that appropriate care was delivered consistently. Checks on people’s diet and fluid intake and repositioning were not always completed. Inaccurate information meant that there was a risk that care and treatment might not be appropriate. This was a breach of Regulation 17 of the Health and Social Care Act 2008.

People’s capacity was not assessed under the Mental Capacity Act 2005 (MCA). We found care records did not consider people’s capacity to make decisions which meant there was risk their rights were not protected or that their care was compromised. This was a breach of Regulation 11 of the Health and Social Care Act 2008.

The registered manager had submitted a number of applications under the Deprivation of Liberty Safeguards (DoLS) but had not identified all care practices that could be deemed as restrictive. We therefore made a recommendation that the registered manager review the use of restraint and restrictive practice to ensure that they act in accordance with the MCA and DoLS were appropriate.

The registered provider had a system in place to monitor the quality, safety and effectiveness of the service. Although this had highlighted where improvements were required, we found that actions were not taken in a timely manner .This meant that this system was not effective in ensuring the risks to people were minimised quickly. This was a breach of Regulation 17 of the Health and Social Care Act 2008.

We found that people at Pinetum were being supported to take their medications. However, we found that some improvements were required to ensure that medicines that were on an “as required basis” were given in a consistent manner and that thickening agents were appropriately recorded and stored.

People spoken with and relatives told us that they felt safe and cared for. They lived in an environment that was clean and maintained. They said that the registered manager was approachable and that they had already made some improvements. We saw that there had been where complaints had been raised appropriate action had been taken.

The registered provider had ensured that staff responsible for recruitment had followed the appropriate recruitment checks. This meant that people were receiving their care from staff that had been thoroughly vetted to ensure

We carried out this visit to Pinetum in response to concerns that we had received about certain aspects of the care provided at the service.

During inspections we routinely ask five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

We asked on this visit if the service is effective, safe, responsive, safe and well -led.

Is the service effective?

The service was effective

We found that people provided consent to their treatment as well as their personal arrangements to be made in the event of their deaths. We found that the care and welfare of people was promoted by the provider. We found that the nutrition and hydration needs of people were met.

Is the service safe?

The service was safe.

We saw that staffing levels at night met the needs of the people who used the service. We saw that staffing levels were maintained during the day and that staff were able to meet the needs of people. We also saw from staffing rotas that night staffing levels were maintained.

Is the service responsive?

The service was responsive.

We observed care being given and found that people were treated in a respectful and dignified manner at all times. We observed that staff took the independence of people into account; particularly in respect of eating. We saw that staff carried on their work in a manner which was carried out in a responsive manner.

Is the service well led?

The service was well led.

Since our last visit, the service had tightened up on the way it measured the quality of the care it provided. Audits from the manager and actions from visits by the registered provider had now been completed.

We spoke to two relatives. One told us that their relation had only just come to live at Pinetum. They told us that they had been able to contribute to the assessment information of their relative during their admission. Another relative told us that they were generally happy with the care provided and felt that their relative's health was getting better.

Two inspectors and an expert by experience carried out this inspection. Forty-five people were living at the home, or having a short stay there, and this included four people who were being cared for on a high dependency unit. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? 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 safe?

The expert by experience spoke with six people who lived at the home and they all reported that they felt safe in the home. The expert by experience also spoke with five relatives who were visiting and considered that their loved ones were safe.

Two care staff who were working on the high dependency unit told us about the additional training they had received in order to support people who used ventilation equipment. They had good knowledge of the equipment that was in use and the needs of the individual.

One person we spoke said that there were two members of staff who they felt afraid of and who had refused to provide the care that they required. Immediate action was taken by the person in charge to ensure that these allegations would be investigated appropriately and the person protected.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We looked at maintenance records and saw that safety checks had been carried out for gas, electrical circuits, portable electrical appliances, passenger lift and hoists, fire alarm and emergency lighting. Regular fire drills took place and the maintenance person carried out fire checks.

We saw that there were key pad locks on the staircases to keep people safe and secure however, the provider may find it useful to note that there was no lock on the passenger lift. The lift was situated opposite the main entrance door which was sometimes left open in warm weather. There was no risk assessment in place for this. There was a risk assessment folder which covered areas including the control of substances hazardous to health, and the management of slips, trips and falls however, the provider may find it useful to note that this contained only very basic information and did not give full guidance to staff on managing these hazards.

Is the service effective?

A relative who spoke with the expert by experience said “People are well looked after.” and a relative we spoke with by telephone said “I am extremely happy with the care.” Staff we spoke with considered that there was sufficient time for people to receive support with personal care as planned and when needed.

The expert by experience observed an art group supported by two members of staff . Staff interacted positively with the people who were participating and there was a friendly and cheery atmosphere. The people who spoke to the expert experience said they really enjoyed it and some of their work was displayed.

Care records showed that where there was a concern about a person's health needs such as their nutrition, risk of falls or pressure area care, the advice and support of medical professionals including dieticians, GPs and specialist nurses had been sought.

We looked all around the building and found that it was clean and adequately maintained. Some people had personalised their bedrooms with their own belongings brought from home. There were a sufficient number of toilets and assisted bathrooms.

Is the service caring?

People who spoke with the expert by experience said that staff treated them with respect and dignity, and were kind and caring. One person said “The bulk of staff are kind and helpful.” and another person said “Staff are very good, kind and caring.” A relative who was visiting said “Staff are kind and caring, couldn’t ask for a better place.” A person who lived at the home told us “These ladies are perfect.” The expert by experience commented: “During the day I observed staff being very patient, respectful and caring with the residents.”

Is the service responsive?

The care plans we looked at showed how the needs of the people who used the service were to be met, including the management of any identified risks to their well-being. A person we spoke with said they were getting the care and support they required and staff were available when needed.

A nurse we spoke with said that a number of people had swallowing difficulties. A dietician and a speech and language therapist were closely involved with a number of people’s care and reviewed their care. We spoke with the chef who said that menus were being revised following input from a dietician and the people who lived at the home. Following advice from a dietician, he had been fortifying meals to make them more calorific.

Prior to our visit, we had received a concern that the building was excessively hot. The acting deputy manager was aware of this and told us that this had occurred during a period of very hot weather. She told us about measures that had been taken to ensure that people who lived at the home were kept comfortable.

A ‘Quality and Governance Support’ visit in April 2014 identified that a number of rooms did not have call bell extension leads for people to use. The home’s maintenance person told us that the call bell system was obsolete and replacement parts were no longer available. A new call bell system had been ordered and the re-wiring work required had been carried out, however there was no date confirmed for the system to be installed. We were assured that all of the people who were able to use a call bell had access to one.

Is the service well led?

The home had a registered manager who had been in post for several years. We were informed that the home had been without a deputy manager for several months. A member of staff told us “The provider is good to us and the manager is supportive.”

A ‘manager self-audit schedule’ on the noticeboard showed that audits of various aspects of the service were planned to be carried out each month of the year. However, there was no evidence to show that these had been carried out. A representative of the provider had carried out a ‘Quality and Governance Support’ visit in April 2014 and produced a report, however we did not see records of what actions had been taken as a result of the report.

People told us that there was a significant problem with staff sickness levels that needed to be addressed. One member of staff said "We have plenty of staff but attendance is appalling." We found evidence that staff had not received one to one supervision over recent months.

We found that care records showed that people who used the service and / or their relative were involved in the planning of care with plans appropriately signed and dated by them. We found that before they received any care or treatment they were asked for their consent.

People who used the service told us they were happy at Pinetum and had no concerns with the care and treatment provided. They also told us they received their medication in a timely manner. Comments from them included: “They are wonderful. I like to be independent and staff help me to do that”, “The staff are very nice and helpful. They are a wonderful crew”, “They (the staff) are brilliant. I know I’m looked after” and “Nothing is too much trouble for the staff. They are very friendly.”

We found that the equipment the service used such hoists, slings and bed rails were in good working order. We looked at certificates that verified the service were compliant with Lifting Operations and Lifting Equipment Regulations (LOLER) 1998.

From our observations and discussions with staff we found the service had enough qualified, skilled and experienced staff to meet people’s needs.

We found that people who used the service and / or representatives were asked for their views about the care and treatment that was received and they were acted on. There was evidence that learning from incidents and investigations took place and appropriate changes were implemented.

We spoke to three people who used the service who said they were well looked after and happy with the service they received. They were positive about the staff who supported them. They said that they were treated in a respectful manner by the staff and that they felt safe at the service. Some comments made were:-

“It’s an excellent service. The staff are friendly and give me the help I need.”

“I feel lucky to be here. It’s a really good service.”

We spoke to three relatives who told us that they were happy with the care and support provided.

We received feedback from two health care professionals who reported that people were well supported at the service.

Records showed that people had been assessed before they began to use the service and they had a care plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

There were practices in place to ensure that the recruitment of staff appropriately supported the people who used the service.

The home was clean and there were procedures and training in place to promote good hygiene and prevent infection.

There were systems in place to obtain the views of the people who used the service and their relatives about how the service operated.

Cheshire West and Chester Council had been involved in investigating some concerns that had been raised about the home within the last twelve months. They found that the home had taken appropriate action.

We were accompanied by an expert by experience during this inspection. An expert by experience is someone who has personal experience of using or caring for someone who uses health or social care services. We work in partnership with them to help us get a clearer picture of what it is like to live in or use a service.

The expert by experience looked at two outcome areas as set out in the Essential standards and safety which helps providers of health and social care comply with the Health and Social Care Act 2008. The two particular outcomes areas looked at during this inspection were:

• Outcome 1: Respecting and involving people who use services

• Outcome 4: Care and welfare of people who use services.

The findings of the expert by experience are included in both outcome areas.

People we spoke with told us they were not always aware that plans were in place that set out how they were to be cared for and supported with their daily lives. One person told us they only saw their care plan when asked to sign it.

People told us they were treated with respect by staff and their dignity and privacy was maintained when supported with personal care.

The relatives we spoke with told us they were made very welcome and could visit the home as they wished.

People who use the service told us they felt safe living in the home. They also told us they had choices in areas such as where they could have their meals and which gender of staff supported them with personal care. One person when asked if they felt safe living in the home replied ‘Well you would, it’s your home’. They told us they liked the staff who cared for and supported them.

Information received from Cheshire West and Chester City Link (Local Information Network) told us they had visited the home in November 2011 and found that staff respected and maintained the dignity of the people who use the service