This inspection took place on 12 and 17 April 2018. The first day was unannounced and the second day was announced.

The last inspection of the service was carried out in January 2017 and during that inspection we found breaches of regulations in respect of the management of medication and assessing and monitoring the quality and safety of the service. 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; is the service safe, effective, caring, responsive and well-led, to at least good.”

During this inspection we found that the required improvements had been made.

Prospect House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Prospect House is registered to provide accommodation, personal and nursing care for up to 24 people. There were 21 people living at the service at the time of the inspection.

The person registered with CQC as the manager of the service no longer works there. A new manager has been appointed and they are in the process of applying to CQC to become the 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.

Improvements had been made to the management of medication. Safe procedures were followed for storing, administering and recording medication. Medication was ordered and obtained in good time to ensure that people received all their prescribed medication when they needed it.

Improvements had been made to the systems for checking on the quality and safety of the service. There were effective systems in operation for checking on aspects of the service and making improvements.

The environment had undergone some improvements since the last inspection making it more comfortable and suitable for people living with dementia. Improvements included the redecoration and refurbishment of some areas. The management team and staff were constantly looking at ways to further improve the environment for people living there.

People told us they felt safe living at the service. They were protected from abuse and harm because staff understood how to recognise and report safeguarding concerns. Risks to people and others were assessed and managed safely. This included risks associated with aspects of people’s care and the environment.

The environment was clean and hygienic and smelt pleasant throughout. Staff followed good infection prevention and control practices such as the use of personal protective equipment (PPE) to help minimise the spread of infection.

Safe recruitment processes were followed. The suitability of staff was assessed prior to them being offered a position. This included checks carried out with previous employers and a check on their criminal background. There were sufficient numbers of suitably skilled and experienced staff to meet the needs of people and keep them safe.

Staff received training and support for their role. New staff completed induction training to learn their role and they were provided with ongoing training in areas of health and safety and topics relevant to people’s needs. Staff received an appropriate level of support through one to one supervisions, appraisals and staff meetings.

People’s nutritional and hydration needs were understood and met. People were given a choice of food and drink which was prepared in accordance with their likes, dislikes and dietary requirements. People received the support they needed to eat and drink in a pleasant and relaxed and environment.

This inspection was carried out over two days on 09 & 11 January 2017. The first day of the inspection was unannounced.

Prospect House is a care home registered to provide accommodation and personal care for up to 24 adults, there were 24 people using the service at the time of our inspection.

The service did not have a manager who was registered with the Care Quality Commission. 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. The manager who was in post at the time of our last inspection in July 2016 resigned from their post shortly after the inspection. A new manager has been appointed and was due to commence work on 24 January 2017. At the time of this inspection the deputy manager and business manager were responsible for the day to day running the service.

The last comprehensive inspection of the service was carried out in July 2016 and we found that the service was not meeting all the regulations. We asked the registered provider to take action to make improvements to the management of people’s medication, safeguarding people, prevention of infection, protection of people’s rights, staff training, meeting people’s needs, and record keeping. The registered provider sent us an action plan following the inspection detailing how and when they intended to make the improvements. During this inspection we found improvements had been made. However we found further improvements were required in relation to the management of people’s medication.

Improvements had been made to the management of medication; however we found further improvements were needed. Controlled Drugs (CDs) (medicines controlled under the Misuse of Drugs legislation and subsequent amendments) were not regularly checked. Medications prescribed by a doctor were not available for some people at the service because stocks for some people had run out. Care plans to instruct staff on the application of topical creams where not always in place.

Improvements had been made to the systems for checking on the quality of the service and making improvements. More robust audits had taken place to check on aspects of the service such as people’s care records, medication, and the safety of the environment. Action plans were developed to address any identified areas for improvement and they were made promptly to mitigate risks to people and others. However checks failed to identify and drive improvements to the management of people’s medication and associated records.

We have made a recommendation about making the environment more dementia friendly. The environment had been improved since the last inspection, which included some redecoration and deep cleaning of some areas which were unhygienic. However there was a lack of stimulus and signage to help orientate and stimulate people living with dementia.

Improvements were made in relation to maintaining people’s safety. Following an incident or accident follow up action had been taken to identify why incidents had occurred and how they could be prevented from happening again in the future. Falls were closely monitored and appropriate referrals were made to the falls team for assessment.

People’s rights and liberties were protected in line with the Mental Capacity Act 2005. The use of CCTV inside the service had been disconnected in the best interest of people’s rights, privacy and dignity. Staff had completed training in the Mental Capacity Act 2005, and they had an understanding of the basic principles of the act.

The right amount of suitably skilled and qualified staff were on duty to meet people’s needs and keep them safe. People told us that they thought there was enough staff on duty to keep them safe and this was ec

The inspection took place on the 21 and 22 July 2016 and was unannounced. At the last inspection in July 2016 the service was rated as good. This inspection was brought forward in response to a number of concerns raised by the local authority.

Prospect House provides accommodation for people who require personal care, and supports older people living with dementia. The service is registered to accommodate up to 24 people, and at the time of the inspection there were 17 people using the service.

The service had not had a registered manager in post since January 2016. At the time of the inspection there was a manager in post who was in the process of applying to CQC to become the registered manager. However following this inspection we were informed that the manager had left the service before their application to become registered manager had been processed. A deputy manager and business manager were in post to support with the running of the service whilst the registered provider was recruiting for a replacement 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.

During our inspection we identified multiple breaches of the Health and Social care Act 2008 (regulated activities) 2014. We will publish the actions we have taken at a later date. 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. As a result of serious concerns found during the inspection we raised two safeguarding referrals to the local authority for investigation.

We identified a number of issues around the safe storage and administration of people’s medicines. These issues had also been identified by staff working for St Helens Contracts and Commissioning Group (CCG), during a medicines management audit in April 2016. At our inspection we found that limited action had been taken to complete the action plan outlined by the CCG. This placed people at risk of harm due to medication errors. There were no quality monitoring processes in place by either the manager or the registered provider. This meant that areas of improvement could not be identified and acted upon.

People’s safety was not always maintained, and follow up action had not been taken to identify why incidents had occurred, or how they could be prevented from happening again in the future. For example one person had sustained serious bruising, however no action had been taken to identify what had caused this, or to report this to the local authority. The registered provider had failed to carry out checks on the water supply to ensure they were free of dangerous bacteria, and there were parts of the environment which were unclean and dirty, which placed people at risk of infection. This meant that people were at risk of harm and ill health.

People’s rights and liberties were not always protected in line with the Mental Capacity Act 2005. Mental capacity assessments had not been completed for people requiring covert medication, and the correct procedure had not been followed with regards to the use of CCTV that was in place. Staff had not completed training in the Mental Capacity Act 2005, and were not aware of their roles and responsibilities in relation to this. For example, one person was having covert medication administered without due regard being given to whether this was in their best interests. This placed people at risk of having their right and liberties undermined.

Staff had not undertaken the training necessary for them to carry out their role effectively. For example a majority of staff had not recently completed training in Dementia awareness, infection control or moving and handl

This was an unannounced inspection, carried out on 09 July 2015.

Prospect House Care Home provides accommodation and personal care for up to 24 people living with dementia. The service is set in its own grounds, within a short car journey from local amenities and bus routes.

The service has had a registered manager since June 2014. 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 last inspection of Prospect House was carried out in August 2014 and we found that the service was meeting all the regulations we assessed.

People who used the service felt safe. Staff knew about the systems in place to protect people from the risk of harm and they knew how to recognise and respond to abuse correctly.

There were sufficient staff on duty to ensure the needs of people were met.

Effective recruitment processes were in place and followed by the service, and staff received on-going training and support to ensure they carried out their role effectively.

Medicines were managed safely and the processes in place ensured that the administration and handling of medicines was suitable for the people who used the service.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We saw that there were policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and DoLS to ensure that people who could not make decisions for themselves were protected. Some people who used the service did not have the ability to make decisions about aspects of their care and support. The registered manager understood the systems in place to protect people who could not make decisions and had followed the legal requirements outlined in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Where people lacked the capacity to make decisions about something, best interest meetings were held and documented in people’s care records.

People had enough to eat and drink. People were offered drinks and snacks throughout the day. People who were at risk of poor nourishment were regularly weighed and provided with food supplements and drinks.

Staff were patient and friendly and knew people very well. Staff interacted well with people and engaged in conversation with them about things of interest.

The registered provider supported and encouraged learning and the staff team had the collective skills and knowledge to care for the diverse needs of the people who used the service.

People’s care and support needs were up to date and reviewed on a regular basis with the person or other appropriate people. Staff provided people with person centred care and support.

No complaints had been made to the registered provider. People were aware of how to make a complaint if required and they told us they would not be worried about complaining if they needed to. People were confident that their complaints would be listened to and acted upon.

Systems were in place to regularly check the quality the service provided and to ensure improvements to the service were made. The registered manager and staff established good working relationships with family members and visiting professionals to the benefit of people who used the service.

We considered our inspection findings to answer questions we always ask.

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection of Prospect House, speaking with people who used the service, the staff supporting people and from looking at various records.

Is the service safe?

We carried out a tour of the premises and saw that it was safe in the areas that people occupied and lived. We observed that up to date fire extinguishers and portable appliance checks had been carried out and were found to be suitable and safe to use.

Some of the people living Prospect House during our inspection had complex needs which meant they were not able to tell us their experiences.

We saw members of staff positively interacting with the seven people who lived in the home. On the day of our inspection it was quite warm and we observed members of staff providing cold drinks to people throughout the day.

In discussion and in observation, we saw that people were relaxed and at ease. One person told us they were content and treated with respect and dignity.

We found satisfactory safeguarding procedures in place, with staff having had up to date safeguarding training in order to recognise any potential issues and take appropriate action.

Is the service effective?

We spoke with the members of staff who were on duty throughout the day and they all demonstrated that they had a clear understanding of people’s needs and how to meet them.

We found that people’s health and care needs had been appropriately assessed, with peoples care plans being detailed and the newly reviewed care plans being more person centred and individualised.

Is the service caring?

During our inspection we observed that members of staff were attentive, caring and enthusiastic about meeting the needs of people who lived in Prospect House. We saw people positively responding to members of staff, which showed that a good rapport existed between them.

Throughout our inspection we saw that people were treated with dignity and respect by the staff. Some of the staff comments were, “It’s much better now, improving all the time”, “It’s a lovely place to work now” and “It’s a lot better and I mean a lot better . We have much more time with the residents”.

Is the service responsive?

During our inspection we saw written evidence that highlighted when any issues had been identified; the service had responded and addressed them.

In reviewing people’s care plans we saw that assessment reviews had taken place, with appropriate changes made to help ensure that people’s needs were met.

We saw members of staff responding to people’s requests in a prompt, skilled and knowledgeable way.

Is the service well-led?

The service had a manager registered with CQC in post. Prospect House Care Home had quality assurance monitoring processes in place. We saw that the service sought the opinions and views of people who lived in the home and also when possible sought the views of their relatives.

The registered manager at Prospect House had been in post since February 2014 and it was clear that improvements regarding the daily running of the home had taken place. Some of the staff comments were, “I don’t know where this manager has been all of our lives” and “The home has improved so much since the new manager came”.

We saw documented evidence that staff team meetings had been taking place.

We saw that audits to monitor the quality of service delivery were in place including, medication audits, accident audits and records of completed accident forms, with appropriate and relevant action recorded. We were informed that no complaints had been made since our last inspection.

We were informed by the local authority’s contract monitoring unit that they had seen some positive changes with the new manager and the provision of care had also improved.

This inspection was carried out by two inspectors.

Prospect House has been non-compliant in a number of the regulations, since February 2013. Since then we (Care Quality Commission CQC) have carried out six inspections, including this one. The providers were issued with Warning Notice’s in July 2013 and in November 2013, further enforcement action was taken. We carried out this inspection to assess if any of the areas of non-compliance had been addressed. At the time of our inspection we spoke with the seven people who were living there.

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Is the service safe?

We carried out a tour of the premises and saw that it was unsafe in some areas. We saw a number of fire doors wedged open with both door wedges and chairs. A number of vacant bedrooms on the ground floor had bad odours including urine and a smell of fire damage. The outside balcony areas to some of these rooms were crumbling, which created a high risk of trips and falls. The window frames in some of these rooms were rotting.

We saw an electricity meter cupboard with a sign stating “danger of death” to be kept locked was open and accessible to all.

We observed that up to date fire extinguishers and portable appliance checks had been carried out and were found to be suitable and safe to use.

Some of the people living in Prospect House during our inspection had complex needs which meant they were not able to tell us their experiences. Two people, when asked if they felt safe? They replied yes. We saw members of staff positively interacting with people who lived in the home. People were treated with dignity and respect. In discussion and in observation, we saw that people were relaxed and at ease with the care staff.

We found satisfactory safeguarding procedures in place, with all staff having had up to date safeguarding training. We also saw that the majority of staff had received Fire Safety and Health and Safety training.

Staff recruitment records contained all the information required by the Health and Social Care Act 2008. This meant the provider could demonstrate that the staff employed to work for the service were suitable and had the skills and experience needed to support people living in Prospect House.

Is the service effective?

We spoke with the members of staff who were on duty throughout the day and they all demonstrated that they had a clear understanding of people’s needs and how to meet them.

We saw that staff training and staff supervision was consistent and up to date. This helped to demonstrate that the staff employed to work for the service had received the correct training and support to meet people’s needs.

We found that people’s health and care needs had been reassessed, with people’s care plans being reviewed and updated to reflect their changing needs.

Is the service caring?

During our inspection we observed that staff were attentive, caring and enthusiastic about meeting the needs of people who lived in Prospect House. We saw people positively responding to members of staff, which showed that a good rapport existed between them. We saw that people were treated with dignity and respect by the staff.

Some of the staff comments were, “I love working here, and it’s a much better atmosphere for us (staff) and the residents” and “We now have more staff, which means we can spend more time with the residents”.

Is the service responsive?

Prospect House had some quality assurance monitoring processes in place. We saw questionnaire surveys that had been returned by relatives of people who lived in the home. The comments were positive; however there were no dates on the survey forms. The manager informed us that there is a garden party planned for June and they will hand out quality monitoring surveys to families and any other visitors to the home and will try and get comments from people on the day.

We saw that audits to monitor the quality of service delivery were in place including, medication audits, accident audits and records of completed accident forms, with appropriate and relevant action recorded. We saw that other audits had taken including, care plan audits, staff file audits and infection control audits. There was a new ‘Comments and Suggestions’ box prominently situated in the entrance to the home.

Is the service well-led?

The manager at Prospect House has been in post for three months and it was clear that some improvement regarding the daily running of the home had taken place. Some of the staff comments were, “It’s much more organised here now, you know what you are supposed to be doing” and “The manager is really approachable. All of the staff get on better. I am not thinking of leaving anymore”.

We were informed by the manager that they were in the process of developing the policies and procedures for the home. For example, dementia care diversity in care; safe and positive touch; safeguarding; nutrition and dignity; equality and moving and handling.

The service has been inspected four times since February 2013. A number of outcomes remain non complaint with concerns. As a result a condition was imposed that the service could not admit any one else to live at Prospect House Care Home.

At this inspection we saw that improvements had not been made.

We saw that care and welfare remained in need of improvement. At this inspection we found risks to people’s care and welfare had not been identified or plans put into place to protect the people living in the service.

Records within the service were not sufficient to make sure staff consistently delivered and monitored the care of people living in the service.

We also saw that not all staff had received training to meet people’s assessed needs to enable them to provide the care and support they needed.

People living in the service were at risk of poor nutrition. Diets and fluids were not monitored in order to make sure that instructions from dieticians were carried out.

There have been 11 safeguarding concerns raised since the last inspection. Three of these have been upheld as neglect by social services at meetings that the manager attended and the rest remain as ongoing investigations both by social services and the police.

The service has been inspected 3 times since February 2013. A number of outcomes remain non complaint with concerns. As a result a condition was imposed that the service could not admit any one else to live at Prospect House.

At this inspection we saw that improvements had been made to the environment. This had included replacing furniture, improving lighting and repairing fire doors.

We saw that care and welfare remained in need of improvement. At our inspection there had not been sufficient staff to meet the needs of people living in the service. This had resulted in staff being unable to deliver care and support to at least two people. Following our inspection we referred both people to social services safeguarding for investigation of potential abuse.

Records within the service were not sufficient to make sure staff could consistently deliver and monitor the care of people living in the service.

Observations during our inspection showed that equipment that had been agreed as unsuitable by relevant professionals was not in use. We also saw that not all staff were skilled in communicating effectively with people with assessed dementia care needs. We saw staff giving people food with no interaction and no explanation as to what the food was.

There were no effective arrangements in place to check the quality of the service and plan how improvements were made.

Some of the people who lived at Prospect House were not able to tell us about their experiences of living there or comment about the care and support they received, due to a variety of complex needs. We observed interactions between members of staff and people who lived at the home. These interactions were not always positive.

We observed that some people who lived at the home were not receiving the appropriate level of nutrition or the support to eat their meals, which they had been assessed as needing.

We looked at the level of staffing, the qualifications, skills and experience of the care workers. We found that two of the staff on duty during our inspection had not undertaken any training in the delivery of personal care and one member of staff said they felt uncomfortable providing personal care on their own.

We looked at the recruitment process within the home and we saw there were some shortfalls in the recruitment procedures. This potentially placed people who lived in the home at risk.

We found there was a strong smell of urine in some areas of the home; this was both human urine and a smell of urine from the cats, which lived in the home.

These issues were relayed to the Registered Manager at the end of our inspection.

During our visit we spoke with four people who used the service, the manager, three members of the care staff and we spoke with four relatives of people who lived in the home. We observed that people's care were generally unhurried and that people with dementia care needs were supported to make choices. One person told us, "The staff are good, they are helpful". The relatives we spoke with were satisfied with the care their family members received.

During our inspection we identified some areas for improvements with the record keeping. There was a risk peoples needs would not be met and the quality of care compromised if the records are not detailed and person centred. The systems in place to monitor the quality of the service did not always identify the shortfalls. We found there was a commitment to staff training but some staff had not received training relevant to their role. Other concerns were in relation to omissions in reporting notifications to Care Quality Commission (CQC) and a shortfall in the management of a person's prescribed medication. The provider told us action would be taken to address shortfalls identified during this inspection.

Family visitor said,"I have no concerns or complaints" "the general care is very good" "As far as I know the food is ok" "not seen any evidence of the cats soiling in the home,and there's no foul smells" "I have never seen anything that has caused any concern with the animals" "The home always smells nice" "The home is clean and tidy" "They have recently bought new furniture" "They are painting the lounge now" and "quite a bit of redecoration has taken place".

Service users comments were, "They treat you alright" "The staff are really nice" " I look after the chickens, I love animals" and "I like living here".

During our inspection in February 2013 some areas of non- compliance were identified. During the inspections of 19 June 2013 and 1July 2013 we followed up and focused on the previous areas of concern.

We spoke with some of the people living in the home and found their feedback was positive. Some of the comments were, “It’s a nice place and nice food” “The homes okay, the girls are really good” and “I love the place, I’m fine thank you”.

During our inspection we observed positive interactions between members of staff and people living in the home. We saw members of staff speaking to people in a calm and sensitive manner and encouraging people to get involved in different activities. It was a sunny day and some people were sitting outside, enjoying the nice weather. People wore hats and sat under sun umbrellas to protect them from the sun.

We carried out a tour of the premises and found a number of areas that were in need of attention, which would help ensure that people living and working in the home are safely protected.

We looked at the homes records including care records, medication, maintenance records, staff training and supervision records. We found the care records to be lacking in sufficient detail, with which to appropriately inform staff of peoples care needs. The medication, training and supervision records were satisfactory. The training and supervision records for staff showed they had received relevant and appropriate training and supervisions.