The inspection took place on the 23 and 24 May 2018 and was unannounced. At the previous inspection in November 2016 we identified breaches of Regulations 10 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people were not always being treated with dignity and respect and appropriate recruitment checks had not been completed to ensure people’s safety.

We issued a warning notice in relation to Regulation 19 and following the inspection the registered provider gave us evidence to show they had met the necessary standards in relation to this regulation. At this inspection we found that the registered provider was no longer in breach of these Regulations, however; we did Identify breaches of Regulations 12 and 17.

Redwalls Nursing Home 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.

The service accommodates up to 44 people in one adapted building. At the time of the inspection there were 40 people living within the service. The service is situated over two floors, has access to a large garden to the rear and side of the premises and has on-site parking.

At the time of the inspection there was no registered manager in post; however, a new manager had started a few days before the inspection commenced. 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.

Parts of the environment were not always safe. We identified a shower in which the water temperature exceeded safe limits. In addition there was exposed pipework in the shower which also exceeded a safe temperature and posed a risk of scalds. This had not been identified during routine temperature checks that had been completed within the service.

In one room, boxes had been stacked one on top of the other. These boxes were unsteady and would cause injury if they fell on someone. This room remained unlocked which enabled one person to enter. We ensured the person safely left the room before requesting the room was made secure.

Fluid thickener was not stored securely in people’s rooms. This can pose a risk of death if ingested inappropriately. We raised this with management who immediately acted to ensure this was stored safely.

During the inspection we observed people being offered fluids throughout the day; however, records showed that people were not being offered the amount of fluids stated in their care records. We raised this with the registered provider for them to investigate.

Whilst quality monitoring systems were in place within the service, these had not always identified or addressed those issues found during the inspection. For example, whilst the registered provider had identified occasions where some doors had been left unlocked, this continued to be an issue at the inspection which showed that effective measures had not been implemented to prevent this issue from reoccurring.

You can see what action we told the provider to take in relation to these issues at the back of the full version of the report.

Records showed that not all staff training was up-to-date. The registered provider showed us that plans were in place to ensure that this training would be brought up-to-date. Following the inspection the registered provider informed us that training sessions were underway.

People were protected from the risk of abuse. Records showed examples where staff had appropriately reported concerns and these had been passed to the local authority. Staff knew how to report concerns and told us they wouldn’t hesitate to do so.

People received th

We undertook an unannounced inspection on the 28 November 2016 and returned with notice on the 29 November 2016.

We had previously carried out an unannounced comprehensive inspection of this service on 14 October 2015 and found there to be breaches in legal requirements. The purpose of this inspection was to check if the registered provider now met legal requirements and to ensure that people who receive the service are provided with safe and effective care

Redwalls Nursing Home is registered to provide personal and nursing care for up to 44 older people. The home has 41 single and two double rooms the majority of which have en-suite facilities. At the time of our inspection the home had full occupancy. Four rooms were utilised by the clinical commissioning group to provide rehabilitation to minimise a person’s length of stay in hospital or to avoid it in the first place.

The service had 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.

Following the inspection on October 2015, the registered provider submitted an action plan telling us they would be compliant with the legal requirements by the end of July 2016. On this inspection, we found that the registered provider had made some improvement and had met some of the previous breaches in legal requirements. However, we identified two continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we told the provider to take at the back of the full version of the report. 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.

Recruitment processes were still not robust. Staff had commenced their employment without appropriate checks from the Disclosure and Barring Service and without appropriate or verified references. This meant that adequate measures were not in place to ensure that people were only supported by people of suitable character and skill.

There were some positive interactions between staff and people and staff were observed to treat people with respect. However, we identified some areas of practice where people’s dignity or safety were at risk of being undermined due to a lack of attention to privacy, comfort or social inclusion.

People told us that they felt safe and were well cared for by staff. They said they had a good relationship with the staff that provided their support; and this had improved now that there more continuity in the staff team. On the day of the inspection, there was not a full complement of staff available due to staff sickness but people’s needs were met and call bells were responded to in a timely manner.

Accidents and incidents were recorded but there was no detailed analysis of overall themes and trends. This process had recently been put in place by the registered provider but had not yet been utilised.

Staff kept daily records such as the support offered/delivered or food and fluids consumed. These were not always up to date to reflect accurately what had occurred. This meant that there was a risk that concerns may not be picked up and acted upon.

Care plans were updated where there had been a change of need and information around the risk of harm was clearly available to staff. Care plans were personal to the person and contained information about their needs and wishes. This meant that staff had information available to them to respond appropriately to a person’s needs.

People were offered choices in relation to their care and support. Staff understood the principles of the Mental Capacity Act 2005, and said that they would be able to make a judgement aroun

This inspection took place on the 14 October 2015 and was unannounced.

Redwalls Nursing Home was last inspected on 9 September 2013 and we found that the service met the regulations we inspected against.

Redwalls Nursing Home is registered to provide personal and nursing care for up to 44 older people. The home has 41 single and two double rooms the majority of which have en-suite facilities. At the time of our inspection the home had full occupancy. Four rooms were used by the clinical commissioning group to provide rehabilitation to minimise a person’s length of stay in hospital or to avoid it in the first place.

There was 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.

At this inspection we found that whilst there were some elements of good care and practice, there were a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

People told us that they felt safe and secure at the service and that they had a good relationship with the staff that provided their support. There were some positive interactions between staff and the people they supported. At times, staff treated people with respect but we also saw examples of poor practice where people’s dignity was undermined.

On the day of the inspection, there were enough staff available to meet the needs of those people who used the service and call bells were responded to in a timely manner.

People were offered basic choices in relation to their care and what they wanted to do throughout the day. However, staff did not know the basic principles of the Mental Capacity Act 2005, and would not feel confident making a judgement around a person’s mental capacity. The majority of staff lacked a basic knowledge of the Deprivation of Liberty Safeguards and where they may be required. Staff had not been supported to undertake training in these areas. This meant that people were at risk of having their human rights infringed and care and treatment may not always be provided with the consent of the relevant person.

People needed medicines to keep them well and we saw that the registered provider had processes in place to ensure that medicines were ordered and stored safety. However we had concerns about the use of “Thick and Easy” as staff were not aware of the prescribers’ instructions and it was not stored safely. This could place people at risk of choking. There were also inadequate measures in place to ensure that a consistent approach was taken with people who had “as required medicines.”

Not all people who used the service were fully protected from harm. Accidents and Incidents were recorded but there was no detailed analysis of these undertaken. Risk assessments were not always in place, or implemented following an incident which prevented effective learning and further minimisation of risks. Care plans were not consistently updated where there had been a change of need and information around the risk of harm was not always clearly available to staff. This could have impacted upon the ability of staff to respond appropriately.

People’s health and safety was put at risk because parts of the environment were unsecure, unclean and appropriate infection control measures had not been implemented. The Cheshire & Wirral Partnership NHS Foundation Trust made a number of recommendations following an infection control audit in March 2015 but the registered provider had not implemented an action plan or made any changes following this.

We found that recruitment processes were not robust. Adequate measures were not in place to ensure that people were only supported by people of suitable character and skill. Staff received an induction but this required review in order to meet the recommendations of the Care Certificate. Staff received some training relevant to their role but this was not always kept up to date.

Staff said that they worked in a supportive environment and that they had a good relationship with management; however they had not received supervision or appraisals in line with best practice. We recommended that the registered provider review their supervision and appraisal policy in light of current best practice.

The registered provider told us that they had tried to seek the opinion of people who used the service and their relatives but so far this been unsuccessful. We made a recommendation that they explore alternative ways of seeking opinions. People who used the service and their relatives felt that they could go to the registered manager with any concerns, but not all felt confident that these would be addressed to their satisfaction.

The registered provider has statutory obligation to inform the CQC about a range of occurrences that may affect the health, safety and welfare of people who use the service. This is so that CQC can take follow-up action to safeguard the interests of people if required. The registered provider had failed to report all such events. CQC was, therefore, not able to monitor the events that affect the health, safety and welfare of people who used the service.

We found that care records contained information about the life history of each person and provided detailed guidance for staff on how people wished to be supported. People’s personal preferences such as their daily and bedtime routines were also taken into account as well as their end of life care wishes.

We spoke with six people who used the service and four relatives. They all told us they had no concerns with the care and treatment that was provided. Comments included: "My relative is kept warm, clean and well fed. Their needs are always met" and "I'm satisfied and I couldn't be happier."

We sat with people who used the service during the lunchtime period in one of the dining rooms. We saw that staff were present as people had lunch and assisted people to eat where required. We saw that people who used the service and staff interacted positively throughout this period.

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

We found that records were kept securely and could be located promptly when needed. This included staff personnel files and clinical records for people who used the service. The service also had data protection policies and procedures in place. We saw they were in line with the Data Protection Act 1998.

We spoke to five people who used the service who said that they were well looked after and happy with the service they received. Some comments made were: -

“It’s a lovely place. The staff look after me well.”

“I’m well looked after. The staff are nice people. I like the food.”

“I have been here for five years and I am very happy. The staff are very nice and helpful.”

We spoke to one relative who told us that they were happy with the care provided. They said they were kept informed about their relatives’ well-being. They described the staff as professional, caring and attentive.

There were practices in place to ensure that people who used the service were consulted and that their views were obtained.

People had been assessed before they began to use the service and they had a care plan in place which gave guidance to staff on the support they needed.

We found that the home was clean with and there were systems in place to promote infection control.

There were suitable recruitment checks in place for staff at the time of our visit.

There was a system in place to ensure that complaints were effectively managed.

No information of concern was reported by Cheshire West and Chester Council.

Cheshire West and Chester Local Involvement Network visited the service in October 2012. They said that the home was warm and friendly and that people looked well cared for. They made some recommendations for the improvement of the home environment.

We spoke with people living at Redwall’s and they said that the care they received was very good. They said that they felt supported by the staff and comments made were;

“staff are very helpful”

“staff are caring and considerate”

“the home is friendly and homely.”

People spoken with also said that they felt safe and happy living at Redwall’s. One person said, “I can speak to the staff about anything”.

We spoke to people and they said that there is always staff around when you need them and they told us that they are consulted about their care and support and they feel their wishes are listened to.