This inspection took place on 17 December 2018 and was unannounced.

Richard House offers accommodation for up to 29 people who require assistance with personal care and support. The home is a two-storey building with bedrooms and bathrooms on both floors and secure garden areas. At the time of the inspection 18 people were using the service and one person was in hospital.

At our previous inspection conducted in May 2017 the service was given an overall rating of Good and there was a breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance.

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 question of Well-Led to at least Good, which we received. At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance and safe care and treatment. We also made a recommendation about activities.

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

Richard 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.

There was 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.

Accurate records to demonstrate the safe management of people’s medicines were not always present and the provider was unable to demonstrate sufficient time was being maintained between medicines. Medicines were brought from the upper floor of the building to downstairs to give to people which is potentially unsafe practice.

Records regarding PRN (when required) medicines were not always accurate.

We found gaps in some people’s medicines administration records (MAR’s). MAR charts were not always easy to read for some people. Three MAR’s we looked at were missing a picture of the person and one MAR had no name of the person on it.

Some MAR’s did not have any specialist instructions for people with swallowing difficulties and how this may affect their ability to take their medicines.

When people were identified as having dietary needs either due to swallowing difficulties or weight loss, care plans had not been updated to reflect this need and monitoring charts had not been implemented to demonstrate people’s needs were being met.

One person had been in residence at the home since September 2018, however no risk assessments had yet been undertaken.

The arrangements for assessing quality and safety required further improvements to ensure they were effective and robust in identifying concerns; audits undertaken had not identified the concerns we found during this inspection regarding the safe management of medicines and the absence of up to date records.

Activities provided to people were limited and we have made a recommendation about providing activities in relation to people’s identified preferences and choices.

Any accidents or incidents had been recorded and acted upon.

People who used the service and their relatives told us they felt safe living at Richard House and there was an appropriate safeguarding policy in place.

People told us they felt there were enough staff on duty to meet their needs and the home assessed people’s dependency levels to ensure there were sufficient staff on duty.

We observed many good interactions between staff and people who used the service; people and their relatives told us staff were kind and caring.

The register

This inspection was carried out over three days on the 22, 23 and 24 May 2017. Our visit on 22 May 2017 was unannounced.

At the last inspection on 19, 20 and 21 September 2016 the overall rating for the service was requires improvement, with the well led section found to be inadequate. At that inspection we identified multiple regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014, which related to medication administration, premises and equipment, receiving and acting on complaints, fit and proper person’s employed, safe care, staffing and good governance.

Following the inspection the provider sent us an action plan detailing how the identified breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

Richard House Care Home is located in the Cale Green area of Stockport and is registered to provide accommodation for up to 29 people who require assistance with personal care and support.

Accommodation is provided on two floors, which are accessible by a passenger lift. There are twenty five bedrooms, four of which have the capacity to be used as shared rooms. However at the time of this inspection all of the rooms occupied were single occupancy. Six bedrooms have en-suite facilities.

The home has three lounges, a sun room, a porch seating area and two dining rooms as well as garden space and parking to the rear of the property.

At the time of our inspection there were 22 people living at Richard house Care Home.

The home had a manager registered with the Care Quality Commission (CQC), who was currently on sick leave and not present throughout the three days of inspection. CQC had been appropriately notified of this sick leave. The acting manager was present for the first two days of the inspection and a senior carer was present for the third day of the inspection. A registered manager is a person who has registered with CQC 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 and associated regulations about how the service is run.

During this inspection, we found significant improvements had been made; the acting manager and senior care staff we spoke with were responsive to our feedback and were committed to further improving the service delivered to people living at Richard House Care Home. At this inspection we identified a breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to good governance.

We observed people receiving person-centred care and staff were able to describe the individual care needs of people, but we found some shortfalls in the written plans of care. This was because some parts of the plans of care were pre-printed and staff used a tick box approach to identify if the care need related to the person. This meant that some parts of the plans of care were vague and did not include details of exactly what assistance the person required to meet their assessed care needs.

As stated above during the inspection we found significant improvements had been made since the last inspection. However we found that robust systems had not yet been implemented to monitor all aspects of the quality and safety of the service being provided.

We observed staff giving kind and caring support to people. We saw that people’s privacy and dignity was respected and people were relaxed in the company of staff.

Improvements had been made to medication administration and we saw medicines were managed safely and people were receiving their medicines in line with the prescriber’s instructions.

Since the last inspection the recruitment processes had been improved to ensure only suitable staff were employed to work in the service.

From looking at the training record and speaking with staff, we found improv

This inspection was carried out over three days on the 19, 20 and 21 September 2016. Our visit on 19 September 2016 was unannounced.

We last inspected Richard House Care Home on 11 December 2013. At that inspection we found the service was meeting the regulations we assessed.

Richard House Care Home is located in the Cale Green area of Stockport and offers accommodation to 29 people who require assistance with personal care and support.

Accommodation is provided on two floors, which are accessible by a passenger lift. There are twenty five bedrooms four of which have the capacity to be used as shared rooms. However at the time of this inspection all of the rooms occupied were single occupancy. Six bedrooms have en-suite faculties.

The home has three lounges, a sun room and two dining rooms as well as parking and outside garden space to the rear of the property.

On the first day of our inspection twenty two people were living at the home, however one person was later discharged home so twenty one people were accommodated at the home for the remainder of the inspection.

A Registered Manager was in post although they were not available during this inspection as they were on annual leave. 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 this inspection we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information about Care Quality Commission's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Some medicines were not managed safely. We found there were not always clear, detailed written directions for the use of medicines to enable staff to apply topical prescribed creams for example doublebase cream and fenbid gel as intended by the person’s doctor. This meant there was a risk that prescribed creams may not have been applied when required, which could have resulted in unnecessary discomfort for the person.

We had concerns in relation to staff supervision because staff were not receiving supervision on a regular, ongoing basis. This meant that staff were not being appropriately guided and supported to fulfil their job role effectively.

Some of the routine safety checks had not been undertaken, for example, checks of window restrictors, water temperature delivery testing and the nurse call system. This meant the provider could not be sure people using the service were supported to remain as safe as possible at all times.

Recruitment processes required improvements to ensure only suitable staff were employed to work with vulnerable people.

We saw that some people’s identified care needs did not have a corresponding plan of care to direct care staff on how to meet the person’s individual care need, for example, the use of topical creams or if a person had a chest or urine infection. This meant there was risk that people could receive unsafe and inappropriate care.

Staff training records viewed indicated there were gaps in staff training. This meant some staff were not being appropriately trained and skilled to meet the needs of the people living at the home.

We found that robust systems had not been implemented to monitor the quality and safety of service people received.

People were supported by a stable staff team who had worked together for a number of years and knew the people living at Richard House very well. However we found there was not a systematic approach to determine the number of staff and range of skills required to meet the needs of the people who used the service. This meant the registered provider could not be sure that the staffing lev

The people we spoke with said that they liked living in Richard House and could make choices about how they spent their day. They said that staff treated them well, were very good and they were all very positive about living there.

We found evidence that there were procedures in place to assess the capacity of people to

consent to their care and treatment. We found that people's decisions about how they wished their support to be provided were respected.

We saw that care plans clearly identified the needs of the person and had been reviewed on a regular basis. One person told us, "The care I receive is excellent. I always get what I need when I need it."

We looked around the premises and found it was clean and welcoming. People's bedroom's were individualised with their personal items and people could choose where to spend their time.

We observed support staff were friendly towards people and enabled them to be as independent as possible.

We found evidence that there were systems in place for the safe administration of medicines.

We saw evidence that there were effective recruitment procedures in place to ensure that people who used the service were protected from inappropriate staff.

We found that suitable arrangements were in place to manage an effective complaints process for identifying, receiving and handling complaints for people living at Richard House.

The people we spoke with said that they liked living in Richard House and could make choices about how they spent their day. They said that staff treated them well, were very good and they were all very positive about living there.

People said “this is a lovely place to live and I can go in to any room or stay in my bedroom.” “I have not been here long and the staff are good they do talk to me about my care plan,” “there are activities but I don’t take part you can choose if you want to join in.” “Another said “we play board games and really have a good laugh.”

People said they felt well cared for by the staff that supported them. Everyone we chatted to was positive about the support provided.

People told us that they felt safe and have no concerns about the care and treatment they receive from staff. People said they could talk to the manager at any time and she would sort anything out. They said she spoke to them each day and that all of the staff would listen if they had any concerns.

Relatives spoken with were happy with the care their relative received.

Comments such as “the staff are marvellous;” a great team of girls” “the staff are second to none” “the staff treat me very well and we have a good laugh” were made.

People we spoke with said that the staff asked for their views on the routines at the home and they have meetings with the manager to discuss anything they wanted to.