This inspection was carried out over two days on the, 14 and 17 May 2018. Our visit on the 14 May was unannounced. At the last inspection we rated the service as good.

Rushes House Care Home provides personal care and accommodation for up 17 older people in a domestic style property. Accommodation is provided over three floors with a lift servicing each area. A further additional floor was only accessible via staff. Single and double bedrooms are available. The home is non- smoking and is situated in the village of Marple, close to local shops, parks and the canal. At the time of our inspection 12 people were living at the service.

The registered provider had systems in place to monitor the quality of the service provided. Some areas needed improvements as some issues, such as out of date maintenance certificates, had not been identified within the service’s own monitoring procedures. We found the system to provide good governance had not always identified where updates were needed to show appropriate quality assurance systems were in place.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated activities) regulation 2014 Good Governance.

Out of date maintenance of main systems such as the electrical installation systems can put people at risk within the building and needed improvements in their management to make sure the building was safely maintained. We found the systems to monitor the safety and quality of the service required further development to ensure full compliance with the regulations.

This is a breach of Regulation 12 HSCA RA Regulations 2014 Safe care and treatment.

We saw there was a concerns and complaint policy accessible to each person on admission to the home. People living at the service and visiting relatives we spoke with told us they had no concerns or complaints.

We saw the food looked and smelt appetising and was mainly homemade and attractively presented. People told us they enjoyed the food.

From our observations of staff interactions and conversations with people living at the service, we saw staff had good relationships with the people they were caring for. The atmosphere was relaxed and people told us they felt comfortable. We observed staff being kind, patient and caring to people.

The registered provider reviewed staffing levels using a staffing calculator but there was no information to show other people were included in feedback about the staffing levels. We recommend the registered provider includes staff, people receiving support and relatives to obtain their feedback to help review assessments to provide suitable numbers of staff each day.

Procedures were in place to minimise the risk of harm to people using the service. Staff understood how to recognise and report abuse which helped make sure people were protected.

Staff were recruited following a safe process to make sure they were suitable to work with vulnerable people. The registered provider had not always stored interview notes taken during the recruitment and interview of staff. We recommend the registered provider takes appropriate guidance regarding employment law and reviews their process for storing records relevant to their recruitment of staff.

The building was clean and well maintained. We saw staff had access to personal protective equipment (PPE) to help reduce the risk of cross infection for example disposable gloves and aprons.

The environment was comfortable and homely with domestic style décor in place. We discussed published guidance for adapting environments to meet the needs of people with dementia. We recommended the registered provider look at published guidance to consider further adapting the environment to meet people’s dementia needs if applicable.

Staff understood the need to obtain verbal consent from people using the service before a care task was undertaken and staff were seen to obtain consent prior to providing care or support.

People had access to heal

We carried out this inspection to follow up on concerns we had found during our previous inspection with the safety of the premises and the systems in place to monitor the quality and safety of the service provided. During this inspection we spoke with the provider manager and two members of staff. We also took a tour of the building and looked at a selection of the provider’s records, including people’s care records.

We considered the evidence collected under these outcomes and addressed the following questions, is the service safe and is the service well led?

Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service safe?

We saw that following our previous inspection the provider had taken steps to improve and maintain the standard of the home’s environment. We saw that some action had been taken by the provider in response to recent inspections carried out by the local fire safety officer and infection control nurse. We were told that follow up inspections with these organisations, to check that the required improvements had been made, were yet to take place.

Is the service well led?

We were shown a fire risk assessment tool introduced by the provider, however this had not been completed. This meant that the provider did not demonstrate they had robust measures in place to assess and address fire safety risks at the premises.

The provider did not have sufficient time to carry out their management duties for the service. There were not effective systems in place for the provider to identify risks or shortfalls in the service that people received, which included the quality of people’s care records. We also saw that records relating to people who used the service were not always kept securely.

During our inspection we spoke with the manager, who is also the owner of the home, a member of care staff and a visiting health care professional. We also spoke with three people who lived at the home and two visiting relatives. We took a tour of the building and spent some time observing how people were cared for. We looked at a selection of the provider’s records, including a sample of people’s care records. On the day of our inspection there were 15 people living at the home.

We considered the evidence collected under the outcomes and addressed the following questions: 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. Please read the full report for the evidence supporting our summary.

Is the service safe?

We saw that people were treated with dignity and respect by staff. The people we spoke with who lived at the home or were visiting relatives, all made positive comments about the service, they told us they had no concerns about people’s safety or the care provided. One person told us “it’s wonderful, [the manager] looks after us well”. We also spoke with a member of care staff who told us they thought people were well looked after and commented “it’s [the home] a good environment for residents and staff”, “it cheers me up coming to work”. During our visit we spoke with a visiting GP, they also told us they had no concerns about the care people received, they commented “[people are] cared for very well” and “everyone seems happy”.

During a tour of the building we noted several concerns. We saw that the environment was cluttered, which not only had a negative impact on the appearance of the home, it also posed a ‘trip hazard’ and a fire risk. Following our inspection, we referred our concerns to the local fire service for them to consider and take appropriate action to ensure fire safety regulations were complied with. We also saw areas where cleaning products and prescribed medications were easily accessible to vulnerable people, which posed a risk to their health and wellbeing.

Is the service effective?

People’s care needs were assessed with them, and where appropriate their families were involved. People’s care plans were person centred and generally provided clear guidance for staff in how to deliver people’s care. We did find some examples where people’s care records were not as complete as they could have been; however there was no indication that people were receiving poor care.

Staff demonstrated a good understanding of the needs of the people they worked with. The people we spoke with all made positive comments about the staff and the care they or their relatives, living at the home received. A visiting relative told us they had seen improvements to their relative’s condition during their stay. They told us “the care is very good”, “[the home is a] small place, with good individual care”. This relative also told us they had confidence in the staff and that they were involved in their relative’s care.

Staff understood the importance of working with the other professionals involved in people’s care and people were supported to access medical advice and treatment. Staff felt they had good working relationships with local medical professionals. During our inspection, we spoke with a GP who regularly visited people living at the home. They told us that the service made appropriate and timely referrals to them and that the manager had a good understanding of peoples’ needs, care and treatment. They told us staff were available to assist them on their visits and advice was followed by staff. They felt people received good care at the home.

We saw that staff received training and support to enable them to carry out their role. The staff member we spoke with told us they felt supported and that the manager was approachable. We saw that staff received regular supervision sessions and annual appraisals.

Is the service caring?

The atmosphere in the home was relaxed and friendly and we saw that people were treated with warmth and respect. The care we observed was provided in a sensitive, unhurried and personal way. All the people we spoke with made positive comments about the care they or their relative received. A visiting relative told us “[their relative was]always well presented, dressed nicely, hair nice”. We were told that before people started using the service, they were encouraged to spend some time visiting the home, where they could enjoy a meal or a short stay to experience the environment. This was to help them to settle in.

Is the service responsive?

We saw that reviews of people’s care were generally carried out and people’s preferences and preferred routines considered. We saw that people’s independence was encouraged.

The manager was aware of the importance of engaging medical practitioners and other professionals involved in people’s care and worked alongside them to help ensure people’s changing needs were met.

We saw that there was a complaints procedure in place. All the people we spoke with told us they had had no cause to complain, but would feel comfortable in doing so if needed.

Is the service well led?

The manager assessed people’s needs before they started using the service to ensure that their needs could be effectively and safely met.

The manager took the lead in liaising with other professionals required to meet people’s needs. We spoke with a visiting GP who made positive comments about their working relationship with the manager, commenting “[the manager] gets things done”.

We saw that due to staff recently leaving the manager was spending half their time providing care assistance to people. This meant that they were not able to spend the majority of their time on their management duties. We saw that the home did not have an effective systems in place to monitor the quality and the safety of the service that people received. This meant that the service was unable to reliably identify and respond to shortfalls in the service.

During our visit in November 2012 we had concerns in the following areas:- Respecting and involving people who use services; Care and welfare of people who use services; Meeting nutritional needs; Safeguarding people who use services from abuse; Management of medicines; Safety and suitability of premises; Staffing; Records.

This inspection visit was carried out to check if improvements had been made. At the time of our visit new recording systems were still being put in place therefore it was too soon to judge the long term impact or effectiveness of the new processes. We will therefore look at record keeping during our next visit when we expect them to be completed to a standard that meets with requirements. Until all the records including assessments, plans of care and training records are in place we have minor concerns that people may be at risk from unsafe or inappropriate care.

We spoke with a number of people during our visit including people who use the service, family members and care workers. Everyone we spoke with said that they were happy with the care people received and no one had any complaints.

One person said; “Couldn’t be better”; “Food very good”; “Mary (provider) very good gets me what I want, food lovely”; “Can go to bed and get up when I want, saw GP when I was not well, I play bingo”; “I like it, I agreed to come because I liked it”

We spoke with four people about medicines handling at the home. Everyone we spoke with was happy with staff administering their medicines. One person we spoke with told us “I know what medicines I have” and, “have everything I need.”

However, we found that the home’s medicines policies were not always followed, increasing the risk of errors.

During our visit to Rushes Care Home we talked to two relatives and an advocate of one person. We also talked to eight of the people who lived there.

All but one person told us that they were happy with the care they received and had no complaints. However we did receive one comment; “I think there could be more stimulation but I have no problems with the care”.

Other comments we received were; “Mary (provider/manager) is very nice, has a slight tendency to be abrupt sometimes but she is a very busy person and always on the go”; “Mary is approachable.” When we asked one person if they liked living at the home they said; “Oh yes” and to our questions about the food they said; “We have three meals a day which are good, the chef is very good”.

We also spoke with two members of the staff team both of who said that they had no complaints and that the provider/manager was very supportive.

We contacted the district nursing service and asked if they had any concerns. They told us that they had no concerns and that “It is one of the nicest homes we go to”.

However we did find a number of concerns during our visit regarding record keeping and care planning. We found that there were no written plans of care that told people what their current needs were. Therefore people did not have the opportunity to agree to the plan of care and have the opportunity to change them if they wished to. The lack of a written plan of care also meant that the care workers had no guidance on how to support people with their health and social care needs. The absence of good record keeping and care planning was putting the people who lived at the home at risk of not receiving the care and support they needed.

We were also concerned about care practices such as people being in their night wear at 3:30pm in the afternoon. Other areas of concern were the length of time for some people between supper and breakfast which could be as much as 12 hours. Medication records and the administration of medication were also of concern.

We spoke to one person who told us all about a recent trip to the ballot for her birthday. The lady looked relaxed, happy and content and sang us some songs form the ballet.

People who used the service told us they were able to express their opinions about

what they liked or disliked about the service and about what they wanted to do.

People told us that they felt they were well cared for and one person said ‘Mary is a good listener and she’s always available.’

People living at Rushes House told us, ‘the home has changed immensely since Mary came, It’s a nice place to live,‘Mary is brilliant and staff are very kind’.

This inspection was carried out over two days on the 19 and 21 January 2016. Our visit on 19 January was unannounced.

We last inspection Rushes House Care Home in September 2014. At that inspection we found that action was needed to improve assessing and monitoring the quality of service provision.

At our last inspection of the service in June 2014 we found that action needed to be taken to ensure an effective system was in place to identify, assess and manage the quality of service provision in the home. During this inspection we found that appropriate action had been taken and maintained to address those concerns identified in our last report.

Rushes House Care Home provides care and accommodation for up to 17 older people. Accommodation is provided over four floors with a lift servicing each area. Only people with good mobility are accommodated on the top floor. Single and double bedrooms are available. The home has a no-smoking policy and is situated in the village of Marple, close to local shops, parks and canals. There is also a private car park to the rear of the property.

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.

Staff we spoke with had a clear understanding of their role in protecting people and making sure people remained safe and free from harm.

Risk assessments were in place and provided guidance for staff to follow about how to manage identified risk(s) in order to promote and maintain people’s independence wherever possible.

Staffing rotas showed that there was consistently enough care staff on duty with the right competencies, experience and skills to keep people safe.

Only members of staff who had received appropriate training were responsible for the management and administration of medicines at the home. A policy and procedure was in place for the safe handling of medication in an adult care setting and the registered manager carried out annual competency checks of those staff with the responsibility for administering medicines in the home.

Suitable arrangements were in place for the prevention and control of infection. All bathrooms and toilet areas were extremely clean and hygienic and all contained a wall mounted liquid soap dispenser and paper towel dispenser.

We saw that people’s healthcare needs were reflected within their care plans, based on a full assessment of their individual needs which were reviewed on a regular basis. Staff also undertook a range of training which staff told us was good and ‘met their needs’ to carry out their job roles effectively and enabled them to meet people’s needs safely and appropriately.

Staff gained people’s consent and cooperation before any care or support was offered or given. Where people were unable to give verbal consent, staff knew by the person’s facial expression or body language if they did not agree with the action being suggested and did not force the person, but tried again later.

We spoke with the cook who was very knowledgeable about providing well balanced and meals and told us about the different types of meals provided and how nutritional values were monitored for each person using the service. The cook also explained how those people with varying dietary needs due to medical conditions had their nutritional needs met.

We saw that good relationships were had with visiting healthcare professionals such as doctors and the district nursing service.

Wherever possible, people using the service would be involved in discussions about their care and treatment and the decision would then be recorded in their care plan. Where people were unable to be involved we saw representatives participated in the care planning process. We spoke with a relative who confirmed such discussions had been held with them about their relatives care needs.

People’s private space was respected by staff and permission was asked before staff entered a person’s room.

We were told that wherever possible, people using the service would be involved in discussions and the decision making process about their end of life care and this would then be recorded in their care plan. Staff we spoke with understood their role when dealing with such a sensitive matter, but still needed to complete end of life care training.

The individualised approach to people’s needs meant that both registered manager and staff provided a flexible and responsive approach to meeting the individual care needs of people using the service.

Staff we spoke with told us that they had regular conversations with people who used the service, or their representatives, to see if they had any worries or concerns.

We saw that the registered manager worked much of the time ‘on the floor’ which provided them with opportunities to assess and monitor the culture and openness of the service being offered to people. Staff we spoke with told us that the registered manager ‘led by example’ and gave the staff team confidence.