This inspection took place on 27 November and 4 December 2018 and was unannounced.

Ryeview Manor Care Home is a care home service. People in care homes receive accommodation and personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided. Both were looked at during this inspection.

Ryeview Manor Care Home provides care for up to 94 people, some of whom were living with dementia. At the time of the inspection, 91 people were living at the service.

The service had 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.

Ryeview Manor Care Home is a three-storey building set in secure grounds in High Wycombe. The home comprised four units. Three for people living with dementia in need of residential care and one specialised residential unit for people with increasing needs, living with advancing dementia. Each unit had a sitting area and dining area. There was a secure garden with seating which was accessible to people living in the service.

The service was last inspected in August 2016 and was rated ‘Good’ in all key questions. At this inspection we found the service no longer met the criteria for Good in caring, responsive and well led and was rated ‘Requires improvement’.

Most staff interacted with people in a caring and sensitive way. We did however, observe that at times people were left seated in communal areas with little stimulation for periods of time.

Staff supported people to communicate their needs and protected their privacy, dignity and independence.

The registered manager used systems and processes to monitor quality and safety in the service, however, these were not always effective. Audits of medicines management contained insufficient detail to show all actions taken to mitigate risks and correct errors.

The provider had robust systems and processes in place to protect people from harm and abuse. Staff had completed safeguarding training and were knowledgeable about actions to take if they suspected abuse.

The registered manager deployed sufficient numbers of staff to meet people's needs and keep them safe. They used safe recruitment processes to ensure only staff who were suitable to work in a care setting were employed.

Safe systems were in place for the management of medicines and people were protected from the risk of acquiring an infection. Staff reflected on incidents to maintain people’s safety and prevent reoccurrences.

People received care from skilled, knowledgeable staff who had been appropriately trained. Staff were supported with regular supervision to help develop their knowledge.

Staff were aware of the legal protections in place to protect people who lacked mental capacity to make decisions about their care and support.

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.

People were supported to maintain a balanced diet. Risk assessments were in place for those at risk of malnutrition and dehydration. Staff supported people to access care from appropriate health care professionals.

Care plans contained details about the type of care and support people required. There was however, insufficient evidence to show these had been written in partnership with people and their families where appropriate. In addition, some language used by some staff to describe people and their behaviours was not person-centred.

Care plans showed that some details had been recorded regarding end of life care for people. There was however, a lack of sufficiently d

This inspection took place on 14 and 15 July 2016. It was an unannounced visit to the service.

We previously inspected the service on 24 and 25 June 2014. The service was not meeting all the requirements of the regulations at that time; there were concerns in relation to management of medicines, monitoring of the service, management of risk and choice of meals.

Ryeview Manor Care Home provides care for up to 94 people, some of whom have dementia. Eighty four people were living at the service at the time of our visit.

The service did not have 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. However, an application was in the process of being made to the Care Quality Commission.

We received positive feedback about the service. Comments from people included “It’s nice here, I like the smiling faces,” “The staff here are excellent” and “We’re kept comfortable.” A relative told us “I would give the staff here 10 out of 10. I can go home knowing (my family member) is being well looked after.” A healthcare professional said “I think it’s a wonderful local resource.”

There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Risk was managed well at the service so that people could be as independent as possible. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care. People’s medicines were handled safely and given to them by staff who were trained to do so.

Although there was mixed feedback about staffing levels, we found there were sufficient staff to meet people’s needs at the time of our visit. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a range of social activities. Staff supported people with their healthcare needs to keep them healthy and well.

The building was well designed for its purpose. It had been well maintained and complied with gas and electrical safety standards. Equipment was serviced to make sure it was in safe working order. Evacuation plans had been written for each person, to help support them safely in the event of an emergency. Regular fire safety checks were carried out.

The service was managed well. The provider checked quality of care at the service through audits and quality assurance questionnaires. There were clear visions and values for how the service should operate and staff promoted these. For example, people told us they were treated with dignity and respect. Records were generally maintained to a good standard.

We visited the home at 9.30pm. At the time of our visit we were told there were seven people with dementia on the first floor and 14 people with mixed care needs on the ground floor. Two care staff were on the night shift, one per floor. In addition a senior care worker was on call. At 10.20pm a member of the day staff was still on duty.

We saw care staff responded to people in a patient way and talked to them respectfully and appropriately. We were told by one resident “staff do very well but they are very busy” and by another “staff are very attentive”.

We saw in a care plan and staff told us there was occassionally the need for more than one carer to assist a person for example if there was a fall. With two care staff attending one resident one floor would be left unattended. We saw hourly check records had not been completed while we were on site. Staff said this was because they had not had time yet. Staff told us, “While attending one resident others would have to wait” and, “most people will tell you sometimes needs are not being met”. Care staff were unaware two people had been risk assessed as at risk of leaving the building and required half hourly checks to be carried. out overnight. This placed people at risk of harm or injury.

The care staff on duty were not trained to administer medication. If people needed medication overnight their needs would not be met in a timely way.

You can see our judgements on the front page of this report.

This visit was undertaken over the course of two days. The inspection team included two inspectors and a pharmacist inspector. They gathered evidence against the outcomes we inspected to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. We saw some people who lived in the home had a DOLS in place. Correct procedures had been followed in that a referral to the Local Authority (as "Supervisory Body") had been made and all were approved. This showed the provider had identified people could have potentially been deprived of their liberty and understood that an application was to be made and knew how to submit one.

We looked at care plans and spoke with staff. We found there were some risk assessments in place to identify and manage risks to people's health, safety and welfare. However there were instances in which risks were evident but no risk assessments were in place or strategies of how staff were to minimise those risks. We found people's care plans were not person centred and specific as to how people wished to be supported with their identified needs.

The provider monitored and kept a record of the falls, accidents and incidents people experienced whilst living in the home. However, Records of these were not being accurately recorded. The records we looked at indicated a high level of falls taking place but there was no adequate explanation for these in the records we looked at. Consequently there was no guidance in place for staff to follow to minimise risks posed to people. There was no analysis of these incidents being undertaken to ascertain why they were happening and how they could be minimised.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.This was because appropriate arrangements were not in place for the safe storage of medicines that required cool storage, protocols for the administration of ‘as required’ medicines were not available and on some occasions there was no trained member of staff available after 8pm to administer medication.

These findings demonstrated to us the service was not safe.

Is the service effective?

Whilst risks had been considered as part of the provision of care we saw some records in two people's files of risks which had not been considered. There was no risk assessment in place or strategies of how staff were to minimise these risks. This meant that risks posed to people were not always being managed effectively.

We found the measures to meet people's medical appointments outside of the home were ineffective. We were informed as part of people's contracts it was down to family members to do this. However, we found an instance in which one individual's appointment was overdue by eleven days. This was because alternative arrangements were not in place to meet their health care needs when families were unable to do so.

These findings demonstrated to us the service was not effective.

Is the service caring?

People said they were happy with their care and support and the staff met their needs well. Comments included “I would recommend this place to anyone who asked me, I have been happy since I have been here. I feel safe and well looked after.” “I am very happy here I would not want to go anywhere else.” and '' It is all very good here; the staff are approachable and nice. The care is very good and the food is excellent, there is a nice atmosphere and everyone gets on well, I have no complaints.'' Throughout our visit we observed positive interactions between staff and people living in the home. We saw staff spending one to one time with people and saw others involving people in group activities.

We spoke with two family members who told us they were happy with the care and support their relative received. They told us the staff always kept them up to date about any accidents or incidents their relative had. They told us the staff always made them feel welcome when they visited.

Staff showed they had a good understanding of people’s needs and knew them well. We observed staff were gentle and patient with people and provided assistance to those who required help. They were respectful when they spoke with people and did not hurry them but enabled them to answer at their own pace.

These findings demonstrated to us the service was caring.

Is the service well led?

There was a registered manager in post who is also registered for another care service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting requirements of the law with the provider. There was also an appointed manager in post who was managing the service with the support of the registered manager, although the support had been reduced as the registered manager was spending time overseeing one other service and managing another. The registered manager said they were initially in the home three days a week to support the appointed manager but had only not visited the service once every couple of months since December 2013 as the service was being managed well. At the time of registration in July 2013 we were informed the appointed manager would be applying for registration, however there is no application with the Commission at present.

The provider did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service. There were no systems in place to show the provider was assessing and monitoring the effectiveness of the registered manager overseeing the running home whilst managing one other service and overseeing another. Neither were there any systems in place to show how the registered manager was monitoring the running of Ryeview Manor Care Home to ensure people received safe effective care and support.

Systems to assess and monitor the quality of service were ineffective because they were not followed in practice.

Staff we spoke with told us they felt well supported. They told us the registered manager, appointed manager and deputy manager had an 'open door' policy and could discuss any concerns they had with them. They said they were approachable and accessible and provided support when it was required.

These findings demonstrated to us the service was not well led.