The inspection took place on 3 and 8 January 2018. The first day of our inspection visit was unannounced.

Shaw Red Hill Care Centre 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.

Shaw Red Hill Care Centre accommodates up to 60 people across three separate units within one adapted building, and specialises in care for people with physical disabilities and people living dementia. At the time of our inspection visit, there were 53 people living at the home.

A registered manager was in post and present during our inspection. 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 our last comprehensive inspection of the service on 6 December 2016, we found breaches of Regulations 9 and 10 of the Health and Social Care 2008 Act (Regulated Activities) Regulations 2014. We gave the service an overall rating of Requires Improvement. These breaches related to the provider’s failure to treat people with dignity and respect, and to consistently meet people’s individual needs. The provider sent us an action plan setting out the improvements they intended to make.

At this inspection, we found the provider had made significant improvements to the service, and that they were now meeting the Regulations. People’s privacy and dignity was promoted and respected by staff and management. People received person-centred care, shaped around their individual needs, choices and preferences.

People were supported by staff who had received training in, and understood, how to protect them from avoidable harm, discrimination and abuse. The staffing levels maintained at the home ensured people’s individual needs could be met safely and flexibly. Systems and procedures were in place to ensure people received their medicines safely and as prescribed, and to protect people from the risk of infection. Accidents and incidents involving people who use the service were analysed by the management team to stop things from happening again.

People’s needs and choices were assessed in order to develop effective care plans and achieve positive outcomes for people. Staff received effective induction, training and support to enable them to fulfil their duties and responsibilities. People were supported to have a balanced diet and any risks associated with their eating and drinking were assessed and managed. Staff and management worked collaboratively with external professionals, team and agencies to ensure people received coordinated care. Steps had been taken to adapt the premises to the individual needs of the people using the service. People’s consent to care was sought and their right to make their own decisions respected.

Staff treated people in a kind and caring manner, and took the time to get to know them well. Staff protected people’s personal information, ensuring this was stored securely. People were encouraged and supported to express their views about the service.

People’s care plans reflected their individual needs and were kept under regular review. Staff supported people’s participation in a range of social activities. People and their relatives were clear how to raise a complaint about the service, and felt comfortable doing so. People received appropriate support at the end of their life.

The management team promoted a positive, open culture within the home. Staff were clear about their responsibilities, and felt able to approach management for any additional support needed. The provider’s quality assurance enabled them to drive improvement in the service people recei

The inspection took place on 6 and 7 December 2016. On 6 December 2016 the inspection was unannounced. On 7 December 2016 the inspection was announced. Shaw Redhill Care Centre provides accommodation and nursing care for up to 90 people. There were 57 people living at the home at the time of our inspection.

The home consists of four units. Three of these were being used to provide care to people at the time of our visit. Topaz unit provides care to people living with dementia. Sapphire unit provides nursing care to people and the Entimos unit provides care to people with brain injuries.

A registered manager was in post at the time of our inspection. 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 the previous inspection on 11 and 15 December 2015 we found the way people were cared for required improvement and that the provider was not meeting the law. This was because people were not always treated with dignity and respect and people’s privacy was not always maintained. The provider had sent us a plan to say how these matters would be addressed. At this inspection we found people were not consistently supported by staff to maintain their dignity and people’s rights to privacy were not always acted on.

We also found at this inspection people did not always receive the individual care they needed when they were anxious. Staff did not always find out why people were distressed, or take action so their needs would be met.

People had plans in place which detailed how they preferred their care to be given and their risks managed. However, we found staff had not always taken action to follow the plans so people would receive the care they needed. We also saw people’s plans did not consistently reflect their preferences or care needs as their circumstances changed. Some people enjoyed the interesting things staff had provided for them to do, but other people’s needs were not met and they were withdrawn.

The provider and registered manager checked people’s experiences of living at the home, but this did not consistently drive improvements in the care people received.

People’s safety and care needs were understood by staff, but people were not consistently supported by staff so their needs were met in the ways they preferred. There were enough staff to meet people’s safety needs, but some people told us they did not always receive care from staff who knew them well, in a timely way.

Staff had received training so they would have the skills and knowledge they needed to care for people, but we found staff did not always use their training to inform how they supported people.

Most people had built good relationships with staff who were permanently employed to care for them. People told us it was more difficult to do this with temporary staff. People were supported by staff to make their own day to day decisions about their care. There were systems in place so complaints raised would be investigated.

Staff were confident action would be taken if they raised any concerns for people's safety or well-being, and we saw examples where staff took action to promote people’s safety. Some people administered their own medicines, with other people receiving support from staff to do this.

Staff cared for people in ways which recognised people’s rights to make their own decisions. Staff supported people in ways which protected their freedom and recognised their independence. People were able to make choices about the meals and drinks they wanted and had enough to eat and drink to remain well. People received help from staff to see health professionals when this was needed.

You can see what action we told the provider to take at the end of this

At our previous comprehensive inspection of this service on 18 and 19 January 2015 there was a breach of legal requirements. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to person-centred care, Regulation 9 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

We inspected the provider to see if they were now meeting the legal requirements. This inspection took place on 11 and 15 December 2015. The inspection on the 11 December 2015 was unannounced. We visited the service again on the 15 December 2015, which was announced, to conclude our findings. We checked that they had followed their plan and to confirm that they now met legal requirements. We found that the provider had followed their plan which they had told us would be completed by the 30 April 2015 and we found that the legal requirements had been met. The provider ensured people were assessed for their individual care needs and care and treatment was followed in-line with the plan of care.

Shaw Red Hill Care Centre is registered to provide accommodation and nursing care for up to 90 people. There were 72 people living at the home at the time of our inspection.

The home is purpose built and consists of four units. Topaz unit specialises in the care of people living with dementia. Sapphire unit provides nursing care to people and the Entomos unit provides care for people with brain injuries. The Worcester Intermediate Care Unit (WICU) provides nursing and personal care to people who may require rehabilitation. People who are on this unit may have been discharged from hospital but need extra support before they return home or to another service. The inspection team made checks in all four areas of the home.

At the time of our 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.

People who lived on Sapphire, Entomos and WICU told us that staff treated them kindly, with dignity and their privacy was respected. We spent time on the Topaz unit to understand how staff supported people to maintain their dignity. However, we found staff did not always promote or maintain people’s dignity and privacy. For example, ensuring people’s clothes protected their privacy, or that doors were always shut when people received personal care in their bedroom. We raised our concerns with the registered manager who agreed that this was not acceptable.

People lived in a safe environment as staff knew how to protect people from harm. We found that staff recognised signs of abuse and knew how to report this. Staff made sure risk assessments were in place and took actions to minimise risks without taking away people’s right to make decisions.

People and relatives told us there were enough staff to help them when they needed them. Staff said there were enough staff to provide safe care and support to people. We found when staff raised concerns about low staffing levels during a night shift the provider had responded and put further staff in place.

People who lived on Sapphire, Entomos and WICU units told us that their medicines were managed in a safe way and received their ‘as required’ medication, such as pain relief, when they requested it. We found that medicines were handled and stored in a safe way.

People felt staff cared for them in the right way and that staff were competent in their roles. Care and support was provided to people with their consent and agreement. Staff understood and recognised the importance of this. Where it had been deemed that the person did not have the capacity to make decisions on their own behalf the provider had taken steps to e

We carried out an inspection to help us answer five 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. The summary is based on our observations during the inspection, discussions with nine people using the service, three relatives, ten care staff supporting them, one physiotherapist and looking at six people's care records. The care centre is divided in to four separate units, Entimos, Topaz, Sapphire and Worcestershire Intermediate Care Unit (WICU). If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People who used the service told us that they felt safe. One person told us, "I feel safe here". Safeguarding procedures were in place and staff understood their role in safeguarding the people they supported. Staff were aware of the provider's whistleblowing policy.

People were asked for their consent to care and support and where people did not have the capacity to give consent, the provider had acted in line with legal requirements.

People had not always been cared for and supported in line with their individual care plan and risk assessment. This meant that people's welfare and safety was not always protected.

People were not cared for in a clean and hygienic environment. This meant that people were not protected from the risk of infection.

Systems were not in place to make sure that the manager and staff learned from events such as accidents and incidents, complaints and checks made on the service. This increased the risk to people.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Is the service effective?

People were not included in the planning of their care. One person told us, "I had been prescribed some treatment and I didn't know about it. No one had discussed it with me". We found that care plans and risk assessments were not followed by staff. This meant people were not receiving effective care that met their needs.

Where people had complex needs that required the input of specialist health care services, assessments had been made by the appropriate professionals. Their recommendations were carried out by the staff. This meant the provider worked well with other services to ensure people's health care needs were met.

The manager ensured that staff rotas were planned in advance to maintain the staffing numbers required to provide care in a safe way.

Is the service caring?

People were supported by care staff that were kind and caring. We saw that care staff gave people encouragement and respected their privacy and dignity. One person told us, "The staff really care about us". Some people raised concerns about the way in which some staff approached them. For example, people told us there was a lack of respect shown to them by night staff and that night staff kept them waiting for support.

People’s preferences, interests and diverse needs had been recorded but care and support was not always provided in accordance with people’s wishes.

Is the service responsive?

People we spoke with told us that the manager was always responsive to requests that they made. Relatives, staff and health care professionals all told us, where issues had been raised or comments made about improving the service that these had been acted on.

We found that the provider employed people specifically for the purpose of organising and carrying out activities.

Is the service well led?

People and staff told us that the registered manager was striving to improve the quality of the service provided.

The service had quality assurance and risk management systems in place. The provider sought the views of people who used the service. Records seen by us indicated that shortfalls in the service were addressed.

Staff told us they were clear about their roles and responsibilities and understood the quality assurance and risk management systems.

We found that the provider had made improvements to its medicines management system since our last inspection in June 2013. People were protected from risks associated with the unsafe use of medicines because they were managed appropriately.

72 people were living at the home when we visited. We talked with nine of them as well as four relatives who were visiting. We also spoke with the registered manager, deputy manager and nine members of staff. This included nursing, care staff and catering staff.

The people we spoke with told us that they were happy with the home and the staff. One person told us: “It’s grand, couldn’t be better,” and another said: “It’s a smashing place.“ A third person told us: “The staff are good, very friendly.”

We watched staff as they cared for people. They provided care and support that met people’s needs.

Staff knew about the needs of the people they were caring for. We looked at care records for eight people and found that these contained guidance for staff on how to meet their needs. We saw that people’s needs were reviewed regularly.

We found that people were able to have a choice of suitable and nutritious food and drink in sufficient quantities to meet their needs.

We found that people’s medicines were not managed appropriately. There were discrepancies between the amounts of medicines recorded as given and the amounts remaining in stock.

The provider had a system in place to monitor the quality of its service regularly.

There was a system in place for people to make complaints if they were not happy with any aspect of the service.

We found that staff kept accurate and up to date records of the care that people had received.

We found that processes were in place to minimise the risk of infection. Lapses in hand hygiene practice by some staff members decreased the effectiveness of these measures.

We found that people received their medication at the right time and that staff had appropriate guidance in when to administer medication prescribed 'as required’.

We found that the equipment that was used in the home was maintained appropriately and that staff had been trained in its use.

Some of the people who lived at the home were not able to talk directly with us because of their dementia so we used different methods to see whether they received the care and support they needed. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people who could not talk with us.

We found that there were sufficient numbers of trained and qualified staff to meet the needs of the people at the service on the day of our inspection. We also saw that an increasing number of staff had received specialised dementia training in order to meet the needs of this group of people.

We found that the provider had made some improvements to its quality assurance system but this system was not working effectively in relation to record keeping.

The provider had taken steps to improve the physical security of people’s records since our last inspection.

During this inspection we also followed up on issues that we had found during our previous inspection of January 2012. We spent time on all four units within the service.

People that we spoke with told us that staff respected their privacy and dignity. One person told us, “If they come to do anything the door is always closed.” People said that staff knocked before they came into their room, and we saw staff doing this.

People told us that staff supported them to make choices, for example about what they would like to eat and where they would like to eat it. People also said they were able to make choices that helped maintain their independence. One person said, “They ask me what I want to wear,” and another said, “We’re able to get up and go to bed when we want.”

We received positive comments from people who used the service. People told us they liked the staff. One person on the elderly and frail unit told us, “The staff are all very good, they’ll listen.” A person on the dementia unit told us staff were, “very good, very helpful. They seem to do what you ask them.”

One person on the unit for people with physical disabilities told us, “I’m very happy. I like being here. It’s a lovely place.” On the rehabilitation unit one person said, “I think it’s very good once you know what you are doing. I can’t really fault it,” and another person there said, “I find it alright. They keep an eye on me to make sure I’m okay.”

A relative of a person with diet controlled diabetes on the elderly and frail unit expressed frustration that staff were sometimes providing their relative with inappropriate foods.

People on all of the units at the service told us that they felt safe and that they knew who to speak to if they had any concerns. One person said, “If I wasn’t happy I’d go and see one of the staff in the office. Another person said, “If I wasn’t happy I’d speak to one of the head staff – or anybody really. They’re all sympathetic.” People on the rehabilitation unit were less sure of who to speak to than people on the other units, although they all said they would find a senior person. One person on that unit told us, “I’d go to whoever is in charge – we could do with more information.”

People that we spoke with did not raise any concerns about cleanliness and one person told us they felt the service was kept very clean.

People told us that they usually received their medication on time although we found an issue with the way this was recorded.

Most of the people that we spoke with told us that they felt there were enough staff on duty to meet their needs, although on one unit we received a mixed views, with one person saying they sometimes had to wait for a long time for someone to come and help them. They told us, “When you have to go, you have to go.” Another person on the same unit did not raise waiting times as an issue for them.

Since our last visit to the service there has been a change in ownership. As a result of the changes there had already been a number of improvements made to the environment. These had included the upgrading some of the bathing and showering facilities, replacement of furniture and redecoration of some areas. Additional improvements were planned for the near future.

The home was generally clean and tidy although there was a noticeable bad odour in the lounge on Topaz unit during the day.

During our visit we spent time walking round the four units and observing the care provided by staff .During these observations we saw that staff did not always knock before entering people’s rooms and we heard some inappropriate terms of endearment. For example we heard staff refer to people who needed assistance as ‘feeders’ and one member of staff described one person saying ‘ he is not with us’ and another person referring to people as ‘darling’.

On Entimos unit we saw that each bedroom door had sliding red and green cards on them. These were used as ‘do not disturb’ cards and they were on red when personal care was being provided or privacy was required.

The relative of one person told us ‘they could do more to keep people occupied, there’s not much going on’. They told us they are ‘always made to feel welcome’ when they visit and as far as they know the care is good.

We were told by the registered manager that the provision of recreational activities had ‘improved greatly ‘and that care staff now led activities on a day to day basis.

In addition to this they were recruiting an activities coordinator for an additional 20 hours to support the 35 hours currently contracted. We observed the lounges on both Topaz and Sapphire units during the day. We saw that there were long periods when people were sat in the lounge with no staff in the room to engage with them.

One person we spoke to told us that they felt there weren’t enough staff on Topaz unit and that ‘people had to wait’. Another relative said there was ‘not always enough staff’. They said staff were kind but ‘very busy sometimes’ and that ’they do have to wait and that’s not good if you need the toilet’.

We observed lunch being served on Sapphire and Topaz units. On Topaz unit we saw no evidence that people were shown food on plates to make meaningful choices but we saw that some people were able to have something different if they did not like the menu choice for the day. Staff on the unit were observed assisting people with their meals in a caring manner, taking time to describe the food to them.

The food served to people looked appetising and was served in generous portions. On Sapphire unit we saw that people who were sitting in the dining room were offered a choice of fruit juices with their meal. When meals were being served to people in their rooms on trays no fruit juice was offered to these people. No serviettes were offered to people with the exception of one person who was being assisted by staff. We saw that people who were able to eat independently were given their meals first and those who required assistance had to wait until some time later before they had their meals therefore spending a long period watching others eat.

We observed staff on Sapphire unit assisting people in a calm and caring manner but the level of engagement was minimal and some people were given meals but not being told what they were given or what they were eating .

For example we saw a person asking staff for gravy with their meal. The person later changed their mind when staff told them they had scampi on their plate. They had not been told what their meal was when they were given it.

On one unit we saw that two people had been sat together at a table. One of the people was demonstrating inappropriate behaviour at the table. There was no evidence that staff had considered the impact on the other person.

During our observations on Topaz unit we found seven sets of unlabelled dentures in a sluice room. When we asked staff they told us that they were confident everyone on the unit who needed dentures was wearing their own but they were not able to give an explanation about why these were there.

We pathway tracked the care of five people and looked at how their care was provided and managed. The records for two people provided evidence that their individual needs had been assessed, any risks had been identified and where necessary supporting care plans were documented and were regularly reviewed.

We looked at the records for two people who lived on Topaz unit where a number of significant concerns were identified within the care documentation.

One person had been living on the unit for 18 days before any care plans had been recorded. This meant staff had limited information about the person’s needs and the care they required from staff and there was a risk they may have received unsafe and incorrect care. When we spoke with staff they told us that the delay had been due to the fact there were no permanent nursing staff on duty to complete the care plans during this period. This information was more concerning as it was possible that the person may have been cared for by a number of different staff during this time.

When we looked at this person’s records we found conflicting information about their skin integrity. There was information in their care plans saying they required repositioning every two hours .When we looked at their repositioning records we saw this was actually happening every three to four hours instead. In addition to this there was some confusion about the setting of an electric pressure relieving mattress used to reduce the risk of skin damage and evidence that daily checks of the equipment were not being carried out.

We saw that records relating to fluid and food intake for two people living on Topaz unit were poor. There was no evidence that fluids had been encouraged as requested when people were at risk of dehydration or urinary tract infection and we saw two people experiencing long periods without fluids.

Risk assessments had been completed for these people but we found no supporting care plans to show how staff were to manage these risks.

We looked at a selection of medication administration records. One person was prescribed tablets which were crushable three times a day. When we spoke to staff they told us that the crushed tablets were added to food or fluids as agreed with the person’s doctor and that the person could not make decisions themselves. We found no records of any mental capacity assessment or best interest assessment being carried out to support this action.

During the morning of our visit we walked around the home. We saw that on three units there were delays in people receiving their medication prescribed for 8am with some people not receiving medication until 11am.

Records were kept of any complaints and compliments received by the registered manager and records were kept of any subsequent investigations taking place.

Shaw Red Hill Care Centre is registered to provide accommodation and nursing care for up to 90 people who have nursing or dementia care needs. There were 82 people living at the home at the time of our inspection. The home is purpose built and consists of four units. The Topaz unit specialises in the care of people with dementia. The Sapphire unit provides nursing care to people and the Entomos unit provides care for people with brain injuries. The intermediate care unit provides nursing and personal care to people who may require rehabilitation or have been discharged from hospital but need extra support before they return home or to another service.

This inspection was unannounced and was carried out over two days on the 18 and 19 January 2015. The inspection was carried out by two inspectors and a specialist advisor.

In September 2014, our inspection identified breaches in regulations relating to care and welfare, infection control and assessing and monitoring the provision of the service. Following the inspection the provider sent us an action plan to tell us the improvements they were going to make. We spent our inspection time in all areas of the home. We found that improvements had been made to infection control. However there remained one area which remained as a breach, this was in care and welfare.

At the time of our 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.

People told us they felt safe. We found that people were kept safe by staff who knew how to protect people and knew how to report concerns. We found that people were mostly cared for in a supportive way that did not restrict their freedom. People told us and we found there were enough staff on duty to meet people’s care needs.

We looked at how people’s medicines were stored and managed. We found that this was done so in a safe way.

At our last inspection we raised concerns about the prevention and management of infection control. At this inspection we found that people were better protected against the risk of infection.

People were cared for by staff who had the knowledge and skills to meet people’s care needs. We found that where training needs for staff had been identified, there were plans in place which ensured that staff received this training. There were also arrangements in place, such as one to one meetings with senior staff. This supported staff to provide effective and appropriate care to people.

At our last inspection we found that people were not always supported to drink enough fluid to keep them healthy. At this inspection we saw that staff supported people with drinks and with their meals. People we spoke with were complimentary about the food and their dining experience. Staff knew people’s likes and dislikes and respected their wishes. We observed that staff would offer people more to eat and drink, and that requests were also listened and responded to.

We found that people’s health needs were not always monitored at our last inspection. Which meant that deterioration in a person’s health was not always identified and the correct health care received in a timely way. During this inspection we found that on three units, Topaz, Sapphire and Entomos appropriate monitoring of people’s health care needs was in place. We saw examples where if someone’s health had deteriorated, it had been identified by staff and prompt action had been taken. We found on the intermediate care unit, that proper steps were not in place to ensure people had access to the healthcare that they required when they needed it.

People and relatives told us that all the staff were caring and that staff were respectful. We observed many situations where staff spoke kindly to people and maintained their dignity when providing assistance.

We found that staff were beginning to build positive relationships with people. Staff were working towards involving people, their relatives and friends to gather more background to people’s pasts. These practices would help to provide stimulation which was tailored to meet the individual needs of people. The provider recognised that more work was needed in this area.

People, relatives and staff who lived on Topaz, Sapphire and Entomos told us they found the registered manager approachable, promoted a positive culture in the home and they felt able to raise any complaints or concerns should they need to. People who were cared for on the intermediate care unit were not aware of who the registered manager was. Some people and relatives told us that when they had complained improvements had been made. However, other relatives told us that although they were listened to and improvements had been made, these were not always maintained.

We found that the registered manager had a good understanding of the running of the three units Topaz, Sapphire and Entomos. However we found the registered manager had less understanding of the running of the intermediate care unit. This was reflected in what people and relatives told us.

The provider had systems in place to ensure that the quality of the care was monitored in all areas of the service. Checks in areas such as care planning and staff recruitment had been carried out. However, we were unable to evidence that these actions and checks were followed up. People did not benefit from a service that was continually looking at how it could provide better care for people.