About the service: Sir Aubrey Ward House is a residential care home that was providing personal and nursing care to 58 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

Records at the service were not always robust and required improvements to ensure accurate information was recorded in relation to people’s care.

• People’s confidential information was not stored securely.

• Care plans we viewed were not always consistent with the care and support being delivered.

• Medicines were not always managed effectively.

• Systems and management plans were not always in place to manage the risks associated with people’s behaviour.

• Staff were provided with training and supervision. However, some staff we spoke with told us they could not remember when they last had a supervision.

• The services infection control policy was not upheld. We saw care staff with long fingernails, and wearing rings and several bracelets.

• People told us they enjoyed the food at the service. Where people were at risk of malnutrition appropriate steps were taken.

• The environment was adapted to suit the needs of people living there.

• People were treated in a dignified and caring way.

• End of life care was discussed with people and where appropriate their families.

• Activities were available for people to avoid social isolation.

• Complaints were recorded and responded to appropriately.

• Systems were in place to review the quality of care including feedback questionnaires and meetings.

• Where appropriate notifications were sent to CQC.

Rating at last inspection:

• At the last inspection the service was rated Good (the report was published on 25 June 2016).

Why we inspected:

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

• We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 16 February 2017. It was an unannounced visit to the service.

We previously inspected the service on 2 and 3 June 2016. The service was rated ‘good’ overall at that time. However, there was one area where a regulation was not fully met. This was in relation to the management of people’s medicines. We made a requirement for the provider to improve practice. They sent us an action plan which outlined the measures they would take to make improvements. This focussed visit was to check the improvements had been made and only covered the ‘safe’ domain.

Sir Aubrey Ward House provides care for up to 60 older people, including people with dementia. Fifty nine people were being cared for at the time of our visit.

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.

We saw staff interacted well with people; there were lots of smiles and laughter and the busy morning routine was managed in a calm and organised manner. People told us staff were around when they needed them. One person said they were happy at the home and added “Most of the staff are friendly. There’s the odd one I don’t get on with. There’s no issues, just different personalities, some you click with.” Another person said “The girls are good, I couldn’t do their job. They’re very busy.” People told us they received support from staff who regularly worked at the home and understood their needs. One person said “That makes a big difference. You’re not having to repeat what you like all the time, they know you.”

Risk assessments had been written to identify areas where people could potentially come to harm and to minimise the likelihood of this. For example, when they were assisted with moving. People had the equipment they needed to get around the building, such as walking frames and wheelchairs. Grab rails had been provided in bathrooms and corridors to help people manage independently wherever possible.

We spoke with an activity organiser. They ran a morning exercise group for people who had strokes. One of the people who attended the group told us “I used to use a walking stick when I first came here but now I don’t need it.” They said this was because the exercises had been helpful in improving their strength. We saw the person walked around safely and steadily.

At the last inspection we made a recommendation for staffing resources to be re-assessed, to ensure there were sufficient staff to meet people’s needs at all times. We discussed staffing levels with the registered manager and regional director to see if any changes had been made. They told us additional staff hours had been agreed for the service and these would be advertised. This would provide more flexibility in how staff were allocated to areas of the home that were particularly busy.

Improvement had been made to the management of medicines. Accurate records were now maintained and medicines rooms and trolleys were kept secure. We made a recommendation at the last inspection for the service to follow good practice in the application of transdermal (skin) patches, to ensure a different area of the body was used each day. This was to avoid skin irritation. We saw charts were now used to record where skin patches had been applied. These showed rotation on the body, which reduced the likelihood of skin becoming sore.

People were protected from the risk of unsafe premises. The building was well maintained and complied with gas and electrical safety standards. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

We found although staff were trained to ensure they provided safe care to people,

This inspection took place on 02 and 03 June 2016. It was an unannounced visit to the service.

We previously inspected the service on 26 June 2013. The service was meeting the requirements of the regulations at that time.

Sir Aubrey Ward House provides care for up to 60 older people and people with dementia.

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.

We received positive feedback about the service. Comments from people included “When you loose your health and your own home, you are glad to come somewhere like this,” “It’s quite nice here,” “You don’t have to do the shopping; you can have pets if you want to,” and “I’m certainly happy with the service.” One person told us “It’s a good place to be as you are always with people.” A social care professional described the service as “A very well run home” and added “I can’t really fault them.” A relative said “If there was some award you gave out I would say could you please give it to Sir Aubrey Ward. They have a dedicated team of carers and staff. All I can say is that if it had not been for them, my mother would not be here today.”

People were protected from the risk of harm. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns.

Staff 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. We have made a recommendation for staffing resources to be re-assessed, to ensure there are sufficient staff to meet people’s needs at all times.

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 wide range of social activities.

Staff supported people with their healthcare needs to keep healthy and well. We found staff did not always follow best practice in the management of people’s medicines. We have also made a recommendation about the recording of transdermal (skin) patches, to ensure a different area is used each day, to avoid skin irritation.

People’s complaints were listened to and responded to. The service was managed well. The provider regularly checked quality of care at the service through visits and audits. The registered manager was skilled and experienced and was assisted by a team of senior staff. 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 and we saw they were given choices.

Records were generally maintained to a good standard and staff had access to policies and procedures to guide their practice.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to medicines practice. You can see what action we told the provider to take at the back of the full version of this report.

When we visited the service on 17 April 2013, we had concerns about how medication was being managed. This was because the provider had appropriate arrangements in place to manage medicines, but staff were not consistently following these in relation to recording practice. We set a compliance action for the provider to improve practice.

We returned to the service on 26 June 2013 to check whether improvements had been made. We looked at medication practice in two parts of the home. We found staff were now following the arrangements for the recording of medicines.

We spoke with a range of staff as part of this inspection. For example, the manager, senior on duty, care workers and the housekeeper. We spoke with people using the service but they were not always able to tell us their views about their care. We relied upon our observations of care, speaking with staff and looking at records to help us understand people's experiences.

We saw there were good infection control practices at the home. We found the building to be clean and hygienic. Staff had undertaken training on infection control and had procedures and guidance to refer to. A five star/very good rating had been awarded by the Food Standards Agency in October 2012, for food hygiene standards.

We had concerns about medication practice at our last inspection. We found improvement to some areas of medication practice on this occasion. Records of medication administration were legible and there were specimen staff signatures and initials to help with auditing. We saw medication was stored safely and staff who handled it had received training. However, there were some inaccuracies in records associated with medication practice.

There were enough staff to ensure people's needs were met. The staff we met were experienced in working with older people. We saw they had access to a range of training courses to keep their skills and knowledge up to date. We found staff were attentive to people's needs and took an interest in their wellbeing.

We found people were treated with dignity and respect. We joined people in the dining room during tea time. We observed staff offering people choices of food and provided discreet assistance to those who needed help. People were enabled to eat their tea at their own pace.

People and their relatives had the opportunity to visit the home before they moved in to ensure it met their needs and expectations. A relative told us they looked at many homes and "this one stood out." They said their mother's key worker assessed her needs before she moved into the home.

Care plans contained detailed information about people’s individual needs. They were reviewed regularly to ensure care provided was current.

People said they felt safe and staff looked after them well. They knew who to speak to if they had concerns. One person said ‘’if I wasn’t happy I would go to the person in charge but I’ve never had to complain.’’ Another said ‘’I would tell my key

worker if I wasn’t happy.’’

Daily activities were provided to those who wished to take part. These included trips out into the community as well as in house activities. One person told us "we have bingo, simple exercises and we have the odd trip out to Marlow and High Wycombe."

We found poor practices in relation to the management of medication which failed to ensure people were protected against risks associated with the unsafe management of medication.