This inspection was carried out on the 22 August and 4 September 2017 and was unannounced.

Snaith Hall Nursing and Residential Home provides accommodation and residential care for up to 47 people. The service supports older people including those with a physical disability and those who may be living with dementia. In May 2016 the provider deregistered two of its three regulated activities and stopped providing nursing care. At the time of this inspection there were 44 people living at the home and receiving a service.

The home has two units, each spread across two floors; The Garden Wing and The Hall and is located near the centre of the town of Snaith, close to shops and amenities in the East Riding of Yorkshire.

Accommodation on both units is provided over two floors and a number of bedrooms have en-suite facilities. People living in the two units have access to outside gardens and seating areas, which are provided in secure settings. There is car parking for staff and visitors to the front and side of the service.

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. The registered manager will be referred to as 'manager' throughout the report.

At the last inspection in June 2016 the overall rating for the service was Requires Improvement. This was because they were in breach of four Regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were in Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 18 Staffing and Regulation 17 Good governance. We asked the provider to submit an action plan regarding the breaches identified. During this inspection the actions were met and no further breaches were identified during this inspection.

Systems and processes were in place that helped keep people safe from harm and abuse. Care workers had completed safeguarding training and knew the signs of abuse to look out for and how to raise any concerns.

The provider ensured there were sufficient skilled and qualified care workers to meet people's individual needs and preferences. Recruitment checks were completed that helped the provider to make safer recruiting decisions and minimise the risk of unsuitable people working with vulnerable adults.

Systems and processes ensured that where people had been assessed as requiring assistance with medicines, these were administered safely by trained care workers.

Systems and processes ensured accidents and incidents, complaints and concerns were recorded and evaluated to identify trends and to reduce the likelihood of re-occurrence.

People's dignity and privacy was protected and people received support from care workers who showed kindness and compassion.

Support plans were person centred and reflected individual's preferences. Information recorded was reviewed and evaluated as a minimum every month and more often where people’s needs changed. This meant care workers had access to up to date records that were reflective of people’s current needs.

Assessments of risk were carried out to ensure any care and support activities were safe and with minimal restrictions. Assessments were carried out around the home environment to ensure it was safe for everybody. Where any concerns were highlighted action plans were implemented and reviewed for their effectiveness.

The service was working within the principles of the Mental Capacity Act 2005. Care workers understood their responsibilities under the MCA and were actively promoting people’s independence. The manager and care workers had an understanding of Deprivation of Liberty Safeguards. They had made appropriate referrals to the relevant authori

This inspection took place on the 1 and 2 June 2016 and was unannounced. At our last inspection of the service on 11 July 2014 the registered provider was compliant with all the regulations in force at that time.

In May 2016 Snaith Hall deregistered two of its three regulated activities and stopped providing nursing care. From May 2016 the service has provided personal care and accommodation for 47 people within the categories of older people, people living with dementia and people living with a disability. The service is located near the centre of the town of Snaith close to local shops and other amenities.

The service is divided into two units; the Garden Wing and The Hall. Accommodation on both units is provided over two floors and a number of bedrooms have en-suite facilities. People living in the two units have access to outside gardens and seating areas, which are provided in secure settings. There is car parking for staff and visitors to the front and side of the service.

The registered provider is required to have a registered manager in post and there was a registered manager at this service who had been in post since December 2015. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.

The registered manager who was usually in day-to-day charge of the service was not available on the day of our inspection. However, a new manager had started at the service on the 23 May 2016 and they assisted us with our inspection. We have referred to them as ‘the manager’ throughout this report.

During this inspection we found that the service was not always safe. Risks to the health and safety of people using the service were not always thoroughly assessed and effectively managed and this placed people at risk of otherwise avoidable harm. This was a breach of Regulation 12 (2) (a) (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3).

The recording and administration of medicines was not being managed appropriately in the service. This was a breach of Regulation 12 (1) (2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3).

During our inspection we found that although there was a training programme in place and there was a supervision plan for the staff, the training and supervision of staff was not always up to date. This was a breach of Regulation 18(2) (a) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3).

Consent to care and treatment was not always sought in line with relevant legislation and guidance. This was a breach of Regulation 11 (1) (3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Record keeping within the service needed to improve. We saw evidence that medicine records, care plans, risk assessments and food / fluid charts were not always accurate or up to date. This meant that staff did not have access to complete and contemporaneous records in respect of each person using the service, which potentially put people at risk of harm. This was a breach of Regulation 17 (1) (2) (a-c) of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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

Improvements were needed to the number of staff on duty to meet the needs of people who used the service. People and staff commented that the levels of staff on duty fluctuated on a daily basis and this was also evidenced in the staff rotas. We have made a recommendation in the report about this.

Improvement was needed to the prevention and control of infection practices within the service. People and relatives were very plea

At our last inspection to the service in April 2014 we issued the provider with three compliance actions. Our inspector visited the service to see what action the provider had taken to become compliant with regulations 12, 13 and 10 of the Health and Social Care Act 2008. The information collected by the inspector helped answer our five 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. The summary is based on our observations during the inspection, speaking with staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that improvements had been made to medication record keeping within the service so people received their medicines in a safe and effective manner.

Improvements to prevention and control of infection practices within the service had been made so the service was safe, clean and hygienic and people who used the service were not at immediate risk. However, we also saw that further work was needed to develop records and address environment issues in order to move the service forward and enable the provider to sustain this improvement.

We wrote to the provider following our inspection. We asked the provider to send us additional information on a fortnightly basis to evidence how the service was being assessed / monitored and how risks were being managed.

Is the service effective?

We saw improvements had been made to the cleanliness of the general environment and the living areas within the service. One person who used the service said “I like my room, it is clean and staff come in to dust and hoover on a regular basis.” Another person told us “Everything is okay, I have my room how I like it.”

Is the service caring?

People who used the service, their relatives or visitors completed a satisfaction survey. There were a lot of positive comments back about the service but also a few negatives ones. The registered manager was unable to tell us what actions they had taken to address these comments.

We have asked the provider to tell us how they will make improvements in relation to learning from information they received from people.

Is the service responsive?

We saw that staff responded to requests and comments made by people and visitors. Their actions were recorded in the care files we looked at.

Is the service well-led?

We found sufficient evidence to indicate that the manager had made a start on developing an effective quality assurance system within the service, so that people who used the service were not at immediate risk. However, we also saw that further work was needed to develop the audit paperwork and action plans in order to move the service forward and enable the provider to sustain this improvement.

We wrote to the provider following our inspection. We asked the provider to send us additional information on a fortnightly basis to evidence how the service was being assessed / monitored and how risks were being managed.

This visit was part of our scheduled inspection of this service and also included a review of previous compliance actions which had been set at the last inspection in October 2013.The provider had recorded the dates they would be fully compliant with the regulations . The last date for this was with reference to outcome 16, Assessing and monitoring the quality of service provision and was 28 May 2014. Due to the long timescale set we reviewed the providers work towards compliance and have addressed this separately with the provider.

The inspection team was made up of two inspectors. We set out to answer our 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 people using the service, their relatives, the staff supporting them and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they were able to choose what to do each day and this included what time to get up or to go to bed and what activities to participate in, for example, whether to go into the local town. One person said “Support is one of the good points here; right from the beginning they have encouraged my independence.” A visitor told us they staff were “Very polite and very welcoming.”

If people required help with decision making they were supported to have an assessment of their capacity to make decisions and when necessary had received support in making decisions.

People told us they were supported to take risks and this included going out and about and with the managing of their medication. Although risks were assessed as part of people’s care plans this work was inconsistent which meant that people were not always fully protected.

People told us they were happy with the support they received with their medication. However we found that the handling of medication in the home required improvement. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the management of medicines.

The provider had purchased a system to check areas of practice within the home but had not yet started this. Consequently there was no system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This increased the risk of harm to people and failed to ensure that lessons were learned. The provider previously informed us that this would be in place by 25 May 2014 and we have requested further information from the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

The service was not safe, clean and hygienic. We found that one of the kitchens was dirty as were some of the bathroom and sluice areas. Evidence of maintenance work in the home was limited. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to infection control.

Is the service effective?

People’s health and care needs were assessed with them and people told us they knew about their care plans but this involvement was not always recorded. Care plans recorded needs but were not person centred and had limited information about the persons’ life, likes and dislikes. Information or assessments were not comprehensively completed. However information in care plans and people’s needs had been reviewed.

People living in the home and visitors we spoke with confirmed that they were happy with the care provided in the home.

We saw that although there was no staff training matrix in place individual staff records evidenced that staff had undertaken training to support people who lived in the home. Additionally the provider told us about their plans for future training and this helped to ensure that staff had the right skills for meeting people’s needs.

Is the service caring?

We observed staff interacted appropriately with people living in the home and this was respectful. They explained things to people and listened to their responses. One person living in the home said, “It is extremely good and they do their best to look after you.” Another visitor told us that staff were polite and respectful, they explained to people why the visitor was here and if they declined to see them the staff respected their wishes.

People using the service, their relatives, friends and other professionals involved with the service did not complete an annual satisfaction survey. The provider told us how they had organised open days for visitors to come and meet with them whilst visiting their relatives, making this more informal to encourage people to discuss things. The provider told us what actions they were taking to address these shortfalls.

People’s preferences, interests, aspirations and diverse needs had not always been recorded. However in discussion with the deputy manager it was clear that they were aware of each person’s current needs. People who lived in the home felt that their needs were being met and that care was good. Additionally visitors told us that they also felt people’s needs were met.

Is the service responsive?

People told us they had been provided with information about their care and were aware of their care plans, although this was not always recorded in the person’s individual file. People told us they felt able to raise any concerns with staff and one person told us how they had been involved in a review of their care.

People’s care files did not record people’s personal preferences which meant there was a risk that staff were unaware of people’s choices. However people we spoke with told us they could choose how to spend their time which included attending a religious service, participating in activities in the home or spending time in their room.

We saw that throughout the day there were numerous visitors to the home, people told us they regularly visited their relatives. This helped to maintain relationships that were important to people and prevented them from becoming isolated from family or friends.

Is the service well-led?

The provider had recently purchased a formal quality assurance system which they had yet to use in the home. However some checks were already in place but we found these did not ensure that practices always met needs. For example, records were kept of the cleaning completed of the kitchen in one area of the home but when we visited this area was not clean and required attention. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance.

People were supported to receive medical attention if they had an accident in the home and the events of this were recorded. However there was not a system in place to review these to ensure that any patterns were identified and actions taken to prevent re-occurrence.

We spoke with one professional visiting the home and they told us that the service worked well with them, they requested assistance appropriately and followed their advice.

The provider was also the manager of the home and was supported by a deputy manager who worked part time. There were no other persons employed to support the management systems in the home, for example an administration person. The provider was aware that improvements continue to be required in relation to some of the paperwork, quality assurance systems and maintenance of the home. However, for some areas this had now been the case for some time and we have addressed this separately with the provider.

We visited Snaith Hall on 3 October 2013 as part of a scheduled annual inspection.

Staff treated people who used the service with respect and only provided care and support to people with their consent. One person who used the service told us “Staff very much act in accordance with my wishes”. However documentation relating to mental capacity had not been completed.

People told us they were satisfied with their care. One person told us “I cannot fault it. Staff treat me with dignity”. Another person told us “My care plan is all filled in with my photo in. Staff have read it to me”.

Staff were employed in sufficient numbers to ensure the needs of people who used the service were met.

There were no formal quality assurance processes in place across the whole service. The manager told us checks were completed on an informal basis but were not recorded. This meant there were limited quality assurance records on which we could base our judgement.

Records were not always completed in sufficient detail to be fit for purpose and were not always stored stored securely.

People we spoke with said staff were friendly, supportive and professional and that “There is a lovely atmosphere in the home, very friendly and welcoming.”

People told us that they were consulted about their care and were able to make their own decisions about life in the home. People felt staff respected their privacy and dignity and kept personal information confidential.

People said that they had good access to outside healthcare professionals and they were satisfied with the level of medical support given to them. They said staff were good at giving them their medication on time and when they needed it.

People understood about safeguarding of adults and told us that they felt safe within the service. They told us there was an open door policy within the service which worked well and they were confident of using the complaints system if they needed to.