We carried out this unannounced inspection under Section 60 of the Health and Social Care Act 2008 on 26 and 27 September 2017 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At the last focussed inspection of this service on 3 January 2017, the home was given an overall rating of ‘requires improvement’ and two breaches of regulations were identified in relation to good governance because the service had failed to maintain securely an accurate, complete and contemporaneous record in respect of each person using the service and had failed to effectively assess, monitor and improve the quality and safety of the services provided. At this inspection we found the home was now meeting the requirements of these regulations.

St George's Nursing Home provides nursing and residential care and support for up to 62 people in 18 single and 22 shared rooms. At the time of the inspection there were 49 people using the service. The home is a grade 2 listed building in spacious grounds and close to a wide range of community resources and there is a dedicated floor for people living with dementia.

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.

During the inspection we looked at the way the service protected people against abuse. There was an up to date safeguarding policy in place, which referenced legislation and local protocols, including how to instigate adult protection procedures and contact details for CQC, the local authority and the social services duty team. The home had a whistleblowing policy in place.

We looked at records regarding the premises and equipment. There were weekly checks for water temperatures, the fire alarm and means of escape. There was a contract file which was up to date and included certificates and safety records for gas, the fire system, hoists, hoist-sling thorough examination, the lift, pest control, washing machine and dryer, legionella, hot water boiler and COSHH information. Since the date of the last inspection a new fire alarm system had been installed.

Staffing levels were sufficient on the day of the inspection to meet the needs of the people who used the service. We looked at five staff personnel files and there was evidence of robust recruitment procedures.

We looked at how the service managed infection prevention and control (IPC) and found an IPC audit had recently been carried out by a health protection officer in September 2017.Over 90% of all staff had undertaken infection control training since the date of the last inspection.

We looked at how the service managed people’s medicines. We found that the medicines room was securely locked and medicines were stored appropriately with regular fridge temperature monitoring in place. Controlled drugs were also stored correctly and the nurse on duty held the key to the locked controlled drugs cabinet.

We looked at staff training, staff supervision and appraisal information and saw that there was a staff training matrix in place. All care and nursing staff had completed a wide range of relevant training as required.

People told us the food at the home was good. There was a four week seasonal menu in use and this was displayed on the wall in the dining room. The dining tables were laid with table clothes, place mats and cutlery and condiments were also provided. We checked the food stocks in the kitchen and found that there was an adequate supply of fresh and dry goods

This unannounced focused Inspection was undertaken on 03 January 2017. After our comprehensive inspection of St Georges (Wigan) Limited on 14 and 15 September 2016 the provider wrote to us to say what they would do to meet legal requirements in relation to three breaches of Regulations concerning the risks associated with unsafe or unsuitable management of medicines; maintaining securely accurate complete and contemporaneous records in respect of each person using the service; effectively assessing, monitoring and improving the quality and safety of the services provided.

We undertook a focused inspection to check that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Georges (Wigan) Limited on our website at www.cqc.org.uk.

St George's Nursing Home provides nursing and residential care and support for up to 62 people. At the time of the inspection there were 48 people using the service. The home is a grade 2 listed building in spacious grounds and close to a wide range of community resources. There is a dedicated floor for people living with dementia. St George's provides care for people in a variety of single and shared rooms.

At the last inspection on 14 and 15 September 2016 we had concerns regarding the safe management of medicines and this was a breach of Regulation 12 (2)(f) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this focussed inspection on 03 January 2017 we found the service was meeting the requirements of this regulation.

We found that the provider had followed the action plan they had written to meet shortfalls previously identified regarding the safe management of medicines and the service was now meeting the requirements of this regulation.

The medication was stored securely in line with the necessary standards. Temperature monitoring of the medication fridge was in place and carried out daily and the fridge was operating within the required limits

The controlled drugs (CD) cabinet was secure and there was evidence of daily CD balance checks undertaken.

We observed evidence of regular balance checks which identified if people’s medication needed re-ordering as well as weekly audits designed to identify if medication administration (MAR) charts had been completed appropriately.

The clinical manager showed us the monthly medication audits from November and December 2016 and explained that another audit was due to be completed later that week.

We saw a missing entry on 30 December 2016 for one person’s evening dose of medication. We checked the stock balance of this medicine to ascertain if it had been given and found that the medicines had been administered but not signed for.

We checked the care plan and MAR chart for another person who was receiving medication covertly. The appropriate documentation was in place with written authorisation from the person’s doctor and evidence of discussing this decision with the person’s family

At the last inspection on 14 and 15 September 2016 we had concerns regarding the quality of care planning and recording and this was a breach of Regulation 17(2)(c)(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this focussed inspection on 3 January 2017 we found the service was still not meeting the requirements of this regulation.

We looked at both the electronic system and paper copy records for one person. With both systems in place care documentation was difficult to follow. Paper copy records were missing or did not correspond to risk assessments. Care plans existed for pressure care, diet, hypertension, falls and medication. Evidence indicated that regular review by the community dietician was on-going.

Reviews of risk assessments and care plans on both the electronic s

St George's Nursing Home provides nursing and residential care and support for up to 62 people. At the time of the inspection there were 48 people using the service. The home is a grade 2 listed building in spacious grounds and close to a wide range of community resources. There is a dedicated floor for people living with dementia. St George's provides care for people in a variety of single and shared rooms.

We carried out this unannounced comprehensive inspection on 14 and 15 September 2016. This inspection was undertaken to ensure that improvements that were needed to meet legal requirements had been implemented by the service following our last inspection on 16, 18 and 20 November 2015. At the previous inspection the home was found to have eight breaches of Regulations in relation to the safe management of medicines, infection control, supporting staff, staff training, premises maintenance, meeting peoples’ needs, assessing monitoring and mitigating risks, and keeping contemporaneous records.

At this inspection on 14 and 15 September 2016 we found that improvements had been made to meet the relevant requirements previously identified at the inspection on 16, 18 and 20 November 2015. However we found three continuing breaches of regulations in relation to the safe handling of medicines, assessing, monitoring and improving the quality and safety of the services provided and maintaining complete and contemporaneous records for each person. You can see what action we told the provider to take at the back of the full version of this report.

At the time of the inspection there was no registered manager at the home. Following the inspection visit, we received confirmation that the registered manager application forms had been submitted to CQC.

Staff understood the principles of safeguarding and there was a safeguarding and whistleblowing policy in place.

Staffing levels were sufficient on the day of the inspection to meet the needs of the people who used the service.

During this inspection, we found improvements had been made to meet the requirements of regulations in relation to infection control practices. However, a recent audit conducted by Healthwatch Wigan made a small number of recommendations that had not been implemented on the day of the inspection, for example upgrading the sluice room.

The home was clean and we noted no malodours were evident on any of the three floors throughout the course of the day. We saw toilets and bathrooms contained hand hygiene guidance, paper towels and foot operated pedal bins. We checked all hand gel dispensers and saw these were stocked and working correctly.

We saw hoists had been checked and serviced and passed as being safe. We also saw that the slings used with the hoists had been checked, all were in good condition and deemed fit for purpose. Cleaning schedules were also in place for blood pressure cuffs.

There was evidence of robust recruitment practices and each member of staff had a Disclosure and Baring Service (DBS) check in place.

During this inspection, we found improvements had been made to meet the requirements of regulations in relation to premises management. Gas and electricity safety certificates were in place and up to date; all hoists, the alarm call system and fire equipment were serviced yearly with records evidencing this. The testing of portable electrical appliances (PAT) was completed yearly and an up to date certificate was in place. There was a plan in place for on-going maintenance.

All pedal bins had been replaced since the date of the last inspection and were now foot operated with lids.

People had specific care plans in place with regards to their skin and Waterlow assessments which were carried out monthly. We saw that body maps were in place to identify the locations of any pressure sores or areas of redness.

Accidents and incidents were recorded and audited monthly by the manager. However some incidents that had resulted in minor graz

We carried out this unannounced inspection under Section 60 of the Health and Social Care Act 2008 on 18 November 2014 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

St George’s (Wigan) Limited provides nursing and residential care and support for up to 62 people in a variety of single and shared rooms. At the time of the inspection there were 35 people using the service.

There was not a registered manager at the home, but the acting manager of the home was in the process of registering with the Care Quality Commission. 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 previous inspection was carried out on 18 June 2014 when there was found to be a breach of regulation 9 relating to care and welfare. As a result of this a warning notice was issued by CQC.

We observed that the home was clean, but a little cluttered in places. It was not always safe as, for example, one of the supplies cupboards in the upper floor office was unlocked and left unattended. The medicines fridge was not maintained at the correct temperature to ensure safe storage of medical supplies such as eye drops.

The home had up to date safeguarding vulnerable adults policies and staff were aware of the reporting procedures. Safeguarding referrals were made appropriately.

We saw there were sufficient numbers of staff to attend to the needs of the people who used the service on the day of the inspection. Staff were observed to be polite and respectful and administered care in a kind and caring manner. We spoke with people who used the service and some visitors, who felt the care offered was good.

Care plans included relevant health and personal care documents and were, for the most part, accurate and up to date. However, there were some instances when information had not been cross referenced with other documents, which could have impacted on the accuracy of care records.

Risk assessments were in place within care records and up to date. Staff were working within the requirements of the Mental Capacity Act (2005). Appropriate Deprivation of Liberty Safeguards (DoLS) applications had been made and documentation was in place.

Medication was administered by qualified staff and systems were in place to help ensure the safe ordering and disposing of medication.

There was no signage to assist with orientation around the home for people living with dementia and some of the areas designed to stimulate people living with dementia were not appropriately situated. There were no activities taking place on the day of the inspection and we saw little recorded in care plans about people’s participation in activities at the home.

People had choices regarding meals and when and where they had their meals. We observed staff assisting people with their meals and ensuring people’s dietary needs and preferences were adhered to.

Staff training was comprehensive, up to date and on-going and staff we spoke with displayed good knowledge of their roles and responsibilities. Some staff support was in place but staff meetings were poorly attended. Staff reported morale was improving amongst them, which was further evidenced via a recent staff survey.

There was an up to date complaints policy displayed on the notice board at the home and complaints were followed up appropriately.

We saw that the home worked well in partnership with other agencies and professionals.

Some notifications had not been submitted to CQC in a timely way, but this had recently improved.

We saw from minutes that staff meetings were poorly attended, which could possibly result in staff not receiving information and support needed to carry out their jobs well. The manager agreed to address this.

Staff reported morale had been low during the period without a manager, but was improving amongst them since the new manager had taken over. They also said improvements were being made to the systems in the home.

We saw evidence of audits and that analysis of the results had taken place and actions taken.

Our inspection team was made up of two inspectors. They helped 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, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

On the first day of the inspection the staffing numbers on the lower floor were insufficient to ensure care delivery was effective and safe. We highlighted this with the manager who took the immediate decision to increase staffing levels and gave an assurance that the increase would be maintained.

We saw that some care needs were not adequately recorded in people’s care plans, and some people were, therefore, not receiving appropriate care, resulting in these people being at risk. For example, there was a risk of cross infection due to one person’s personal care needs not being met.

Equipment, such as bed rails, had been fully assessed against each person’s needs. Equipment was regularly checked and maintained well, ensuring equipment was safe to use.

Safeguarding policies and procedures were regularly reviewed and updated and included all appropriate information and guidance. The home’s whistle blowing policy was up to date and comprehensive. Staff were aware of the procedures and how to access the policies.

New systems had been implemented to help ensure staff and management could effectively evaluate and learn from events and incidents at the home. This was to help minimise risks and keep people who used the service safe.

Is the service effective?

Some of the care delivery was not effective as people’s care plans were not all complete and there was not enough information and guidance to ensure good and effective care for everyone.

Some care was not being effectively delivered, for example, we saw that some people who used the service were not receiving care that addressed their personal care needs.

Some accidents and incidents had not been recorded and handed over to subsequent staff members effectively. For example, one person had an injury that had been bandaged, but nothing had been recorded about how or when this injury occurred.

Efforts had been made with the environment at the home to provide areas which were positive and beneficial for people who live with dementia. There was a memory room, a seaside area and a pub area and items such as bags, hats and scarves were hung in the corridors for people to pick up and touch. This was in line with the current focus on positive environment and experience for people living with dementia.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service caring?

Staff were observed to be respectful, kind and friendly and assisted people in a courteous manner. However, on the first day of the inspection, staff on the lower floor were struggling to deliver care in a timely manner due to the needs of the people on that floor. The low staffing numbers on this floor were addressed immediately by the manager putting on an extra member of staff the following day and giving an assurance that this would continue.

We observed that, although staff appeared kind and caring, some basic care needs, such as attention to personal care, had not been provided in a timely way and people were sometimes left in a poor state due to this. Some care needs were not recorded well in people’s care plans and risk assessments were, in some cases, lacking in enough detail. More personalised care planning was being addressed by the manager, but at the time of the inspection there were people who were at risk due to care plans not yet being comprehensive and detailed enough.

Is the service responsive?

We found the service had not always responded to people’s changing needs and recording was incomplete in some cases, making it difficult for staff to respond to individual needs.

The service had an up to date complaints policy and we looked at the most recent complaint which had been responded to in a timely and appropriate way.

Some activities took place within the home, but the activities co-ordinator had left their post and the manager was in the process of recruiting a member of staff for this position. In the meantime the manager told us they were offering extra shifts to existing staff to facilitate activities to take place within the home.

Is the service well-led?

There was a new manager in place at the home and they had begun to introduce new and effective audit systems to facilitate an efficient oversight of the running of the home. This would enable them to monitor and improve the service. For example, a new handover form had been implemented, to be used at the end of each shift, detailing all incidents, accidents and events that had happened. This was to help ensure nothing was overlooked. However, some incidents had not been recorded on the forms, so staff required more supervision and training in this area to make the system work effectively.

We saw that the manager had carried out an accident audit in April, which had highlighted that the recording of accidents was poor. This had been followed up with education for staff around recording accidents and following policy and procedure. The audit carried out in May evidenced that this had improved and records were now being completed appropriately, demonstrating that the audits were being used correctly and improvements were being made within the home.

Other audits, such as medication, wound care and kitchen audits, were in place, complete and up to date.

We saw a recent quality audit, undertaken with people who used the service, helping to ensure their involvement and opinion was being sought. Relatives and residents meetings were now held on a monthly basis and provided another forum for people to discuss issues, raise concerns and make suggestions.

We spoke with a range of people about the home. They included the deputy manager, nurses, staff, relatives, visiting medical professionals and people who lived at the home. We also had responses from external agencies including social services. This helped us to gain a balanced overview of what people experienced living at St Georges Nursing Home.

Most residents had difficulty communicating due to their dementia condition. However observations we made demonstrated people living there were comfortable, also responded positively with staff members. We saw they liked to move around the home, use their rooms and other communal areas.

We received comments such as: “Care is generally very good”; “Feedback I have received from relatives is good”; “No complaints, if do I would go to the management”; “Staff are lovely” and “My relative has been here for four years and we have no concerns.”

We spoke with a range of people about the home. They included the manager, nurses, staff, relatives and people who lived at the home. We also had responses from external agencies including social services. This helped us to gain a balanced overview of what people experienced living at St Georges Nursing Home.

Most residents had difficulty communicating due to their dementia condition. However observations we made demonstrated people living there were comfortable, also responded positively with staff members. We saw they liked to move around the home, use their rooms and other communal areas. There were no restrictions noted and staff were seen to encourage people to make choices about what they wanted to do.

Residents and relatives told us they could express their views and were involved in decision making about their care. They told us they felt listened to when discussing their care needs. One person living at the home said, “The staff listen and are always polite and helpful.” One relative we spoke with told us the staff have been ‘fantastic’ with her husband and said, “They are very competent in the way they care for my husband since coming here he has been so much better. The staff know what they a\re doing.”

People told us that the care provided was good.

People told us that they felt their relatives were safe.

People told us that if they had any concerns they would be dealt with.

People told us that they were satisfied with the accommodation.

People told us that the staff are all very good.

People told us that the staff are always responsive and act on professional advice when given.

People told us that the staff are very responsive.

Relatives told us that the staff always contact them to report any changes in their care needs.

We carried out this unannounced inspection under Section 60 of the Health and Social Care Act 2008 on 16, 18 and 20 November 2015 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At the previous inspection on 18 November 2014, the home was found to be requiring improvement against four of the five questions we ask about services during an inspection: ‘Is the service safe’, ‘Is the service effective’, ‘Is the service responsive’ and ‘Is the service well-led’.

At the inspection on 16, 18 and 20 November we found eight breaches of Regulations in relation to the safe management of medicines, infection control, supporting staff, staff training, premises maintenance, meeting peoples’ needs, assessing monitoring and mitigating risks, and keeping contemporaneous records. You can see what action we told the provider to take at the back of the full version of the report.

St George's Nursing Home provides nursing and residential care and support for up to 62 people. At the time of the inspection there were 43 people using the service and one person was in hospital. The home is a grade 2 listed building in spacious grounds and close to a wide range of community resources and there is a dedicated floor for people living with dementia. St George's provides care for people in a variety of single and shared rooms.

There was not a registered manager at the home, but the provider told us that it was their intention for one manager to become the registered manager for the service and an application to become the registered manager had recently been submitted to CQC. 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 that surveillance cameras were in place in the corridors throughout the home. People who used the service and their relatives had been informed about the use of these cameras but had not been consulted about their installation.

During the inspection we looked at the way the service protected people against abuse. There was an up to date safeguarding policy in place, which referenced legislation and local protocols, including how to instigate Adult Protection procedures and contact details for CQC, the local authority and the social services duty team. The home had a whistleblowing policy in place.

There was an on-going programme of refurbishment being undertaken at the service, which included bedrooms, a walk-in wet room and decorating, lighting and electrical works. Prior to the commencement of the refurbishment work, the home had informed people using the service and their relatives about what would happen at different stages. Following the completion of the refurbishment work it was the intention of the provider to consult with people and their relatives regarding their choice of furnishings and décor.

We looked at records regarding the premises and equipment and spoke with the staff member who was responsible for carrying out these checks. There were weekly checks for water temperatures, the fire alarm and means of escape. There was a contract file which was all up to date and included a gas safety record, a fire system annual inspection certificate, a hoist examination and service report, a hoist-sling thorough examination report, routine servicing and examination reports for the lift, a pest control certificate, records of washing machine and dryer checks, a legionella report, a hot water boiler check report and COSHH information.

We checked all bedrooms and found that all the rooms had television wires that were loosely hanging down from the television unit which presented a risk of ligature and trips. We spoke with the provider about this and the wires were made safe. Some bedrooms had old taps with no indicating marker that would identify if it was hot or cold water. Some wardrobes had glass-fronted doors which were cracked presenting a risk to people’s safety and visual difficulties for some people living with a dementia. Some bedrooms did not have lampshades or toilet seats. The provider told us that a questionnaire had been sent out to people who used the service and their relatives on how they would like their room to be decorated but at the time of the inspection the responses had not all been returned. Additionally some rooms had window restrictors that were broken or loose which presented a falls risk. We raised our concerns about the window restrictors and these were repaired immediately.

These issues meant there was a breach of Regulation 15 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; premises and equipment, because the service had failed to ensure that the premises used by the service were secure, properly maintained and suitable for the purposes for which they were being used.

This was also a breach of Regulation 17 (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance, because the service had failed to effectively assess, monitor and improve the quality and safety of the services provided.

Staffing levels were sufficient on the day of the inspection to meet the needs of the people who used the service. The manager told us that if there was an unforeseen shortage of staff, the home initially contacted existing staff and as a last resort would use agency staff. We looked at four staff personnel files and there was evidence of robust recruitment procedures.

We looked at how the service managed infection prevention and control (IPC). The manager told us that no IPC audits had been carried out by the service.

Since the commencement of the refurbishment there we could not find any evidence of environmental/cleaning risk assessments or audits being undertaken. We saw that the drainage holes in the wet rooms all looked very dirty and staff did not know whether and/or how they were being cleaned. However, at the time of the inspection the wet rooms were not being used and building work was on-going. We found cutlery soaking in an old plastic jam container which contained detergent that was accessible to people using the service.

In one room we saw that staff were re-using single use syringes for feeds and flushes, water used for flushing was stored in old plastic milk containers and there was no notice in the room to say that the person should not be given anything orally.

There were no covers for the tympanic thermometer that was being used to measure people’s temperature. We saw that blood pressure (BP) cuffs, used to determine blood pressure, were dirty.

Hoist slings which were repeatedly used for many service users, were not washed regularly and only washed when visibly soiled.

We found that Infection Prevention and Control (IPC) training was being offered by the Trust and three staff members had signed up to this training. We saw from the information that was on a notice board that it was up to the staff members to opt-in to this training rather than the managers nominating people to go. The clinical lead told us that they hoped that all staff would have IPC training.

This is a breach of Regulation 12(2)(h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; controlling the spread of infections, because the service had failed to operate systems to assess, detect, prevent and control spread of infections.

We looked at the care records for a person using the service and saw that records relating to the management of their wound were unreliable as the wound had previously been assessed as grade 3 then subsequently grade 2, then grade 4. If (the persons’) wound had deteriorated to a grade 4 the tissue viability nurse should have been asked to review the position but this had not been done, which meant that the person was at risk of further deterioration.

This meant there was a breach of Regulation 9 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person centred care, because the service had failed to ensure people’s care and treatment was appropriate and met their needs.

We looked at how the service managed people’s medicines. We found that the medicines room was securely locked and medicines were stored appropriately with regular fridge temperature monitoring in place. Controlled drugs were also stored correctly and the nurse on duty held the key to the locked controlled drugs cabinet.

We looked at the MAR charts on the first floor and found that the majority were without a photograph of the person concerned and in some cases we found that the persons’ allergy status was not included. On the first floor we saw MAR charts that had missing signatures with no explanation.

We found that one person that had gone for nine days without receiving medication. The home had not investigated this or filled in any form of incident report. The GP had not been notified and all the medication was re-started without medical advice after a nine day medication-free period.

There were no body maps to explain where creams should be applied and it was unclear if it was the job of the nurse or a carer to apply creams. We saw that prescribed creams were also kept in other rooms insecurely, for example in a person’s in a bedroom.

We observed medicines being administered at lunchtime on the ground floor and saw the nurse retrospectively filling in MAR charts for medicines that they said they had administered in the morning. We found there were significant gaps in some MAR sheets that were not accounted for.

We asked the manager about staff competency checks and they explained that these had not been carried out. There was no specific reporting for medication errors or evidence of investigations and shared learning. There was a medication policy which was up to date and relevant but lacked a PRN policy.

This was a breach of Regulation 12(2)(f)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the proper and safe management of medicines, because the service did not have appropriate arrangements in place to manage medicines safely.

We looked at staff training, staff supervision and appraisal information and saw that there was a staff training matrix in place. All care and nursing staff had recently completed training in safeguarding. Care staff had also undertaken training in challenging behaviour, COSHH, equality and diversity, infection control, fire training, dementia and DOLS, food hygiene, and manual handling. We asked the clinical manager for a copy of the staff training records in relation to PEG care and found that only 14% of staff who delivered care to a person between the period 13 November 2015 and 16 November 2015, when the electronic care planning system was unavailable, had done this training. This meant that staff may not understand how to ensure the safe delivery of PEG care.We looked at the training records for tissue viability training and saw that there was a tissue viability nurse in post.

These issues meant there was a breach of Regulation 12 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the service had failed to ensure that persons providing care or treatment to service users have the qualifications, competence and skills to do so safely.

We could not find any evidence of a staff supervision matrix and the manager and staff told us that these meetings had not been happening.

This is a breach of Regulation 18 (2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, appropriate supervision and appraisal because persons employed by the service had failed to receive appropriate supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

People told us the food at the home was good. We observed the lunch time meal in the first floor dining room using SOFI. We saw that staff who were giving meals to people were wearing an apron but not wearing any gloves. A staff member told us they had been instructed not to use gloves as this was impersonal. There was a four week seasonal menu in use and this was displayed on the wall in the dining room. The dining tables were sparsely laid with no table clothes, no other form of table decorations, and very few available condiments. This meant that the dining room did not feel homely or welcoming. We checked the food stocks in the kitchen and found that there was an adequate supply of fresh and dry goods and the freezers were well stocked.

There was a food hygiene policy and we saw that staff had completed training in food hygiene.

There were appropriate records relating to the people who were currently subject to DoLS. There was documentation of techniques used to ensure restrictions were as minimal as possible. There were appropriate MCA assessments in place, which were linked to screening tools and restrictive practice tools which outlined the issues and concerns. There were applications for DoLS where the indication was that this was required and these were up to date.

There was a ‘consent for change or shared allocation of room’ document in use but this had not always been fully completed for every person using the service. There was also a ‘consent to treatment’ document in use but this had not always been completed for each person.

The home had a dementia café, providing a safe environment for people who used the service to socialise with each other and members of the local community. There was a memory lane reminiscence room decorated with items to stimulate people’s memories and facilitate conversation. On the day of the inspection, this was cluttered and unusable due to the refurbishment work being undertaken.

People were able to personalise their bedrooms with individual items such as family photographs and personal objects but some bedrooms were sparsely furnished and impersonal. The provider told us that some people had chosen not to personalise their rooms and this was their choice.

We saw staff responded and supported people with dementia care needs appropriately. However, there were few adaptations to the environment to make it dementia friendly or that would support these people to retain independence within their home. We saw people’s bedroom doors did not have their photograph on it, which could make it difficult for people to find their room.

We observed care in the home throughout the day. Interactions between people who used the service and staff members were warm, conversations were of a friendly nature and there was a caring atmosphere. We heard positive chatter between staff and people thorough the course of the inspection. Staff spoken with could give examples of how privacy and dignity was respected.

The home had a Service User Guide and this was given to each person who used the service. The Guide contained information on how to make a complaint but the contact details were out of date.

A number of ‘thankyou’ cards from people who had previously used the service were displayed on a notice board in the entrance area.

We saw that prior to any new admission a pre-assessment was carried out with the person and their relative(s) where appropriate.

We looked at the care planning records for people using the service. The home used both an electronic and paper copy care plan system. On the first day of the inspection the electronic system was not working and the home relied on paper copy care records in people’s care files. Some of the care plans we looked at did not have a photograph of the person. The plans were person-centred and contained a profile of the person concerned including basic personal information such as height, nationality and previous occupation, food preferences and social activity preferences, but were not always fully completed for every person.

The home employed an activities coordinator and activities on offer were displayed on a notice in the entrance area which included arts and crafts, relaxation, pamper sessions, and dominoes. Other activities included hand massages on a 1-1 basis and information on people’s recreational preferences was recorded in their care plans. Pictorial versions of activities were being developed which would help people to understand what was being offered.

There was a ‘Supporting Residents Outside the Home’ and ‘Religious and Cultural Issues’ policy in place and we saw that information about personal preferences, social interests and hobbies was recorded in people’s care files.

Residents and relatives meetings were not carried out regularly which meant that the views of people using the service and their relatives may not have always been identified and the opportunity to present such views was not provided.

There was a ‘Residents’ Complaints Procedure’ in place and we looked at examples where complaints had been raised and responded to in a timely manner.

Staff told us there was inconsistency in the management team and room for improvement.

There was no registered manager at the home. 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 the time of the inspection a person was in the process of applying for this position and registering with the CQC.

On the date of the inspection, we found that the electronic care planning system had not been working for the previous three days and there was no contingency plan in place. The paper based care plans did not contain all the latest information and some information was missing.

This meant there was a breach of Regulation 17(2)(c)(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance, because the service had failed to maintain securely and accurate, complete and contemporaneous record in respect of each person using the service.

We looked for evidence of service audits and found that although some audits had been carried out there were no audits for people’s beds, mattresses and cushions, infection prevention and control.

There was also a complaints audit completed for the period March to October 2015 and we saw that the appropriate people had been involved where applicable and the complaints had all been resolved to the satisfaction of the complainant in a timely way.

There was a contingency planning handbook in place that identified actions to be taken in the event of an unforeseen event such as the loss of utilities supplies, pandemics, flood disruption and lift breakdown. Policies and procedures were all up to date, having been reviewed in August 2015.