This inspection was undertaken on 03, 04 and 08 January 2019. The first two dates were unannounced which means the provider did not know we were coming. The final visit was announced.

The Boynes Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Boynes Care Centre accommodates up 40 people in a large adapted property with more modern extensions. The home is split into two unit. Malvern unit supports people older people and people living with Multiple Sclerosis. A service is provided for people on short stay as well as permanent. Cedar unit supports people living with a dementia. There were 16 people living at the home at the time of the inspection.

At our previous inspection on 27 and 28 September 2017 we rated the service as ‘Requires Improvement’ in each of the five key questions as well as overall. We identified three breaches in regulation. These included the provider had failed to ensure people received safe care and treatment. The provider had not ensured people were safeguarded against abuse. The provider did not have effective arrangements in place to monitor and improve the quality and safety and welfare of people using the service.

As a result, we had asked for the provider to send us a report explaining the actions they were going to take to improve the service. Shortly before our inspection the registered manager had sent us an update on the actions they had taken since the previous inspection. We undertook this inspection to see whether the provider had made the necessary improvements.

At this inspection we found the provider was no longer in breach however, some areas continue to require improvement.

The provider had a registered manager in place. 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.

Since our previous inspection improvements have taken place in areas such as staffing, staff knowledge on protecting people from abuse and governance. A registered manager was in place and showed a passion to make further improvements at the home.

People who lived at the home as well as relatives and staff were complimentary about the care provided and were confident in the registered manager and the improvements made.

Although improvements had taken place we identified some areas where further improvement is necessary. We brought these to the attention of the registered manager as well as other senior managers working for the provider. Some of these shortfalls were acted upon immediately such as checking whether nurse with their registration to practice renewed. Other shortfalls were investigated and we were sent action plans in relation to these.

We identified shortfalls in how medicines were managed. These were discussed at the time of the inspection and action taken to reduce the risk of reoccurrences.

People were cared for by the staff who had knowledge of how to keep people safe and what to do if they believed people to be at risk. People’s wishes were taken into account to ensure people’s preferred life styles were met.

People had a range of fun and interesting things to do and were involved in deciding in these. People were able to take advantage of a mini bus to go on outings to interesting places as well as shopping and meals out.

People were supported to have maximum choice about their lives and were supported in the least restrictive way possible. Staff spent time with people talking about important things in their life and had developed a caring relationship. People were encouraged to make decisions about

The Boynes Care Centre provides accommodation and nursing care for up to 40 people. On the day of our inspection there were 23 people living at the home. The home was split into two units, Malvern unit supported people living with Multiple Sclerosis, some people were short stay and others lived at the home permanently. Cedar unit provided support for people living with dementia.

We undertook a comprehensive inspection of this service on September 2016. At that inspection the service was rated as requires improvement overall and we identified short falls in two regulations. We asked the provider to complete an action plan highlighting what they would do to improve the quality of care. We found some improvements, however not all of the action points on the providers plan had been completed.

After this inspection we received concerns in relation to how people were safely cared for and how their care was managed. As a result we undertook an unannounced comprehensive inspection to look into those concerns on the 27 and 28 September 2017. The inspection was carried out by two inspectors, a specialist advisor and an expert by experience.

At the time of our inspection there was no registered manager in place. The previous registered manager had left in August 2017. There was a new manager in post who was completing the registration process, they had been in post two and a half weeks at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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 there was not always sufficient staff effectively deployed to ensure people remained safe. People had not always had their risks identified, and these risks assessed and mitigated. Staff were not always aware of the safe way to support people. Accidents and incidents were not consistently investigated and actioned. Incidents of potential abuse were not always reported to ensure the manager took appropriate action. The management team had started to take action with some of the areas that needed improving. People told us they had their medicines as prescribed.

People were not always assessed when needed to ensure they were able to consent to their care. People may have been deprived of their liberty without a best interests assessment being completed. Staff told us they were not confident to complete assessments despite the training they had received. Staff respected people's rights to make their own decisions and choices about their support. People had food and drink they enjoyed to maintain a healthy diet. People said they had access to health professionals when they needed to. Relatives were confident their family member was supported to maintain their well-being.

People said they were supported by kind staff. Relatives told us they were happy with the care their family member received. However we saw staff were not always able to spend the time they needed to meet people’s needs. Staff were not consistently focussed on people, we saw there was a culture of task focussed care. Staff did not show a consistent dignified approach to supporting people living at the home. People living at the home were able to see their friends and relatives as they wanted. Staff knew people well, and worked with people to maintain their independence.

People told us they did not always have interesting things to do. The management team had identified people needed more interesting things to do. They were looking at increasing staff support in this area. People and their relatives had had access to regular meetings and further meetings had been arranged to keep them updated with changes in the management team. They knew how to raise complaints and were confident to raise them. There

At our last inspection on 27 and 28 April 2015 we asked the provider to take action to make improvements in how people received person centred care and this action has been completed. The service was rated as “Requires Improvement” overall.

At this inspection, we could not be assured that the necessary improvements to other areas of people’s care had been made. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 18 and 24 May 2016 and was unannounced.

The home provides accommodation for a maximum of 40 people requiring nursing and personal care. There were 23 people living at the home when we visited. A registered manager was in post when we inspected the service. 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 and associated Regulations about how the service is run.

People’s medicines were not always stored appropriately and concerns about how the medicines were stored were not shared with the registered manager. This meant that people may have taken medicines that were not stored as they should have been and the medicines may have been affected.

People were supported when they needed help in communal areas where there was likely to be a staff member around. Staff offered help and support to be people when they were in the lounge or dining areas.

People were supported by staff that received training and support from their line manager. This gave staff opportunities to discuss issues of importance to them and discuss people’s care if needed.

Staff supporting people did not always know which people were subject to a Deprivation of Liberty and how they were affected. This meant that we could not be assured that people were not unlawfully restricted when they were being cared for.

People were not always offered choices throughout their meal and were allocated a pudding based on their ability to eat. People’s mealtime experiences were affected by staff that did not always engage with them or who spoke about them to other staff in their presence.

People were not always cared for in a manner that demonstrated dignity and respect. Staff were at times task focussed and did not empathise with the person they were supporting. This caused some people unnecessary distress. Staff did not always engage and support people in a manner that showed a caring attitude as people were categorised as either having “Dementia” or “MS”.

People’s care was updated based on people’s changing medical needs. People’s individual interests were being supported although people who had specific needs about their care did not get an opportunity to discuss these.

People understood they how they could complain if they needed. Where people had raised a formal or informal complaint they were satisfied that action had been taken. A process was in place for acknowledging and responding to complaints.

People did not always benefit from care that was high quality because systems in the home for ensuring people received this were ineffective. The registered manager did not have a team that understood or delivered care to people, that was high quality, regardless of where they lived within the home.

Staff supporting people did not ensure issues affecting people’s care were brought to the attention of the registered manager so that action could be taken. The registered manager's system for ensuring staff demonstrated caring with dignity and respect was not effective. Although staff was behaviour was being monitored, staff did not consistently demonstrate a caring attitude throughout the home.

People understood they how they could complain if they needed. Where people had raised a formal or informal complaint they were s

We visited The Boynes Care Centre and spoke with people who used the service. Most of the people we spoke with told us they were happy. They told us staff included them in their treatment and they knew what to expect from it. People also told us staff treated them with respect and they appreciated the support they were given.

Staff were aware of the importance of involving people in their care, treatment and support planning. Staff we spoke with also knew about the importance of making sure people had choices about their lives. We were made aware of times when people’s choices in relation to their care were not always met. For example, when we spoke with staff they told us of times when they were unable to give people a choice about what time they got up in a morning and what time they went to bed. We found that people who used the service did not always have their choices respected.

We looked at three people’s care records, this included assessments, care plans and risk assessments. These records showed us the service were keeping people’s needs under review and took action when changes happened. We found that people who used the service experienced effective and appropriate care that met their needs and protected their rights.

We spoke with three people who used the service. They told us they felt safe and well cared for in the home. One person said, “I have always felt safe here”. All of the staff we spoke with told us they had taken part in training that showed them what abuse was and how to recognise the signs. They all told us they would feel confident reporting any allegation of abuse and knew how to do this. We found that people who used the service were protected from abuse because there were appropriate systems in place to do this.

We found that the provider was not maintaining appropriate standards of cleanliness throughout the home. This meant that people and staff were not living or working in a clean and pleasant environment which placed them at risk of acquiring an infection.

We found that the provider needed to make further improvements to the standard of the equipment provided. This would make sure that there was enough equipment to promote the independence and comfort of people who used the service.

We found that staff received appropriate induction and training which meant that people were cared for by staff who were supported to deliver care and treatment to an appropriate standard.

People who used the service were asked for their views about the care and treatment provided. Systems had been put into place for the monitoring of the quality of the service. These needed to be improved and applied consistently for all audits to make sure that people’s health and welfare needs were being met and that they were not being placed at any unacceptable risk of harm.

When we visited The Boynes Nursing Home we spoke with people who lived there and also spoke with some relatives. Some people that used the service had a dementia related illness or were not well enough to tell us about their experiences. We saw that people were neatly dressed in clean clothes and had clean hair and nails, indicating that staff knew the importance of helping people look their best. Relatives of people who used the service that we have spoken with made the following comments:-

“Well looked after by the staff.”

“Impressed by their professionalism of the care workers”.

“Staff have a very good attitude, they are friendly without being over familiar”.

“Flow of information to relatives could be improved”.

“The care staff interact well with residents”.

“The home is caring”.

“The staffs’ attitude is very good and they do care”.

One relative expressed concern about their experience of the care for an indentified person and with their permission this information was passed to the registered manager to follow up in accordance with their internal complaint & concerns policy.

We tracked the care of two people who used the service. Our visit found that overall people were receiving effective and appropriate care, treatment and support to meet their personal needs.

We found that improvements had continued since our last visit to the standard of hygiene, policy and practice in the home for the prevention and control of infection. However, people remained at potential risk off harm through cross infection due to poor practice and lack of maintenance of the home.

We found that improvements to the management and coordination of maintenance of the home were still required to make sure that identified broken equipment was repaired promptly to ensure the comfort and safety of the people who used the service and the safety of staff working at the home.

The induction process of staff had improved since our last visit. However, the supervision of all staff was not taking place on a regular basis to make sure that they had the correct skills and competencies to meet the needs of the people who used the service.

We found that systems were not in place to effectively audit the quality of the service which may be a potential risk to the safety and welfare of the people who use the service and the staff who work at the home.

Improvements were needed to care and maintenance records to make sure that peoples’ safety and wellbeing is being maintained at all times.

When we visited the service we met some people who lived there and also spoke with some relatives. We asked the people about the care they received and they told us the care was ‘pretty good’. They ‘sometimes do it very well’. One person told us they had ‘no complaints’ and they also told us that when they ‘had a problem with their leg the staff picked it up straight away’. People told us they felt safe living at the home and they get all the care they need, but ‘it may take longer some days’. One person told us they had activities most days of the week but they don’t always attend these activities.

People told us that the staff were ‘on the whole alright, one or two are a bit awkward’. They told us the staff were ‘kindly’. One person said that the staff response when they rang the call bell was ‘sometimes alright and sometimes not. This depends on the staffing levels and how many people need help at the same time’.

We spent some time observing staff and their approach to people in the communal areas in the part of the home where they care for people with dementia care needs. We saw some good interaction between staff and the people, but we also saw some less positive care. For example, a member of staff made an inappropriate comment about a person saying ‘they were difficult’ and the person heard this. Another staff member asked a person if they were ‘ok’, but walked away before the person could respond.

We saw that people’s dignity was mostly respected at all times, but we did observe examples of lack of respect for people’s privacy and dignity. For example, a care worker continually called a person ‘my love’ rather than using their name and we saw a nurse undertake a dressing to someone’s leg in the lounge area in full view of the other people.

We saw some medicines being given in the morning and at lunchtime. People who had been prescribed medicines for pain relief were asked if they needed them. We saw staff taking time to give medicines in a caring way.

People told us they had a choice of food and the quality was ‘quite good’.

Improvements have continued since our last visit to the standard of hygiene, policy and practice in the home for the prevention and control of infection, although further improvements have been highlighted. These were needed to ensure people who use the service and the staff are not placed at risk of harm through cross infection due to poor practice and lack of maintenance of the home.

Some equipment had been repaired and serviced since the last visit, although records showed that safety systems were not being checked and repairs were not being carried out promptly to ensure the comfort and safety of the people who used the service and the safety of staff working at the home.

People who used the service may still be placed at risk of harm through staff not receiving thorough induction training and ongoing supervision, which is in line with the provider’s stated process for inducting staff in their action plan that was due to be in place by August 2011.

We visited the home to check on progress towards compliance of this outcome following concerns which had been raised during our visits in January and July 2011.

We saw staff giving some lunchtime medicines to people using safe practice.

One person told us they were happy with arrangements to look after their own medicines. Another person told us that the staff looked after their medicines and that they were “very good” and had no problems.

We found that improvements had been made to the handling of medicines in the home since our last review. However further improvements were needed to ensure that the service fully protected people against the risks associated with the unsafe use and management of medicines by means of the making of appropriate arrangements for the recording and safe administration of medicines.

When we visited the service we met some people who lived there and also spoke to some relatives. We asked the people about the care they received and they told us the care was “good”, “very good and acceptable”, “they are very kind and helpful”. People told us when they called for assistance staff “can be quick and incredibly slow” in responding. Another person told us, “one or two are very quick” at answering the call bell. “I don’t expect to be taken to the toilet straight away as there are other people”.

We asked people about the food provided by the home and they told us it was “excellent, cooked on the premises”. “Too many sandwiches on offer but we can have something else”. “Food quite satisfactory but not exciting”. The staff were “very good at helping me to eat, I only ask and someone helps me”.

We were told “things have improved since the new manager has taken over”. A relative told us they “had no concerns about the home”. People told us they would “never be afraid to speak up”. “Nobody has ever been unkind to them”.

People talked to us about the staffing of the home. They told us, “at times there are enough, at times short staffed”. “The night staff are first class”. “I like the night staff a great deal”. The “day staff have bad memories; ask them for a cup of tea and they forget”. “Some of carers I don’t care for, but I have to put up with it”. Some staff “are a bit crude and ill mannered”. The “nurses are fine but I do not think the carers have much training”. “X (name removed) and X (name removed) carers are very good”. “The male helpers have been very considerate”. The staffs “communication is very friendly”.

This inspection took place on 27 & 28 April 2015 and was unannounced.

The service is a care home with nursing which is registered to care for 40 people. Accommodation and personal care are provided to older people requiring personal care and nursing. The service also housed a Respite Care Unit that specialised in offering families a short break by caring for people living with Multiple Sclerosis (MS). There were 23 people living at the home when we visited and there was an interim manager in post. A permanent manager had recently been recruited and was due to take up the post shortly. 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 and associated Regulations about how the service is run.

People were very positive about the care they received and about the staff who looked after them.

People told us that they felt that felt safe and staff were able to tell us about how they kept people safe. However, people’s care and social needs were not always met as people felt staff were under pressure and that they were short staffed. People received their medicines as prescribed and at the correct time and medications were safely administered and stored.

People and families told us they were respected. However we did not feel that people’s care was delivered in a dignified way. People did not always receive care that was based on their preferences and choices and centred around them as a person.

The provider did not act in accordance with the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS). The provisions of the MCA are used to protect people who might not be able to make informed decisions on their own about the care or treatment they receive. Staff and the Manager had some understanding of the law but some staff were less confident in applying the law.

We found that people’s health care needs were not always assessed, and care planned and delivered to meet those needs. People did not always access other healthcare professionals that provided treatment, advice and guidance to support their health needs and families told us that they felt that further help was sought when needed.

People were supported to eat and drink enough to keep them healthy. People had access to choices at mealtimes. Where people had special dietary requirements we saw that these were provided for.

Staff were provided with training that was continually updated that helped them understand how to care for people in most areas. The registered manager told us that all staff received training and regular checks were made to ensure that everyone received the right training.

People and staff told us that they would raise concerns with senior staff or the interim manager although they did not always raise issues of concern. The interim manager made regular checks to monitor the quality of the care that people received. However, there had been a number of staff and managerial changes within a short space of time which had impacted on how the quality of care had been monitored. The interim manager was working on improving the service and acknowledged that some areas required more immediate improvement, areas such as person centred care and improving the dignity of people at the service.