The inspection of The Green Residential Care Home took place on 13, 14 and 19 October 2016 and was unannounced. Because the service also ran a domiciliary care agency (DCA) providing ‘personal care’ from the same registered location, both this and the regulated activity of ‘accommodation for persons who require nursing or personal care’ were inspected at the same time. The care home was inspected and people living there were spoken with on 13 and 14 October while those that used the services of the DCA were spoken with on 19 October 2016. Another visit was made to the care home on 4 November 2016 to look in more detail at the annual fire safety certificate and maintenance reports.

At the last inspection on 26 May 2015 the service met all of the regulations we assessed under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, with the exception of Regulation 12: safe care and treatment, in respect of the regulated activity ‘accommodation for persons who require nursing or personal care’ only. This was because people who used the care home service and others were not protected from the risk of harm as the premises were not properly maintained, in respect of window restrictors, hot water signage, fire door closers and a recommendation to upgrade the fire safety panel. A requirement was made in the report regarding these issues to ensure people were protected from harm.

At this inspection we found that the requirement had been met in these areas with the exception of the upgrade on the fire panel. However, we were assured that the fire panel and alarms were in working order and regular checks on the system were carried out and recorded. Information obtained from Humberside Fire & Rescue Service showed that the system should meet specific British safety standards when assessed by a competent person. This was later checked in more detail with the manager on 4 November 2016 and we were satisfied that the system was in a 'satisfactory' working order and meeting the standard.

At the last inspection other areas for improvement were identified that included: following best practice guidance on mitigating risks when staff were working in an emergency prior to receipt of a Disclosure and Barring Service check, ensuring the environment was kept clean and was suitable for people living with dementia, staff being pro-active about meeting people’s needs and ensuring all records held were signed and dated. Recommendations were made concerning all of these areas, which had been addressed. At this inspection the recommendations had been addressed.

The Green Residential Care Home is registered to provide accommodation and care for 23 older people and to provide a domiciliary care service in the local vicinity. Accommodation is provided over two floors and most bedrooms are single occupancy. There are two sitting rooms and a dining room. A small garden to the rear of the property is accessible to people that use the service. There is a car park to the rear for four cars and other parking is available near the village green. The DCA service, provided from the same location premises, operates in the local vicinity only. At the time of inspection there were 15 people receiving this service, with five staff providing care and support.

The registered provider was required to have a registered manager in post. On the day of the inspection there was a manager that had been in post since 1 May 2016 but they were not yet registered with the Care Quality Commission and had not yet submitted an application to be registered for this position. The previous registered manager had de-registered in August 2016 but had not been working at the service since 1 May 2016.

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 require

The inspection of The Green Residential Care Home took place on 26 May 2015 and was unannounced. At the previous inspection on 29 September 2014 the regulations we assessed were all being complied with.

The Green Residential Care Home is registered to provide accommodation and care for 23 older people and to provide a domiciliary care service in the local vicinity. Accommodation at the home is provided over two floors and most bedrooms are single occupancy. There are two sitting rooms and a dining room. A small garden to the rear of the property is accessible to people that use the service. There is a car park to the rear for four cars and other parking is available near the village green. At the time of our visit there were eleven people using the service and one person receiving day care. There were six people receiving a service from the Domiciliary Care Agency provided by Green Care Homes Ltd.

There was a registered manager in post who had been managing the service for the past eighteen months. 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 found we had some concerns about the premises being adequately maintained to ensure the environment was safe for people and staff. These were in relation to window restrictors to prevent people from climbing out of them and risking a fall, hot water signage to tell people that water was very hot, fire door closers on bedrooms to ensure they fitted tightly into their rebate reducing fire risk and recommendations made at the last fire safety maintenance check in 2014 (the fire safety panel to update) not being completed yet. Improvement in these areas was needed.

This was a breach of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in respect of combined regulations 15: premises and equipment and regulation 12(2)(d) safe care and treatment. You can see what action we told the provider to take at the end of the full version of the report.

We found that people that used the service were protected from the risks of harm or abuse because the provider had ensured staff were appropriately trained in safeguarding adults from abuse and the provider had systems in place to ensure safeguarding referrals were made to the appropriate department. People were safe because risk assessments were in place to mitigate risk and staffing was in sufficient numbers to meet people’s needs. However, though staff recruitment followed safe policies and practices it needed to be improved. It was recommended to the provider that all staff recruitment checks were completed fully before staff began working in the service or risks taken were mitigated with information on action taken. Management of medicines and infection control practices were appropriately carried out, but it was recommended to the provider that general cleaning in the service needed to improve.

We found that people that used the service were cared for by trained, knowledgeable and appropriately supervised staff. They were protected by the use of legislation that upheld their rights and their consent to care and treatment was obtained before the staff supported them with this.

We found that people were given adequate nutrition and their health care was monitored. While the premises were appropriate for older people they did not provide the best environment for people living with dementia and were in need of an upgrade.

We found that people that used the service were treated kindly by staff with whom they had good relationships. People’s individuality was respected and while one staff was over cautious about ensuring medication was taken and therefore dis-regarded people’s independence we found that other staff encouraged people to be as independent as possible.

We found that people were given appropriate information and explanations to make decisions, their privacy and dignity were respected and their overall wellbeing was considered and addressed by staff that understood their needs and wishes.

We found that people that used the service had person-centred care plans in place for staff to follow regarding people’s physical, emotional and social care and health care needs, but some months these had not been reviewed. Sometimes staff did not respond to people’s needs at times when people were unaware they needed help and had not requested it. It was recommended to the provider that they ensured staff were more actively responsive to people’s needs when people were not directly seeking assistance, but were in need of it.

People had things to do at the service to keep them occupied and they sometimes went out on trips. They knew how to complain if they were unhappy about anything and were satisfied with the response they received or would receive if they had a complaint.

We found that people that used the service experienced a family-orientated culture and an open, accountable management style that ensured they were kept informed about things that affected them. Staff provided people with the information and explanations they required and had opportunities to make their views known about the quality of the service. Records were not as well maintained as they ought to have been in respect of dates and signatures.

Our inspector visited the service to check on progress the provider had made to become compliant in outcome 10: Safety and suitability of the premises. The information they gathered helped answer one of 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 people using the service, their relatives, and 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 effective?

Peoples' needs were taken into account with the layout of the service enabling people to move around freely and safely. A programme of refurbishment and redecoration had commenced which meant that people received care in an environment which was suitable and pleasant.

Our inspector visited the service and assessed six essential standards of quality and safety which helped us 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 people using the service and 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?

People received the care and support they required according to their written care plans, which were based on assessment of needs and which included consideration to any risk assessments in place. We saw that staff provided care and support to people with such as their mobility and nutrition which followed safe care practices.

Some safety systems, such as maintenance of electrical equipment, the fire system and the passenger lift, were in place and being maintained through maintenance contracts to ensure people were not being placed at risk of harm. However, much of the building, furniture and furnishings were tired and in some cases needed replacing in order to promote peoples' comfort and protect them from associated health risks. This was a breach of regulation 15.

We have told the provider to take action to address these concerns and we will re-visit the service to check they have carried out these actions in relation to the suitability of the premises.

People that used the service were supported and cared for by staff that were recruited and checked properly, to ensure they were suitable to work in the care profession.

Is the service effective?

People that used the service were effectively cared for because they gave consent to their care and support whenever it was required and so peoples' needs were met. People said, "When we're offered help we can choose to accept it or not", "I have agreed my care plan and the girls (staff) usually ask me what I need assistance with" and "The care staff ask me what I need help with and they have my consent whenever I answer that question. If they offer other help then I would either say yes or no and they would respect my decision."

Is the service caring?

People received support with their mobility, nutrition and health care. The staff were polite, helpful and caring and though they knew peoples’ wishes and preferences they respected that people needed to ask for things and to make choices. This showed that the service was caring. People said, "The staff are always there to help and though it is not like being at home, I could do worse” and "They (the staff) know when I am feeling less independent and they offer the help I need."

Is the service responsive?

The service was responsive to peoples' needs. People said, "I can please myself when I get up or go to bed and I usually do", "The girls (staff) are very helpful when I can’t manager on my own” and “Oh everything I need is provided for. The staff are always there to help." We saw that people required support with their personal comfort, mobility, maintaining their body temperature and nutrition. Staff supported them whenever they required it.

The manager had an approach to complaint receiving and handling that considered complaints to be useful for improving the service. This meant they and the service were responsive to concerns that people raised.

Is the service well led?

The manager told us that care files had recently been updated to ensure all areas of need were planned for and staff knew how best to meet peoples' needs. The manager had vision regarding meeting the care needs of people and we discussed with them the ways of deploying staff more effectively to achieve greater efficiency of staff time.

When we discussed the quality monitoring and assuring system with people that used the service they said, "I have been perfectly happy with everything over the years, they don't need to ask me if I am satisfied" and "I don't think I have been here long enough to complete any satisfaction surveys." Another person said about the domiciliary care service, "I don't think I have been asked about the quality of the service, but it has been excellent." The provider may not have ensured everyone was aware of the need to ask them their opinion of the service, so this was an area for improvement.

While people experienced a service that was well led by a newly appointed manager, using a quality monitoring and assuring system as one of the methods for managing, there were still areas for development within the system to ensure thorough and effective checking of staff performance and service delivery took place. These areas included issuing surveys to all stakeholders, auditing the premises, analysing information gathered and producing an action plan from the analysis to show what improvements would be made.

The service was well led with regard to complaints that people raised, as the manager ensured staff understood their responsibilities to pass complaints to the manager and provider for investigation.

At our last visit of 3 September 2013 we found that although some improvements had been made we were unable to make a judgement regarding sustained compliance. The purpose of this visit was to check that improvements that had been outstanding in September had been completed and that all improvements had been sustained. A new manager had commenced in post since our previous visit. They told us they were in the process of applying to register as the registered manager with the Care Quality Commission.

We found that improvements regarding cleanliness and hygiene noted at our visit of September 2013 had been sustained. Cleaning schedules had been reviewed.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. This included regular staff competency checks.

There were enough suitably qualified staff to meet the needs of people who used the service. One person told us “The carers are very dedicated”.

Staff had completed induction training and outstanding refresher training since our last visit. The manager had made arrangements for all staff to access additional training.

Quality checks had continued at the service allowing the provider to make sustainable improvements to the service people received.

Records had been re-organised by the new manager, including the introduction of computerised records. All records were stored securely.

We visited The Green on 3 September 2013. This visit was a responsive follow up visit to our visits in April and July 2013 when we identified areas requiring improvement. This visit was undertaken to check if the provider had taken the actions required to improve the quality and safety of the service provided to people who lived at The Green. Although we found the provider had implemented a range of changes and improvements it was not possible to make a judgement regarding sustained improvement to achieve on-going compliance in some outcome areas.

People who used the service who we spoke with told us they were satisfied with the cleanliness of the home. We found that domestic staff had increased since our earlier visits.

We checked the management of medicines. We found that although medicines had been given appropriately the records did not always evidence the receipt of medicines or the carrying forward of stock to ensure an audit trail. One person who used the service told us they were “Highly satisfied” with the support they received with their medicines.

Arrangements had been made for additional ancillary staff to provide domestic support to the home. Staff told us they felt there were sufficient staff to meet the needs of people who used the service though there were some times in the day where additional duties made this more difficult.

Staff told us they felt they had the knowledge and skills required to do their job but that some staff needed refresher training. There was evidence that some training had been provided but more training was planned in order to ensure staff had the skills and knowledge to meet the needs of people who used the service.

The provider had introduced a quality assurance process but there had not been sufficient time to evidence that this was responsive to feedback regarding the experience of people who used the service.

Care records had been updated but the records relating to medication had not been completed to provide accurate audit trail. On the day of our visit we found some records were not stored securely.

We received information of concern about the cleanliness of the premises and medication errors. We established that CQC and the local authority were aware of these medication errors and that an investigation had been undertaken by the local authority at the time.

At the inspection on 20 April 2013 we had made a compliance action in respect of outcome 9: Management of medicines. In view of the concerns received by CQC, we decided to look at this area again, as well as outcome 8: Cleanliness and infection control.

We spoke with staff, chatted to people who lived at the home and observed staff practice on the day of this inspection.

We saw that staff wore appropriate protective clothing when carrying out their duties. However, we found that the home was not being maintained in a clean and hygienic condition, especially the laundry room, which posed a risk of infection.

We continued to find errors in the management of medicines. There is an outstanding compliance action with a timescale for compliance of 31 July 2013. We will return to the home after this date to assess compliance with this outcome.

At this inspection we assessed the regulated activity Accommodation for persons who require nursing or personal care, and not the activity Personal care.

During this inspection we assessed compliance with both regulated activities that were operated from the care home. As part of the inspection we spoke with the registered person, the manager, care staff, one person who lived at the home and the carer of a person who received a domiciliary care service.

People told us that staff were pleasant and that the were satisfied with the service they received. One person said, "The staff are pleasant and helpful and, yes, I like living at The Green”.

We found that food provision was satisfactory and that people who lived at the care home received a varied diet.

We had concerns about some aspects of the administration of medication, including staff training and competency checks.

There were sufficient numbers of care staff working within both the care home and the domiciliary care service. However, there were insufficient numbers of ancillary staff employed at the care home and this resulted in care staff carrying out domestic, catering and laundry tasks in addition to care duties. This reduced the amount of time that care staff could spend with people who lived at the home.

Some recent training had been undertaken by staff but there was a lack of evidence about the overall training needs and achievements of staff, including induction training.

There was little evidence that audits had been undertaken to measure the quality of the service provided and we had concerns about some aspects of record keeping.

At the last inspection of the home we issued a compliance action in respect of outcomes 8 and 21. We were concerned that a written infection control management system had been purchased but not completed. We were also concerned about some aspects of record keeping.

At this inspection we saw that the infection control management system had been completed. This included the polices and procedures in place at the home on the control of infection, plus risk assessments. We saw that an infection control 'lead' had been appointed and that there were cleaning schedules in place. There were no unpleasant odours in communal areas of the home although there was a slight odour in one bedroom. Bathroom and shower facilities were seen to be clean and hygienic.

We examined a selection of care plans, medication administration records and the infection control management system. These evidenced that record keeping at the home had improved.

We found that the people who lived at the home were satisfied with the service they received. They told us that the staff were pleasant and helpful. One person said, “I am very happy here and I love all of the staff”. People told us that they could choose how and where to spend the day, and what time to get up and go to bed. People were supported to take part in the local community.

Staff told us that they were well supported and that they received appropriate training and support.

We found that the arrangements in place to ensure that people were protected from the risk of infection were not robust .

Record keeping did not fully protect people from the risk of inappropriate or unsafe care being provided.

Comments were, “It’s a happy and welcoming environment from all the staff”, “I am quite happy – they all look after me well”, “The staff are very good” and “I have felt very much at home since arrival, which indeed was a real surprise and my every request has been met.”

People told us that staff respected their privacy and encouraged them to be independent.

People spoken with had noted the improvements in the environment and said they were very pleased. One person said, “The environment has definitely got better – it feels a better atmosphere.”

People told us they were consulted about things and could express their views to staff or the management.

We interviewed five people in the home and spoke with another three. Generally people had been satisfied with their opportunities to make decisions about their care and support.

People said they had been looked after well enough and the staff had done what they could, though sometimes they had been very busy.

People said the staff were always busy but had been nice. They said they made their own choices and decisions if they had needed minimal support, or had been assisted with personal care, entertainment and mobility if they had needed higher levels of care.

People had been aware of their care plan documents and felt staff had generally provided them with the care and support they had needed and in the way they had preferred or requested. People said they asked staff for the help they needed and usually got it.

People we spoke with said they had found the food to be acceptable. There had been a period when it hadn't been good, but things had picked up since the new cook started. Some people said they had always liked what had been prepared. One person said she had specific dietary needs, which had always been respected.

People said they had not experienced any unkind treatment or mistreatment. One person said although she spent time in other peoples' company this had not always been all day, so she could only relate what she had witnessed or experienced herself. This had been satisfactory care and treatment from the staff.

People said they had been quite satisfied with their rooms. One person said his room was fine as it was and he would not like any disruption with decoration. Another said she had had her room redecorated recently and it was satisfactory.

People said they had been satisfied with the lifting and bathing equipment in use and accepted it was necessary for their mobility needs.

People said they had found the staff to be helpful. They said things had settled down now, as there had been times when staff had been very busy and had not always been able to provide the assistance they had needed. They said things had improved recently.