This inspection took place on 13 June 2018 and was unannounced. This meant no-one at the service knew we were planning to visit. The Laurels and The Limes was previously inspected on 22 March 2017 and rated ‘requires improvement’ overall.

The Laurels and The Limes is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Laurels and The Limes provides both residential and nursing care for up to 88 older people. The service is split into two separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of this inspection there were 48 people living at The Laurels and The Limes.

The registered provider employed two managers, one based at The Laurels and the other at The Limes. The manager based at The Laurels had been registered with CQC since August 2017. The manager based at The Limes had been in post since September 2017 and they were in the process of registering with 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.

On the day of the inspection we saw there were enough staff available to ensure people’s care and support needs were met in a timely way. However, we recommend the registered provider and the managers consider the comments made by some people and most staff regarding variable staffing levels.

Overall we saw the premises were clean and well maintained. However, we saw the kitchen would benefit from a deep clean. We spoke with the regional director about this and they arranged for a deep clean to take place the following day.

Staff were provided with an induction, relevant training and regular supervision to make sure they had the right skills and knowledge to support people. Managers acknowledged some training was overdue for staff, however we saw there were detailed plans in place to rectify this.

The registered provider had effective recruitment procedures in place to make sure staff had the required skills and were of suitable character and background.

Staff understood what it meant to protect people from abuse. They told us they were confident any concerns they raised would be taken seriously by the managers.

Medicines were stored safely and securely, and procedures were in place to ensure people received their medicines as prescribed.

People and their relatives told us they enjoyed the food served at The Laurels and The Limes, which we saw took into account their dietary needs and preferences.

Staff understood the requirements of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The registered provider’s policies and systems supported this practice.

Positive and supportive relationships had been developed between people, their relatives, and staff. People told us they were treated with dignity and respect and we saw this throughout the day of the inspection.

There was a range of activities available to people living at The Laurel and The Limes. People were supported to engage in activities that were important to them.

There was an up to date complaints policy and procedure readily available to people. People, their relatives and staff told us the managers were approachable and responsive to any issues raised.

People’s care records reflected the person’s current health and social care needs. The care records we looked at included risk assessments, which identified any risks to the person and how best to red

This inspection took place on 22 March 2017 and was unannounced, which meant no-one at the service knew we would be visiting.

At the last inspection on 2 November 2016 we found breaches in three regulations: Regulation 9, Person-centred care, Regulation 12, Safe care and treatment and Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following that inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to these breaches. This inspection was undertaken to check that they had followed their plan and to confirm that they now met all of the legal requirements. We saw that sufficient improvements had been made to achieve compliance.

The Laurels and the Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 43 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 11 people living in the Laurels. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 32 people living in the Limes.

The service did not have a registered manager in post at the time of the inspection. The registered provider had recently appointed two managers, one to manage the Laurels and one to manage the Limes. 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.’

There had been some improvements with concerns identified at the last inspection in relation to the management of medicines, but there were some actions that we identified during the inspection that were attended to during the inspection. The senior managers assured us that measures would be put in place to ensure these shortfalls did not reoccur.

At this inspection we saw improvements had been made in managing individual risk, including behaviour that challenged, but staff would benefit from further training in completing behaviour analysis charts.

At the last inspection we found the recruitment of staff was not safe. At this inspection we found sufficient improvements had been made by the registered provider.

Improvements had been made to the meal time experience for people living at the Limes.

At this inspection we saw improvements had been made for people living with dementia, so that they did not become disengaged with their surroundings.

Regular resident and relative meetings had been held at the service since the last inspection. People and relatives we spoke with told us their views about the service were being actively sought.

People we spoke with told us they felt ‘safe’ and had no worries or concerns. Relatives we spoke with felt their family member was in a safe place. Since the last inspection the registered provider had improved the systems in place to ensure people were safeguarded from the risk of harm.

Our observations during the inspection told us people’s needs were being met in a timely manner by staff.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

We saw that su

This was an unannounced inspection which meant the staff and provider did not know we would be inspecting the service. The inspection took place on 2 November 2016.

The service was last inspected on 13 July 2015. At the last inspection we found the service was not meeting the requirements of the following regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 Safe care and treatment, Regulation 17 Good Governance and Regulation 11 Need for consent. As a response to the last inspection the registered provider sent a report to the Care Quality Commission of the action they would take to become compliant with the regulations. The registered provider told us they would complete all the action to achieve compliance by the end of 2015.

The Laurels and the Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 53 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 14 people living in the Laurels. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 39 people living in the Limes.

There was a registered manager in post at the time of the inspection. 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 a 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 last inspection we saw the registered provider had not ensured DoLS authorisations had been obtained for some people living at the service. We saw that sufficient improvement had been made for to achieve compliance in Regulation 11, Need for consent.

We checked that improvements had been made in the safe handling of medicines. We saw that insufficient improvement had been taken to achieve compliance. We found the service continued not have appropriate arrangements in place to manage medicines to ensure people were protected from the risks associated with medicines.

The outcome of the inspection identified the service continued to be in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014, plus a further three breaches were identified. These findings showed the registered provider’s processes to monitor and improve the quality of the service were still ineffective in practice.

Although people told us they felt ‘safe’ and relatives spoken with felt their family member was in a safe place, we found that people were not safeguarded from the risk of harm. We saw the service had not always followed the local safeguarding protocols and made a safeguarding alert in line with the local multi agency agreement.

Staff recruitment records reviewed showed that information was not always obtained in accordance with Schedule 3. This meant we could not be confident that people were cared for by suitably qualified staff who had been assessed as safe to work with people.

At the last inspection we found that people’s daily charts were not maintained to ensure they were accurate, complete and contemporaneous. We saw that insufficient action had been taken so that we could be confident that people’s daily charts were completed accurately and were contemporaneous.

Most people and relatives spoken with told us the activities provided at the service could be improved to meet the needs for a

This was an unannounced inspection which meant the staff and provider did not know we would be inspecting the service. A scheduled inspection took place on 13 July 2015.

The service was last inspected on 19 January and 2 February 2015. At the last inspection we found the service was not meeting the requirements of the following regulations: care and welfare of people who use services, supporting staff, the management of medicines and assessing and monitoring the quality of service provision. As a response to the last inspection the provider sent a report to the Care Quality Commission of the action they would take to become compliant with the regulations. The provider told us they would complete the action for care and welfare of people who use services and the management of medicines by 30 November 2015. The provider told us they would complete the action for supporting staff and assessing and monitoring the quality of service provision by the 30 December 2014.

The Laurel and Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 43 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 16 people living in the Laurels building. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 27 people living in the Limes building.

There was not a registered manager for this service in post at the time of the inspection. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. One of the registered provider’s senior managers was managing the service.

During our inspection we check that improvements had been made in the safe handling of medicines. We saw that improvements had been made. However the provider still needed to make more improvements to ensure that people were protected against the risks associated with the unsafe management of medicines.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). We saw examples where people had been appropriately supported to make decisions in accordance with the MCA. However, we found the provider had not ensured DoLS authorisations had been obtained for some people living at the service.

In people’s records we saw a care plan for identified risks had been completed. We saw evidence of monthly reviews. However, the monthly reviews did not evidence what information had been used to inform the review or how the person and their relatives were involved in the process. We also found gaps in people’s records. For example, two people had gaps in their repositioning records. Both people were able to tell us that staff supported them to be repositioned when they were in bed. It is important that people’s records are accurate, complete and contemporaneous, including a record of the care and treatment provided to the person.

People told us they felt safe and were treated with dignity and respect. People were satisfied with the quality of care they had received and made positive comments about the staff. One person suggested that staff had further training in supporting people with a sensory impairment. We shared this information with the senior home’s manager.

Relatives spoken with felt their family member was in a safe place.

Our observations during the inspection told us people’s needs were being met in a timely manner by staff. We observed staff giving care and assistance to people throughout the inspection. They were respectful and treated people in a caring and supportive way.

People’s preferences and dietary needs were being met. Most people made positive comments about the food.

Relatives told us they were involved in their family members care planning. In people’s record we saw evidence of involvement from other professionals such as doctors, opticians, tissue viability nurses and speech and language practitioners.

Our discussions with staff told us they were fully aware of how to raise any safeguarding issues and were confident the senior staff in the service would listen.

Robust recruitment procedures were in place and appropriate checks were undertaken before staff started work. This meant people were cared for by suitably qualified staff who had been assessed as safe to work with people.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we told the provider to take at the back of the full version of this report.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person told us: “They [staff] let me know when breakfast is and I can have a lie in if I want.”

Food and drink met people’s individual dietary needs. One person told us, “I had toast and jam [for breakfast] it was nice.”

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

Some people living at the home were not able to verbally communicate their views and experiences to us. Due to this we used a formal way to observe people at this inspection to help us understand how their needs were supported. We call this the 'Short Observational Framework for Inspection (SOFI). During the observation we saw some examples of good communication skills by staff that utilised eye contact and touch to engage people who used the service.

People that we could communicate with told us that they were happy living at the home and that they were very satisfied with the care they received. People's comments included, "it’s not home but it’s good." Another person said, “I’m very happy here, everybody is nice and the staff are wonderful."

We spoke with three relatives who were visiting the home and they confirmed that they were very happy with the care provided. One person told us, "I’m happy with the staff, they are caring, cooperative and friendly."

People using the service told us that staff were "Very Kind".

One person said that moving in to the home was "The best thing I could have done" and that staff were" Excellent".

Relatives visiting the home told us they were generally happy with the service provided and confirmed prompt action was taken to address any issues that were brought to the management’s attention.

We saw evidence that meetings with people who use the service and their relatives had not always been well attended well in the past, however we were told a further relatives meeting was due to take place on the evening of our visit to ensure they are consulted about the service and that plans were in place to issue further surveys on different aspects of the home and that the finding from these would “Be analysed and acted upon positive or negative”.

We observed staff interacting with people who use the service in an open and respectful manner and that generally people were provided with support when required. People living in the home appeared to be well looked after and were observed wearing clean clothing and both they and their relatives told us they were generally happy with the service and that staff were doing a good job. One person said the service “Couldn’t be better” and that staff “Look after me well”.

People who use the service said they generally enjoyed their food and that choices were available if they didn’t like what was served. We observed a meal of chicken, potatoes and vegetables followed by ice cream that was plated up attractively from a hot trolley with staff providing appropriate assistance where needed. The atmosphere at lunch was relaxed and unhurried and we were told that specialist diets could be provided. We observed however, that people using the service were all wearing plastic aprons when given their food.

The results from a recent survey about the quality of food were displayed in the home and the findings from this were generally positive. Comments included “I enjoy salads and breakfast”, “There are too many meat dishes” and “I would like my plate warmed before food goes on it”. There was evidence the provider had listened to these comments and an action plan had been developed to include fruit baskets to be made available and for the cook to attend a future residents meeting.

Staff who we spoke to were aware of the correct actions to take should they have any concerns about the safeguarding of vulnerable adults. Staff were observed interacting with people using the service in a friendly and respectful manner and the homes training statistics confirmed all of them had received training on this aspect of their work.

There was a generally calm and pleasant atmosphere throughout the home on the day of our visit, with music playing quietly in lounge and an appropriate level of staff available. Staff were observed offering choices of morning drinks to people who use the service and one was observed supporting an individual with drinking milk from a beaker. Staff said they felt there were generally enough staff available, although some told us more activities should be provided as the last trip out had been to a pantomime in December 2010. Staff told us told us it was not always easy to delegate tasks due to communication difficulties within the staff team and that morale was currently low as a result of the ongoing Local authority safeguarding investigations. Staff told us however that improvements were now being made with more staff completing the food and fluid charts as needed.

Staff were observed to interact with people living in the home in a sensitive and friendly manner and there was evidence of recent meetings between the acting manager and the night manager and of three supervision sessions carried out by him the previous week. However, whilst staff confirmed they had recently had supervision and training sessions on a variety of topics and their files all contained records of this, there was evidence these had not always been regularly held.

People living in the home and their relatives told us they were generally happy with the service and knew how to make a formal complaint and that management responded to concerns that were raised.

Whilst there was evidence the acting manager was doing her job and took the concerns of people who used the service and their relatives seriously; there was some evidence of a further need to develop her role in order to provide clear leadership and support to staff.

This was an unannounced inspection which meant the staff and provider did not know we would be inspecting the service. The service was last inspected on 19, 20 and 27 August 2014. At the last inspection we found the service was not meeting the requirements of the following regulations: care and welfare of people who use services, supporting staff, the management of medicines and assessing and monitoring the quality of service provision. As a response to the last inspection the provider sent a report to the Care Quality Commission of the action they would take to become compliant with the regulations. The provider informed us they would be compliant by the end of December 2014.

The Laurel and Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 52 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 19 people living in the Laurels building. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 33 people living in the Limes building.

There was not a registered manager for this service in post at the time of the inspection. The manager had left their post shortly before the inspection took 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt “safe” and that they would speak with staff and/or a family member if they had any concerns. Relatives spoken with felt their family member was safe.

Most staff had received training in safeguarding vulnerable adults as part of their induction training. Our discussions with staff told us they were aware of how to raise any safeguarding concerns.

People gave mixed views about the staff and how they were treated by staff. We observed that the interaction and communication between staff and people was mainly focussed around completing tasks. People told us staff rarely had time to sit and talk or interact.

A pharmacist inspector from the Care Quality Commission inspected the service on 19 January 2015 to check whether improvements had been made to the management of medicines and that these improvements had been maintained. We saw that some improvements had been made, however we found that the provider had still not made enough improvements to protect people against the risks associated with the unsafe use and management of medicines.

Recruitment procedures were in place and appropriate checks were undertaken before staff started work. However, records showed that these procedures were not always being adhered to. For example, one staff member’s reference from their previous employer had not been obtained before they started working at the service.

Individual risk assessments were completed for people so that identifiable risks were managed effectively. However, we found that some people’s medication risk assessments had not been completed.

There was evidence in peoples care plans of involvement from other professionals such as doctors, opticians, tissue viability nurses and speech and language practitioners.

People’s dietary needs were being met but we found that people were not always asked for their preference regarding the food they would like to eat. We also found the assistance provided by some staff whilst supporting people to eat could be improved.

We found that some staff had not received all their induction training suitable for their roles when they started employment at the service. We also found that staff had not completed refresher training in some areas of training relevant to their role.

Staff had not received regular supervisions and appraisals, which meant their performance was not formally monitored and areas for improvement may not have been identified.

There was a complaint’s process in place in the service and people and/or their representative’s concerns had been investigated and action taken to address their concerns.

Meetings had been held with people’s representatives since the last inspection. We saw evidence that a catering audit had been completed with people at the service in August 2014. However, we found no evidence that the outcome of the audit or the action that was being taken had been shared with people living at the service. We found that no meetings had been held with people living at the service since the last inspection. This meant people did not have opportunities to be kept informed about information relevant to them.

Our findings demonstrated the provider had not ensured there were effective systems in place to monitor and improve the quality of the service provided. This meant they were not meeting the requirements to protect people from the risk and unsafe care by effectively assessing and monitoring the service being provided.

We saw evidence that checks were undertaken of the premises and equipment and action was taken to ensure peoples safety.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we told the provider to take at the back of the full version of this report.