This inspection took place on 25 and 26 September and was unannounced. This meant the provider and staff did not know we would be visiting.

The Manor House is a purpose built 76 bedded care home located in Barnard Castle, near to a range of local facilities. The home has two floors and is divided into three units. The first floor providing residential care, Chesters providing care for people who may be living with a dementia and Teesdale providing residential care. At the time of our inspection 69 people were using the service.

At the last inspection in December 2015 the service was rated Good. At this inspection we found the service remained Good.

At the last inspection we identified a breach of regulation in relation to medicines management. We took action by requiring the provider to send us a plan setting out how they would improve this. When we returned for our latest inspection we saw that improvements had been made and the service was no longer in breach of regulation.

The service had a registered manager. 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.

People told us staff at the service kept them safe. Medicines were managed safely. Risks to people were assessed and action taken to mitigate the risks to people’s health, safety and welfare. Policies and procedures were in place to safeguard people from abuse. The manager and provider monitored staffing levels to ensure they were sufficient to support people safely. The provider’s recruitment processes minimised the risk of unsuitable staff being employed.

People told us staff had the knowledge and skills needed to provide the support they wanted. Staff received the training they needed to support people effectively. Regular supervisions and appraisals were carried out to support staff in their roles. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this. People were supported to maintain a healthy diet. People's care records showed details of appointments with, and visits by, health and social care professionals.

People and their relatives described staff as kind and caring and spoke positively about the support they received at the service. Staff supported people to maintain their independence. People and their relatives told us staff treated them with respect and protected their dignity. We saw numerous examples of staff delivering kind and caring support during our visit. Policies and procedures were in place to support people to access advocacy services and end of life care.

People received personalised care that was regularly reviewed. People were supported to access activities they enjoyed. Policies and procedures were in place to investigate and respond to complaints.

People described the service as well-led, and spoke positively about its culture and values. Staff said they were proud to work at the service and felt it provided excellent care and support. The manager and provider carried out a number of quality assurance checks and audits to monitor and improve standards at the service. Feedback was sought from people, their relatives and staff. People were encouraged and supported to maintain links with the wider community. The manager had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken.

We inspected The Manor House on 18 December 2015. This was an unannounced inspection.

The Manor House is a purpose built 76 bedded care home located in Barnard Castle, near to a range of local facilities. The home has two floors and is divided into three units. The first floor providing residential care, Chesters providing care for people who may be living with a dementia and Teesdale providing residential care.

The service did not have a registered manager, but the manager at the service had applied to be registered with CQC and had just undergone their interview to assess their fitness. The manager was on annual leave at the time of our visit but we did meet them briefly. 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 were systems and processes in place to protect people from the risk of harm. Staff were aware of different types of abuse, what constituted poor practice and action to take if abuse was suspected. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. There was a regular programme of staff supervision and appraisal in place. Records of supervision were detailed and showed the manager and deputy manager worked with staff to identify their personal and professional development.

Staff had been trained and had the skills and knowledge to provide support to the people they cared for. There was enough staff on duty to provide support and ensure that their needs were met. Staff were aware of the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

We found that safe recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

We observed people receiving their medicines safely. Medicines were stored safely but records showed that people were at risk of not receiving their oral and topical medicines appropriately. Medicines audits had consistently highlighted areas for improvement since July 2015, but we could not see how the service had worked to implement these actions.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, showed compassion, were patient and gave encouragement to people.

People’s nutritional needs were met, with people being involved in decisions about meals. People who used the service told us that they got enough to eat and drink and that staff asked what people wanted. Staff told us that they closely monitored people and would contact the dietician if needed.

People were supported to maintain good health and had access to healthcare professionals and services. People told us that they were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

Assessments were undertaken to identify people’s health and support needs. Plans were developed with people who used the service to identify how they wished to be supported but we found plans for people on the first floor needed to be strengthened to make sure they reflected how people wished their care and support to be provided.

People’s independence was encouraged and the service supported people to maintain their hobbies and leisure interests. The activity co-ordinator was supporting people to enjoy the festive season and several had been out to carol services and shopping on the day of our visit.

The provider had a system in place for responding to people’s concerns and complaints. People told us they knew how to complain and felt confident that staff would respond and take action to support them.

There were systems in place to monitor the quality of the service provided, however in relation to medicines, audits did not show actions had been followed up appropriately.

During our inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

During our previous inspection on 26 and 27 June 2014 we identified serious concerns regarding the quality of care people received. We requested the provider send us an action plan detailing how improvements would be made. We received an action plan dated 27 June 2014 immediately following our inspection. The provider told us they would make immediate improvements to care planning, management of incidents and medication and also improve on the quality assurance systems in place.

At our recent inspection we asked ourselves five key questions whilst assessing improvements which had been made.

Is the service safe?

Improvements had been made to ensure people were protected from the risks of abuse and also the protected from poor management of medications.

Is the service effective?

Improvements had been made to ensure staff understood people's care needs and also care planning and risk assessment had been developed to ensure staff were aware of the needs of people to ensure appropriate delivery and planning of care.

Is the service responsive?

We found where people had changes in health needs care plans had been updated appropriately and people and their relatives told us care was better giving examples of people's receiving plenty of drinks and nutrition.

Is the service caring?

We observed staff caring for people in a positive and respectful manner with the exception of one incident which was brought to the attention of the management who recognised improvements were still on-going.

Is the service well-led?

The service does not have a manger which is registered with CQC but an application has been received. We found significant improvements overall had taken place since our previous inspection in June 2014 and people were receiving care which was safe and effective.

As some people who used the service had complex communication needs, they were not able to share with us their experiences. Therefore, during the inspection we observed the interaction between staff and people who used the service.

We saw that the majority of time people were supported to make their own choices, for example, what activities to be involved with or what food they wanted to eat. Also we saw that staff engaged positively with people. We did observe that in some instances staff did not give information to people to enable them to make their own choices about their care and treatment. However, overall we found before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

We spoke with six people who used the service. One person told us, “I’ve only been here a short while, but I love it. It is wonderful. The care is personalised to me.” We found people experienced care, treatment and support that met their needs and protected their rights.

We found that staff were now receiving appropriate training and development opportunities to enable them to meet the care and treatment needs of people who used the service.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People expressed their views and were involved in making decisions about their care and treatment. We spent time observing how staff supported people living at the home. We found staff were very respectful in their approach, treating people with dignity and courtesy.

When we visited the home there were 74 people living there, in four separate units. We spent time talking with several people, and watched how staff gave them support and care. People were very happy with the care provided. Comments included “Staff are very good – thoughtful.”

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were given support by the provider to make a comment or complaint where they needed assistance.

Staff members were not fully trained, supervised and appraised.

We were not able to speak to people who used the service because access was restricted to prevent an infection from spreading.

Throughout the visit, staff made sure service users were treated with respect and dignity. Care was delivered in private and the home was organised with good interaction between staff and service users.

All of the service users spoken to made positive comments about the environment, the care they were receiving and the staff.

Comments included: ‘I could not ask for better I get everything I ask for.’

‘The food is lovely and I am well looked after.’ ‘The staff will do anything for you.’

‘I am now settled and happy here.’ ‘The food is gorgeous.’

‘I could not want for more, I press the buzzer and they come and help me.’

‘My family come and have meals with me.’ ‘It is better than a hotel.’

‘I am very comfortable here.’ ‘I have a beautiful room which lead directly to the garden, that door is alarmed so I am safe.’

‘The staff are kind, I am always warm, and have good food and I am well looked after.’

‘There are plenty of things to do but I like my own company.’

During our inspection we asked the provider, staff and people who used the service specific 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, 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’s health and care needs had been assessed, however the care plans in place did not reflect people’s needs in sufficient depth to ensure they were safely cared for.

We found that whilst staff were caring they were not aware of people’s care needs and therefore were not meeting them in a safe manner. People were put at risk of inappropriate care.

We found medication records were incomplete and unclear which meant people’s medication was at risk of not being safely managed.

On arrival at the service we found two members of staff who appeared to be asleep. This meant people who used the service were potentially placed at risk of harm because staff employed to care for them appeared to be sleeping and were therefore possibly to respond to people who may have required care.

Is the service caring?

People told us they were supported by kind and attentive staff; they also told us the staff were stressed and they were feeling the staff stress levels. One person told us they were tired of having to tell different carers of their needs each morning.

We found people were at risk of dehydration and saw there were no records in place to indicate when people last had a drink. We asked staff to give people drinks as they were thirsty.

We found people were at risk of developing skin conditions as their continence issues were not being appropriately managed.

For those people living with a dementia we found people’s care was supported by comprehensive and personalised information.

Is the service responsive?

People we spoke with knew how to make a complaint if they were unhappy. We looked at how complaints had been dealt with, and found that the responses had not focused on the nature of the complaint. People could not be assured that complaints would be investigated and action taken when necessary to address their concerns.

One person shouted for help for over two hours. When we spoke to the person they wanted to be out of bed but thought they were probably being too impatient.

Is the service well-led?

The service had a quality assurance system. The records we looked at showed did not identify the service shortfalls and were therefore not being addressed. As a result the quality of the service was not continuingly improving.

Staff told us about issues they had raised with the manager and which had not been addressed