About the service: Upsall House is a care home which provides residential care for up to 30 people. The care provided is for older people, some of who may be living with a dementia type illness. At the time of the inspection 21 people were accessing the service.

People’s experience of using this service: People and their relatives were happy with the care and support they received from the provider.

The management team and staff developed good relationships with people and their relatives to ensure they received the right support to improve their quality of life.

People told us they felt safe whilst being supported by staff. Relatives were confident family members were well cared for. There was a proactive approach to assessing and managing risk which allowed people to remain as independent as possible.

The provider promoted person-centred care which was delivered through the assessment and planning of people's individual and specific needs. Care plans were detailed and informative. They identified the specific care that people required.

Staff were skilled and knowledgeable in the care and support people required. They provided flexible care and support in line with a person's needs and wishes. The staff team was consistent with some staff working at the service for many years. Staff worked with family members and a range of professionals to ensure people were provided with the care and support they required.

Medicines systems were organised, and people were receiving their medicines when they should. The provider was following national guidance for the receipt, storage, administration and disposal of medicines.

People were involved in decisions about the care they received. People had 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 practice.

The provider was open and approachable which allowed people to share their views and raise concerns. People told us if they were worried about anything they would be comfortable to talk with staff or the management team.

The management structure in the service ensured people and staff had access to, and support from, a competent management team. The registered manager and provider monitored quality, sought people's views and had plans in place for improvements to the service environment.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection: Good (Report published 29 November 2016)

Why we inspected: We inspected the service as part of our inspection schedule for ‘Good’ rated services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

This inspection took place on 4 October 2016 and was unannounced. This meant the registered provider and staff did not know we would be visiting. A second day of inspection took place on 5 October 2016 and was announced.

The service was previously inspected in April 2016 and was not meeting two of the regulations we inspected. These related to medicine management, risk assessments, quality assurance audits and staff training records. We took enforcement action and issued warning notices requiring the registered provider to be compliant with our regulations by 29 July 2016. We also found that the service was not displaying the rating awarded at an inspection we carried out in October 2015. We also issued a fixed penalty notice in relation to failure to display the October 2015 inspection rating. When we returned for this inspection we found the issues identified had been addressed.

Upsall House Residential Home provides care and accommodation to a maximum of 30 people, some of whom may be living with a dementia. The home is a two storey converted private dwelling situated near Middlesbrough. There are 30 single bedrooms, 24 of which have en-suite facility which consist of a toilet and hand wash basin. There are two communal lounges and a dining room. At the time of our inspection 26 people were using the service.

The service had a manager but they were not 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’s medicines were managed safely. Risks to people were assessed and plans put in place to reduce the chances of them occurring. Regular checks of the premises and equipment were undertaken to ensure they were safe for people to use. Plans were in place to help keep people safe in emergency situations.

Policies and procedures were in place to protect people from abuse. The manager monitored staffing levels to ensure sufficient staff were employed to support people safely and recruitment procedures minimised the risk of unsuitable staff being employed.

Staff received the training they needed to support people effectively, and felt confident to request more. Training was clearly recorded, which helped the manager to monitor it. Staff were supported through supervisions and appraisals.

The service worked within the principles of the Mental Capacity Act 2005 to protect people’s rights to make decisions for themselves. People were supported to maintain a healthy diet and spoke positively about the food they received at the service. People were supported to access external professionals to maintain and promote their health.

People spoke positively about staff at the service, describing them as kind and caring. Throughout the inspection we saw staff treating people with dignity and respect and numerous examples of kind and caring support being provided.

One person was using an advocate at the time of our inspection, and the service worked with them to ensure the person’s voice was heard in planning their care.

Care and support was based on people’s assessed needs and preferences and was person-centred. Care plans were regularly reviewed to ensure they reflected people’s current support needs, and people said they were involved in these reviews.

People were supported to access activities they enjoyed. Procedures were in place to investigate and respond to complaints.

The manager carried out regular quality assurance audits to monitor and improve standards at the service. The registered provider also carried out monthly quality review visits. The manager and registered provider had worked closely with the local authority following our April 2016 inspection to improve quality assurance processes.

Feedbac

This inspection took place on 20 April 2016 and was unannounced. This meant the registered provider did not know we would be visiting. The service was previously inspected in October 2015, and was not meeting two of the regulations we inspected. These related to recruitment procedures and quality assurance audits. At this inspection we found that recruitment procedures had been improved but problems remained with quality assurance processes.

Upsall House Residential Home provides care and accommodation to a maximum of 30 people, some of whom may be living with a dementia. The home is a two storey converted private dwelling situated near Middlesbrough. There are 30 single bedrooms, 24 of which have en-suite facility which consist of a toilet and hand wash basin. There are two communal lounges and a dining room. At the time of our inspection 27 people were using the service.

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.

Medicines were not always managed safely. People’s medicine records did not always contain the information needed to support them safely with their medicines. Controlled drugs stock levels were not always accurately recorded.

Risk to people using the service were not always effectively assessed which meant plans were not in place to minimise them. Some of the risk assessments we looked at contained only basic information. Where people’s support needs gave rise to specific risks these had not always been risk assessed.

During our last inspection in October 2015 we identified a breach of regulation in relation to quality assurance processes. At that inspection we found limited infection control audits, remedial action was not taken following health and safety audits and there was limited detail in care plan and medicine audits. During our latest inspection we saw there were still gaps in quality assurance audits being carried out. Quality assurance processes were not carried out when the registered manager was absent, which meant standards were not consistently monitored. Where audits were completed it was not always clear what records meant.

During the inspection we checked to see if the service was displaying the rating awarded at the October 2015 inspection. The rating was not displayed as required by our regulations.

Recruitment procedures had improved since our last inspection in October 2015. Three members of staff had been recruited since then and we saw pre-employment checks were carried out to minimise the risk of unsuitable staff being employed.

People and staff told us staffing levels were sufficient to support people safely. The registered manager did not use any tools to monitor or assess staffing levels, but all housekeeping staff received the same training as care staff so they could assist in covering staff absences.

Staff understood safeguarding issues and were able to describe the types of abuse that can occur in care settings. There was a safeguarding policy in place, and staff had signed this to confirm they had read and understood it.

Risks to people arising out of the premises were monitored, and remedial action taken where necessary. The service was working with the local fire brigade to address issues identified by a fire brigade inspection in April 2016. Plans were in place to support people and provide a continuity of care in emergency situations.

Accidents and incidents were monitored and steps taken to reduce the chances of them occurring. These included staff making a report on accidents and incidents and the registered manager carrying out a falls analysis to see if any trends were emerging.

Staff received the training they needed to suppo

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with 14 people who use the service, eight visitors, the registered manager, the deputy manager and six care staff. We also reviewed records relating to the management of the home which included seven people’s care records, staff rotas, communication books, medication records, staff files and staff training records. We spent time in home observing how people's care was delivered during the early hours of the morning through to the afternoon.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. People were cared for in an environment that was safe, clean and hygienic. There were enough staff on duty during the day to meet the needs of the people living at the home but not at night.

We saw from records that from April 2014 to date of the inspection that on numerous occasions only two staff had been on duty during the night. During this time occupancy levels were between 23 to 28 people using the service. At least a quarter of these people needed two staff to assist them we found that the staffing levels were insufficient. People told us, “The staffing numbers seem a bit low overnight but otherwise I cannot complain”, “I need two staff to assist me and when there are only two night staff on duty I worry about how much time staff have to take with me, as it leaves everyone else with no one at hand.” A compliance action has been set for this and the provider must tell us how they plan to improve.

Although senior care staff on night duty were qualified to give medication due to the low staffing levels day staff gave out night medication before 8pm. This meant that some people were administered four lots of medication in a 12 hour period. No discussion had been held with GPs or the pharmacists about the safety of condensing administration times into a 12 hour period. A compliance action has been set for this and the provider must tell us how they plan to improve.

Staff personnel records did not contain all the information required by the Health and Social Care Act 2008. This meant the provider could not demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Whilst the majority of people had the capacity to make decisions staff needed to give consideration to what actions they needed to take to meet the needs of those who did lack capacity. No reviews had taken place to determine if the couple of people who experienced some confusion had a dementia and whether this compromised their ability to make decisions or if actions staff took constituted a deprivation of liberty.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us. “I find it a first class service. The staff are so kind and considerate.” Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us

Is the service responsive?

People’s needs had been assessed before they moved into the home. People told us they met with their key workers once a week to discuss what was important to them. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff had a good understanding of the ethos of the home and we saw that the manager had put quality assurance processes in place. People told us they were asked for their feedback on the service they received. Staff told us they were clear about their roles and responsibilities. They said the management had consulted with them before implementing changes to the management of the home and their views had been taken into consideration. However the provider may wish to note that the manager’s understanding of setting staffing levels, safe administration of medication, record keeping inhibited the effectiveness of the monitoring systems.

During the inspection we spoke with five people who used the service. We also spoke with the deputy manager, the training officer and a care assistant. People told us that they were happy with the care and service received. One person said, “We have wonderful care staff. We are looked after very well by both day and night staff. We are warm, comfortable and very well fed. I am very happy.” Another person said, “They are marvellous.”

We were able to observe the experiences of people who used the service. We saw that staff treated people with dignity and respect. Staff were attentive and interacted well with people. We saw that people had their needs assessed and that care plans were in place.

We saw that people lived in safe, accessible surroundings that promoted their wellbeing.

We saw that the service had appropriate equipment. We saw that regular checks and servicing of equipment was undertaken to ensure that it was in safe working order.

We found there was an effective complaints system in place at the home.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because the inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission inspector and joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service and a practising professional.

During the inspection we spoke with 10 people who used the service and one relative. We asked people if they were treated with dignity, respect and were given choice, comments made included:

"I can have help whenever I need it. I just press my button and someone comes to help."

"They talk so lovely to me."

"If he/she spills something on his/her top they change it straight away."

We asked people about the food that was provided. People confirmed that that they were always offered a choice of food and drink at each meal time. People said that the portion sizes were good and that snacks were available throughout the day. Comments made included:

"Drinks come round at regular intervals but you can have drinks hot or cold whenever you want."

"Can't grumble at the selection. I like being able to have jackets or salads and not dinners all the time."

"I often have my breakfast and supper in my own room."

"There's always choice and the bread for the sandwiches is always fresh."

During the inspection we asked people if they felt safe. One person said, "No ones ever been nasty to me. They are always nice here." The relative spoken with said, "I can go home knowing he/she is safe." People confirmed that if they were worried or had any concerns they would speak with the manager.

We asked people if they thought there was enough staff on duty to meet people's needs and to support people at meal time. Everybody spoken with said that they were well supported by the staff team and that they were happy with the care and support that they received. Comments made included:

"The girls are always around when you need them."

"There's always someone to give me help when I need it."

"There's plenty of them."

We carried out an inspection of Upsall House as we had received an anonymous expression of concern informing that there were insufficient staff on night duty and that night staff were forced to get people up early on a morning.

During our visit we spoke to a number of people who used the service and asked them direct questions about the concerns raised. Some people were less able to express their needs due to complex needs.

Comments made by people who used the service included:

"I am happy to get up early every morning. If I wake later because I have had a bad night, I gallop to catch up."

"I like to be up early, I'm frightened I might miss someting."

"I wake about 7am, get ready then lay on my bed until breakfast."

"I set my alarm for 7am. I get ready and the staff bring me a cup of tea."

"I like to stay in bed until about 8am. I have egg on toast and a cup of tea for my breakfast."

"The staff and management are very good and attentive. I get a cup of tea at 6am and get myself washed. I like to come down for breakfast about 7:30am."

"Staff are always there if you need them. You never have to wait long.

"The staff are very busy on a night but I am always cared for."

"The staff are busy day and night. They look after me very well."

During our visit we spoke to three people who used the service and three relatives. Everyone that we spoke to was satisfied with the care and service provided. People who used the service said, “I couldn’t find better and the staff are great. Everything that should be here is”. Another person said, “The staff are lovely they have genuinely wanted to help”. We asked people about the food that was provided comments made included, “The food, I can’t fault it. You’re not limited, there is plenty of it”. Another person said, “The food is excellent. We have three meals a day. We have our main meal at night and you can have supper if you want it”.

One relative told us, “The staff are very caring. We have lots of experience of care homes, but the atmosphere here is just like a family”. Another relative said, “Fantastic, it’s homely, it’s friendly, there is always plenty of staff and there is someone always in the lounge to keep an eye on people. It’s lovely, staff are approachable it is just like a family”.

We inspected Upsall House on 14 October and 4 November 2015. The first day of the inspection was unannounced which meant that the staff and registered provider did not know that we would be visiting. We informed the registered provider of the second day of our visit.

Upsall House provides care and accommodation to a maximum number of 30 older and / or older people living with a dementia. The home is a two storey converted private dwelling situated in spacious and attractive grounds on Guisborough Road in Middlesbrough. There are 30 single bedrooms, 24 of which have en-suite facility which consist of a toilet and hand wash basin. At the time of our inspection there were 29 people who used the service.

The home 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. The registered manager was on annual leave on the first day of the inspection; however the deputy manager was able to help us with the inspection process. The registered manager was present for the second day of our inspection.

At our last inspection of the service on 11 and 19 November 2014 we found that arrangements were not in place to ensure staff received training and supervision. Supervision is a process, usually a meeting, by which an organisation provide guidance and support to staff. The registered manager and staff had limited understanding of the Mental Capacity Act (MCA) 2005. Applications for the Deprivation of Liberty Safeguards had not been considered for people whose liberty may be deprived. DoLS is part of the MCA and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found that some care plans were insufficiently detailed and that they had not been reviewed and updated on a regular basis. The registered provider did not have an effective system in place to seek the views of people who used the service and relatives. The registered provider sent us an action plan telling us they would take action to become compliant. At our inspection on 14 October and 4 November 2015 we found that improvements had been made.

At our inspection on 14 October and 4 November 2015 we found different areas of concern. Robust recruitments procedures were not in place. The registered manager did not get references for people before they started work. This meant that checks had not been made to make sure that the person was a good employee or of good character and that the information supplied on the application form was correct.

We looked at the arrangements in place for quality assurance and governance. Quality assurance and governance processes are systems that help providers to assess the safety and quality of their services, ensuring they provide people with a good service and meet appropriate quality standards and legal obligations. Infection prevention audits were not carried out regularly. Care plan audits were just a tick box and did not inform of the actual checks that had been undertaken.

The majority of staff had received at least three supervisions. There were some night staff who needed supervision the deputy manager told us that they would complete supervision with all night staff over the next two weeks.

Systems were in place for the management of medicines, however some improvement is needed with record keeping.

The registered and deputy manager had ensured that appropriate Deprivation of Liberty Safeguarding (DoLS) applications had been made to the local authority for four people who used the service. The service was awaiting the outcome and decisions in respect of this. The deputy manager had carried assessments of people’s capacity where needed, however some decision specific assessments were still needed. The deputy manager had commenced this process by the second day of our inspection.

Care plans were individual to each person and had been evaluated and updated regularly.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Staff we spoke with were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

Risks to people’s safety had been assessed by staff. They included areas such as the risks around moving and handling; nutrition and falls. Risk assessments provided guidance to staff on how to keep people safe

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, patient and interacted well with people. Observation of the staff showed that they knew the people very well and could anticipate their needs. People told us that they were happy and felt very well cared for.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People were regularly weighed and nutritional screening had been undertaken.

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

Staff arranged activities and entertainment for people who used the service on a daily basis. People told us they enjoyed the activities and entertainment.

The registered provider had a system in place for responding to people’s concerns and complaints. People were asked for their views. People said that they would talk to the registered manager or staff if they were unhappy or had any concerns.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.