This comprehensive inspection carried out by one inspector, took place on 5 and 6 December 2018.

Waltham House 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.

Waltham House accommodates up to 33 older people, some of whom may be living with dementia, in one building over two floors.

A registered manager was in post. 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.

Risks had been identified and personalised risk assessments formulated, so that steps could be taken to mitigate risk where possible. However, we found one incident where risk had been identified and systems in place to minimise the risk had not been followed. Further risk had been identified, but action had not been taken. This meant there had been a delay in one person receiving medical intervention for a pressure sore.

The home was generally clean and tidy, however we found some shortfalls including one bedroom and some toilets requiring a more thorough clean. There were some issues with the safety and maintenance of the environment including a potentially hazardous unused shower area; there was a risk people with dementia may have accessed this. The registered manager confirmed this was secured following the inspection.

Medicines were not always administered as prescribed. We found one person had missed medication when they were asleep and two people had missed eye drops when they were asleep. One person’s cream chart had not been completed, which meant staff were missing guidance about where to apply the cream as prescribed, and guidance for one ‘as and when required’ medicines (also known as PRN) required additional details so staff could administer this safely.

Some systems were in place to assess and monitor the quality and safety of the service, but these were not always effective. This meant the opportunity to drive improvement had been lost and risk had not always been minimised. This had led to some safety issues in the environment and shortfalls in record keeping for the application of the Mental Capacity Act 2005 (MCA). We have made a recommendation about this.

Systems were in place to recruit staff safely. They were supported through on-going supervision and accessed training relevant to people's needs, to ensure these could be met. There were sufficient numbers of staff available to meet people’s needs.

Staff protected people from avoidable harm, were knowledgeable about safeguarding and able to raise concerns. They supported people to meet their health needs. A nutritional diet was offered and choices were available. We received some mixed feedback about the food.

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 practice. We found staff were aware of the MCA and supported people to make their own decisions wherever possible.

Staff were caring and friendly. We observed positive interactions from staff. They supported people to maintain their independence and treated them with dignity and respect.

There was a lack of meaningful activities provided for people. The registered manager told us they were in the process of recruiting a new activities coordinator to address this.

Care plans reflected people’s individual needs and circumstances, which enabled staff to provide person-centred care as a result.

People told us they felt able to raise any issues or concerns. The provider had systems in place to manage and r

This unannounced inspection took place on 01 and 02 June 2016. The service was last inspected on 05 February 2014 when the service was found to be compliant with the regulations inspected.

Waltham House is situated on the outskirts of Grimsby in a rural location. The home provides accommodation and personal care for up to 32 people. The service predominately provides care for older people some of whom may be living with dementia. At the time of our inspection there were 25 people using the service.

There was an acting manager in post who had applied and submitted an application to have their competencies and skills to be formally assessed by the Care Quality Commission and was currently awaiting an interview for this. 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.

Assessments were carried out to enable staff to support people who used the service to take positive risks whilst keeping them safe from harm. Training had been provided to ensure staff knew how to protect people from potential abuse and checks had been carried out to ensure staff were safe to work with people who used the service. Staffing levels were monitored to ensure there were sufficient numbers available to meet people’s needs. People received their medicines from staff who had been trained on the safe handling and administration of medication. Checks were carried out to ensure the building provided people with an environment that was safe.

Staff were provided with a range of training and development opportunities to enable them to effectively carry out their roles and help them develop their careers. Staff involved people in decisions about their support and obtained their consent before carrying out interventions. People’s legal rights were protected and their best interests were upheld when people lacked the capacity to make important decisions for themselves. People received a good range of nourishing home cooked meals which they said they enjoyed. Community based health care professionals advised they had a good working relationship with the service.

Staff demonstrated courtesy and consideration for people’s needs and upheld their dignity and respected their wishes for privacy. People and their relatives were involved in the planning of their support which was reviewed on a regular basis. Information about people was maintained in a confidential manner.

People were provided with a range of opportunities for social interaction to ensure their wellbeing was promoted. A complaints policy was in place to ensure people could raise any concerns and have these addressed when this was required.

Management feedback was provided to staff in a constructive way and meetings took place to ensure staff were aware of their professional roles and responsibilities. A range of audits were regularly carried out to enable the quality of the service to be monitored and enable it to learn and continually improve. People and their relatives were consulted to ensure they could contribute their views to help the service to develop, however service’s without a registered manager cannot be rated higher than requires improvement in the well led domain.

This inspection was completed as part of the national themed inspection programme looking at dementia care. We left comment cards at the home for a week and we received three completed cards.

Just prior to the visit we received concerns from a whistleblower. We took account of these concerns as part of the inspection.

The manager told us that of the 26 people who used the service approximately 70% of people had been diagnosed with dementia. We found there was a clear focus on dementia care in the home. The manager and staff were aware of good practice guidelines and these were incorporated into the care provided at the home. Sufficient and suitably trained staff were provided to ensure people with dementia received all the care and support they required.

A detailed assessment of people's needs was completed prior to admission to the home and personalised care plans were developed using this information. This meant staff had all the information they required to provide individualised care for people with dementia. It also enabled staff to be able to recognise any changes in the person's presentation or behaviours.

The staff worked well with other agencies and were proactive in ensuring that people received all the care and support they required from the appropriate agency. People were supported if they required hospital admission and information was provided to hospital staff to assist them to care for the person with dementia.

The manager had good systems in place to monitor the quality of the care provided and to ensure that people who lived in the home had their views heard.

The environment had been developed in line with some of the best practice guidance for people with dementia. For example, toilets were easily distinguishable as doors were painted a bright colour and signs had been used in picture format.

Due to people's complex needs relating to their mental health, people who used the service were unable to give us detailed information about the home.

We found that the planning and delivery of care had improved and the care plans had been reviewed and rewritten to ensure that they reflected people's needs.

We found that staff had received the training required to enable them to understand and meet people's needs safely.

We were unable to gain the views of some people in the home due to their complex needs and communication difficulties, but other people spoke to us about their experiences living at the home. The people we spoke with were complimentary about the home and said they thought it was a safe place to live. In discussions, one person said ‘’I’m happy here, everything is as I like it.”

People using the service appeared relaxed and comfortable in their surroundings and were supported where possible to choose how they spent their time. People we spoke with told us that staff were kind, helpful and treated them with respect. Comments included “They will do anything for you” and “A lovely and kind bunch of girls, always there if we need them.”

People told us they enjoyed the activities provided by the home and that the meals were good. One person said: “I join in with all the activities and trips out, never miss anything, we have a great time.”

During the visit we spoke with a number of relatives who expressed their satisfaction with the standards of care at the home. They told us the staff were very good and that they were kept informed of any changes. Comments included: “Staff are excellent, always pleasant and very good at keeping us up to date” and “Very impressed with everything especially the care, the staff are very kind and caring.”

Due to people's complex needs relating to their mental health we found that most of the people who used the service were unable to give us detailed information about the home. However those people we spoke with told us they were happy living at the home.

We observed very positive interactions between staff and people living in the home. We saw that staff offered people choices in how care was to be delivered and that they took their time to explain care tasks to people. We observed that staff were proactive in ensuring that people’s privacy and dignity were maintained.

We found that people were consulted about the service provided through regular meetings and questionnaires. The records of meetings showed that meals and activities provided were discussed and that people also had the opportunity to raise any concerns or suggestions that they may have.

We found that the planning and delivery of care did not always reflect people's needs and this put their health, safety and welfare at risk. However visitors told us that their relative's health and mobility had improved during their stay at the home.

We found that staff had not always had the training required to enable them to meet people's needs safely.