This inspection took place on 23 and 29 January. Both days were unannounced.

Warde Aldam is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Warde Aldam can accommodate up to 60 people who require accommodation and nursing or personal care. The home consists of one adapted building across two floors. At the time of our inspection there were 57 people living in the home.

Our last inspection of Warde Aldam took place on 10 October 2017. We rated the service requires improvement. We found there was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Need for consent. This was because conditions on Deprivation of Liberty Safeguards (DoLS) authorisations had not always been recorded and evidenced throughout the care plan. We also found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Good Governance. This was because effective audits were not always in place in relation to peoples care plans.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the service to at least good. At this inspection we found sufficient improvements had been made to meet the requirements of both Regulation 11 and 17 and the service had improved to good.

There was a registered manager employed at the home. A registered manager is a person who has registered with the CQC 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.

Staff had completed MCA training and during the inspection we saw staff asking for consent when providing care to people. People's care records evidenced their mental capacity had been considered and assessed, where appropriate. People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible. The policies and systems in the service support this practice.

At the last inspection we found audits did not always pick up shortfalls in the running of the home. At this inspection we found significant improvements to the governance of the home. The registered manager completed regular audits of the service, to make sure action was taken and lessons learned when things went wrong. Effective systems were in place to support the continuous improvement of the service.

People and relatives told us they believed they were safe. There were enough staff available to meet people's needs in a timely way and to keep people safe. Staff had been trained in how to safeguard vulnerable adults and they had a good understanding of their responsibility to protect people from harm.

People received their medicines as prescribed from staff who had been trained in medicines management.

People told us the staff were kind and caring and respectful of their needs. During this inspection we observed staff treat people with kindness, dignity and respect.

Staff received a range of training which the provider considered to be mandatory. Staff told us they were happy with the training they received and felt it supported them in their roles. Staff were supported by the management team through supervisions and appraisals.

The service worked closely with community health professionals to support people with their health needs. People's care records evidenced they received medical attention when they needed it, to promote their health.

People were supported to eat a varied diet that met their nutritional requirements. The service had protected mealtimes where all staff supported the provision

We inspected Warde Aldam on 10 and 18 October 2017. Both visits were unannounced. Our last inspection took place on 15 October 2015 where the service was meeting all the regulations. At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. We also made a recommendation to the registered manager to ensure the management of medicines were robust in relation to staff recording of their individual codes by completing regular audit checks.

Warde Aldam is a care home with nursing care. It provides care for a maximum of 60 people and consists of three different units. It is located in South Elmsall, near Pontefract. There were 58 people living at Warde Aldam at the time of inspection.

There was a registered manager, who had been registered with the Care Quality Commission to manage the service since July 2015. 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 saw in some people’s care plans information which was conflicting. In one care plan it stated the person should be weighed weekly but had been weighed monthly. We spoke to the registered manager who told us this was an oversight and should be completed monthly. We saw one person’s Deprivation of Liberty Safeguards (DoLS) conditions had not been adhered to. We spoke to the registered manager who told us this would be rectified and completed straight away. The registered manager sent an action plan showing how they would address the issues we found.

We saw some effective audits in place in relation to accident and incidents, staff files and quality assurance in relation to surveys from family and people who live at Warde Aldam.

Most people we spoke with told us they enjoyed living at Warde Aldam and were complimentary about the staff who supported them. They told us they felt safe, enjoyed the food and received good support with their health needs.

We saw most staff interactions were friendly, respectful and caring. Most visiting relatives were happy with the standard of care.

We felt staffing levels were sufficient to ensure people were supported with all their care needs and activities. However we felt the deployment of staff needed to be looked at in relation to allocation on the three units. We spoke to the registered manager about this. The home had a variety of activities within the home which we observed on two units Of the home. However on one unit we saw no activities taking place.

Staff understood how to safeguard people and knew the people they were supporting very well. Medicines were managed consistently and safely through an online system. However we did make the registered manager aware of the importance of ensuring the correct staff name was logged in and out on the online system.

We have made a recommendation to the registered manager to ensure the management of medicines were robust in relation to staff recording of their individual codes by completing regular audit checks.

People lived in a safe environment. Rooms were decorated to individual taste and people could choose what items to keep there. There was an odour across one unit of the home. The registered manager had allocated regular deep cleans within the home. We spoke to the registered manager who felt this would need to be looked at in relation to arranging new flooring across the units to maintain its effectiveness.

Information for people was displayed in the home, this included leaflets about people’s rights, standards people should expect and customer surveys results.

Staff we spoke with told us they were well supported by their colleagues and management. The staff received appropriate training, supervision, appraisal and observations around the

The inspection of Warde Aldam took place on 15 October 2015 and was unannounced. At the last inspection on on 25 June 2014 we found the provider met the regulations we reviewed.

Warde Aldam is a nursing home currently providing care for up to a maximum of 60 older people. The home has three distinct units providing care and support for people with nursing and residential needs including people who are living with dementia. Each of the three units has its own communal space and access to a secure garden area. On the days of our inspection 55 people were living at the home.

The service 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.

People we spoke with told us they felt safe. The registered manager and the staff we spoke with understood what constituted abuse and understood their responsibility in keeping people safe from the risk of harm or abuse.

Risk assessments were in people’s care plans and these were reviewed at regular intervals. Where people required staff support for pressure relief, the records were not always an accurate reflection of the time this support was provided.

Recruitment procedures were thorough, this included completing a number of checks prior to candidates commencing employment to make sure they were suitable to work with vulnerable adults.

Procedures for the storage and administration of medicines were safe.

Staff received regular training and supervision to ensure they had the skills to perform their role.

Where people living at the home had their liberty restricted, an authorisation was in place to ensure this was lawful and their rights were protected.

People told us they enjoyed the food. Staff offered people a choice of what to eat and drink and provided support to people where this was required.

Everyone we spoke with said the staff were caring. During our inspection we heard staff speaking to people in a respectful manner and providing care and support to people in a way which did not compromise their dignity.

An activities organiser was assisted by a number of volunteers who supported people to engage in social interaction and participate in the various activities within the home.

People’s care plans were detailed and person centred. They recorded people’s preferences and support needs and were reviewed at regular intervals.

Complaints were recorded, investigated and analysed.

The registered manager had been employed at the home for two years and they felt supported in their role. Regular audits were completed to ensure the safety and welfare of people who lived at the home.

Regular meetings were held with the staff and relatives to enable two way feedback regarding the performance of the home.

This was a scheduled inspection, which also followed up on our last visit in which outcome 4 (care and welfare) was non-compliant and for which a warning notice was in place.

We carried out the inspection with our five questions in mind; 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.

Is the service safe?

Our previous inspections in October and December 2013 identified significant failings in people’s care and welfare. Since our last inspection we were informed that serious concerns were looked into by the Local Authority and neglect was substantiated with regard to one person’s care whilst in Warde Aldam. This was because the person had received insufficient food, drink or medical attention and had been severely dehydrated, resulting in their admission to hospital.

We found there had been significant improvements in the standards of care at Warde Aldam to ensure people’s safety with regard to their individual care. Staff demonstrated a clear understanding of how to respond to people if they showed signs of illness, abuse or neglect and they were confident to approach managers or other appropriate agencies to pass on any concerns.

Is the service caring?

We saw staff were kind, patient and caring with the people they cared for. They communicated warmly and at people’s eye level and demonstrated a person centred approach, acknowledging people’s individual needs. We found interactions with people had significantly improved since our last visits.

Is the service effective?

We saw communication between staff had improved and there were clear systems to ensure people’s care was personalised and effective. Staff had key information about people’s needs at handovers between shifts and concise and clear information was contained in newly revised care records for staff to read.

Is the service responsive?

We found the home worked in cooperation with other professionals to ensure people’s care was responsive to their needs. For example, where people’s weight or food intake gave a cause for concern, we saw the home referred promptly to the GP or dietician. We saw within the daily routine, staff were responsive to people’s needs. For example, one person seemed to be in a draught and staff responded to ensure the person was comfortable. We found people’s buzzers were promptly attended to.

Is the service well led?

We saw all staff were well informed and supported in undertaking their roles through regular training, supervision and appraisal, plus day to day team and peer support. Staff told us: “We all work really well together. It’s a good team”. We found the managers within the organisation had responded positively to areas of concern highlighted through inspections and complaints, ensuring systems to improve people’s care were implemented and the quality of the provision was monitored.

This was a responsive inspection to check whether there had been improvements to the quality of care for people, since our last inspection. Following our last inspection we issued a warning notice for the provider to improve.

We set out to answer our five 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.

Is the service caring?

Most staff interacted with people in a kind and friendly manner. We saw the majority of staff were attentive to people’s needs overall and acknowledged people with smiles, gestures and friendly greetings. Staff talked with people at their eye level and gave them time to communicate at their own pace.

We observed staff were kind and supportive of people at mealtimes, although we noticed there was insufficient engagement for one person being supported to eat. We saw when one person was upset, staff gave sensitive reassurance until they felt better.

Is the service responsive?

We found improved systems were in place to help staff be aware of people’s individual needs. For example, we saw staff divided up into teams, with named staff responsible for each person’s care. Every staff member carried a laminated card in their uniform pocket, with key information at a glance about every person’s needs and particular requirements. Staff we spoke with were confidently able to describe people’s needs and had a sound knowledge of how to care for each person.

However, one person told us they sometimes had to wait to go to the toilet because staff were busy. We observed this happening during our inspection and we had to remind staff this person was waiting to be supported to go to the toilet.

Is the service safe?

Individually named staff had been allocated responsibility for ensuring specific care tasks had been completed. This information was updated on the daily handover report and included safety checks as well as people’s individual information to ensure care was delivered safely. Handover information was more detailed and enabled managers to maintain an overview of care delivery.

Is the service effective?

Our findings at this inspection were that the provider had made some improvements to people’s care following the last inspection. However, we found that the warning notice had not been fully complied with. For example, some people’s care records were not fully updated and still contained some out of date and conflicting information. The manager told us care records had yet to be finalised for the Upper and Lower Cedar units.

Due to the improvements that had been made we decided it was appropriate to give Warde Aldam a further period of time to enable them to fully meet the requirements.We will make further checks to ensure requirements are met.

Is the service well led?

The manager had applied for registration with the Care Quality Commission, although this process was not yet complete at the time of our visit.

Since our last inspection, managers had implemented systems to ensure closer monitoring of people’s care and their food and fluid intake. We saw there had been many positive steps taken to address the issues raised and to improve the quality of care for people. In particular, the provider had made arrangements for people’s care records to be fully revised and we saw new care plans were in the process of being completed.

We made an unannounced visit to follow up the action we asked the provider to take at our previous inspection in October 2013. At that visit we found people were not always cared for in a way that reflected their individual needs. Care records did not accurately reflect people’s needs and wishes. People could not always reach call bells if necessary. Following our previous visit the provider submitted an action plan which stated actions would be completed by 9th November 2013.

We observed care given to people, spoke with four staff, including the senior nurse in charge. The manager was not present during our inspection. We looked at care records for six people.

We found although there had been some improvements to care records, there were also gaps in recording, inconsistencies of information and four of the six records we looked at had not been updated since September 2013.

We found people spent a lot of time either seated or wandering round, with little available for them to capture their interest. We found staff deployment did not promote people’s care and welfare as we observed people alone in the main lounge, dining room and corridors, with little staff interaction.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

The atmosphere on each unit was very warm and welcoming, with staff joining in and supporting people. We saw people were attended to promptly on the whole and appropriate consent was given for their care and treatment. People seemed happy and their behaviour showed they were content in their environment.

We saw people were mostly happy and settled in Warde Aldam. People had smart clothes on and visited the hairdresser if they wanted to. We found communal areas to be homely and people spent time doing activities of their choice. However, we found that not all people had their care needs met effectively.

Staff showed interest in ensuring people’s needs were met. Staff expressed satisfaction in their role. We found staff were recruited and vetted thoroughly and had attended mandatory training to enable them to carry out their roles effectively.

We found the premises to be clean and free form offensive odours, with practices in place that prevented the spread of infection.

We saw the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

We focused our visit on people who needed general nursing care (The Bethal Unit) and those who required residential or nursing care for their mental health needs on Lower Cedar Unit.

People who used the service told us the staff were very good, friendly and courteous when carrying out their care and support. One person said; “Staff provide very good care and are gentle and thoughtful. They are attentive and always respond quickly if I need anything.”

People told us they were treated well and said that staff understood the care and support people needed.

A relative said; “Whenever I visit my mother is always nicely dressed and clean. This helps to maintain her dignity.” Another relative commented “The care seems good and the place is always clean and tidy.”

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Relatives commented about being involved in decision making about their relative’s care. One relative told us “Staff are welcoming and keep me informed about what is going on.”