About the service: Washington Manor Care Home provides accommodation and personal care for up to 68 people, including people living with a dementia. At the time of the inspection 64 people were using the service.

People’s experience of using this service: Medicines were not managed safely. Risks were not always identified. Information from accidents and incidents was not carried through into people’s care records to support staff to reduce the risk.

The service did not effectively support people with the risks associated with malnutrition and hydration. Some people were not receiving supplements to their diets as directed by a healthcare professional. Recording was poor and we could not establish if people had received adequate fluids.

Pre-assessments were not always completed and did not cover all the protected characteristics of the Equality Act. Care records were not always accurate or up to date. The service failed to adhere to the Mental Capacity Act 2005 (MCA), mental capacity assessments and best interest decisions were not in place.

Some staff did not have all the appropriate training to support people safely.

Management checks were not robust and when audits found issues the service was slow to make things right. People’s information was not held securely. Record keeping throughout the service was chaotic. Documentation was not fully completed, contained inaccurate information and in some cases, was missing.

People and relatives told us staff were kind and caring. We observed staff were very busy supporting people and had limited time to sit and chat with people. Staff were keen to do the right thing and determined to provide great care and support for people.

A range of group activities were available for people to enjoy. Although there were limited options for men and for people on bed rest.

The provider set about resolving issues we identified following the first day of inspection, creating an action plan and placing additional staff to support the home.

Rating at last inspection: At the last inspection the service was rated good. (Report published 2 August 2018).

Why we inspected: This inspection was brought forward following concerns raised to us. These included concerns around staffing, provision of care and hygiene, nutrition and hydration. We also shared these concerns with local authority safeguarding and commissioning teams.

Enforcement: We identified 5 breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 including safe care and treatment, need for consent, nutrition and hydration, person-centred care and good governance.

Follow up: We will continue to monitor the service and will undertake another comprehensive inspection within six months.

During the inspection the provider submitted an action plan in response to the serious concerns letter we sent to them and has started to address issues identified.

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

This was an unannounced inspection which took place on 29 June and 5 July 2018. This meant the staff and provider did not know we would be visiting.

We inspected the service to follow up on the breaches and to carry out a comprehensive inspection.

At the last inspection in May 2017 the service was not meeting all of the legal requirements with regard to regulation 10, dignity and respect, regulation 11 need for consent and regulation 18, staff training.

Following that inspection, we asked the provider to complete an action plan to show what they would do and by when to remedy the breaches of regulations.

At this inspection we found improvements had been made and the service was no longer in breach of regulations 10, 11 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Washington Manor is a care home. People in care homes receive accommodation and 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.

Washington Manor accommodates a maximum of 68 older people who require personal care, some of whom may live with dementia or a dementia related condition. At the time of inspection 57 people were accommodated at the home.

A registered manager was 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 said they felt safe and they could speak to staff as they were approachable. People and staff told us they thought there were enough staff on duty to provide safe care to people. Staff knew about safeguarding procedures. Staff were subject to robust recruitment checks. Arrangements for managing people’s medicines were safe. However, we have made a recommendation about the management of medicines.

Risk assessments were in place and they accurately identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. Activities and entertainment were available to keep people engaged and stimulated.

The home was being refurbished and people were very positive about the changes taking place. There was a good standard of hygiene. The environment promoted the orientation and independence of people who lived with dementia.

People had access to health care professionals to make sure they received appropriate care and treatment. Staff followed advice given by professionals to make sure people received the care they needed. People received a varied and balanced diet to meet their nutritional needs.

Appropriate training was now provided and staff were supervised and supported. Staff had a good understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves. 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.

Detailed records reflected the care provided by staff. Care was provided with kindness and people’s privacy and dignity were respected. Communication was effective to ensure people, staff and relatives were kept up-to-date about any changes in people’s care and support needs and the running of the service.

A complaints procedure was available. People told us they would feel confident to speak to staff about any concerns if they needed to. People had the opportunity to give their views about the service. There was regular consultation with people and family members and their views were used to improve the service. All people were complimentary about the changes that had taken place in the home.

At the last inspection of this service in February 2016 we found the provider had breached three legal requirements. These related to staffing levels and training, person-centred care records and quality assurance checks by the provider.

We carried out this inspection on 3 and 4 May 2017. During this inspection we found the provider

had made improvements to the staffing levels. The provider had also begun to make changes to personalise people’s care records although this was on-going area of improvement. The provider had improved the quality assurance systems although it was too early to assess the effectiveness of the new governance arrangements.

However we found some areas of essential staff training had still not been completed. This included safeguarding training and fire safety training. This was a continuing breach of regulation.

During this inspection there were occasions when people’s privacy and dignity were not protected. Also, some restrictions had been applied to people without considering their choice or ability to consent.

You can see what action we told the provider to take at the back of the full version of the report.

We found there were no adaptations to help people who were living with dementia to find their way around. We have made a recommendation about this.

Since the last inspection a manager had registered with the Care Quality Commission but had left six months later. A new manager had been in post for four weeks and was in the process of applying for registration. 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 they felt safe and secure in the home. Staff were clear about how to recognise and report any suspicions of abuse. Staff told us they were confident that any concerns would be listened to and investigated to make sure people were protected. The provider used a dependency tool to decide the level of staffing.

There were robust checks before a new member of staff started to work at the home, although renewed checks of established staff were not always carried out in line with the provider’s own policy. Medicines were administered to people in a safe way but the storage of medicines was not always suitable.

People were supported to eat enough and they had choices about their meals. People were given choices of drinks throughout the day but there were no jugs of drink for people to help themselves. Records about how much people had to drink were not always filled in fully.

People who could express themselves told us the staff were helpful and friendly. Relatives had mixed views about how staff engaged with people. They felt some staff were friendly and compassionate; whilst others were not. The manager was aware that there were improvements to be made to the overall culture in the home.

There were activities in the home and occasional opportunities for people to go out. Staff felt this would be improved when the second activity staff member was recruited. There was clear information for people and visitors about how to make a complaint or comment and these were acted upon.

People, relatives and staff felt the manager was approachable, open and honest. They had been invited to be involved in discussions about future improvements to the home.

The inspection took place on 2 and 3 February 2016 and was unannounced. The service was last inspected in January 2014 when the service met the standards we inspected against at the time.

Washington Manor is a residential home which provides personal care for up to 68 people, with dementia or general care needs. There were 62 people living there at the time of our inspection.

The service did not have a registered manager but a manager had been in post since May 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.

During this inspection we found the provider had breached a number of regulations. Suitable numbers of qualified staff were not available at all times. People’s care plans did not always reflect individual needs and were sometimes incomplete. The provider’s audits had not identified the concerns we had about staffing levels.

Although the service looked clean there were odours on the first floor, and some areas needed redecorating.

A significant number of people told us they did not like the range of food available, and it was not up to standard.

Whilst staff responded appropriately when people’s needs changed, the provider did not always respond appropriately. There were several people with dementia who lived on the residential floor. Their needs could have been met better if they lived on the floor for people living with dementia.

Checks on equipment such as wheelchairs and hoists were not always carried out regularly. Regular premises maintenance checks were carried out.

Medicines were managed in the right way. Medicine administration records we viewed contained no gaps or inaccuracies.

Staff received regular supervisions and appraisals to assist their professional development.

People’s weight was checked regularly and action taken where concerns were identified. Referrals to health care professionals such as the community nursing team, dietician or GP were made appropriately.

The service was working within the principles of the Mental Capacity Act 2005. Deprivation of Liberty Safeguards (DoLS) applications had been made appropriately and contained details of people’s specific needs.

People and their relatives told us staff were kind and caring. Staff knew people well and how best to support them if they were anxious or upset. People’s dignity was maintained and their choices respected.

Staff told us the management team were supportive and approachable.

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with a number of people and visiting relatives throughout the day. People we spoke with told us they were happy with the service provided by the staff. One person told us “As soon as I ring my buzzer they come”. A relative we spoke with said “The home is very clean and the staff are very approachable". Another relative told us "“He has come on leaps and bounds”.

Staff members were seen to interact well with people and knew them by their first name. We saw how the privacy and dignity of residents was respected as we observed care interventions being carried out. Staff spoke to people in a pleasant and respected manner.

There were enough qualified, skilled and experienced staff to meet people's needs. Care plans were written in a clear and easy to understand way and people's personal preferences were clearly recorded.

There were sufficient staff on duty to support people for their care needs.

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.

The provider had made appropriate arrangements to protect service users and others from the risk of unsafe equipment.

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, gave reassurance and interacted well with people. We saw that staff communicated well with people and explained everything in a way that could be easily understood.

From our observations and discussions with the people we found that care staff worked in ways that supported the people and treated individuals with humanity as well as empathy.

Care plans were written in a clear and easy to understand way and people's personal preferences were clearly recorded. There were sufficient staff on duty to support people for their care needs.

We looked at how the service recruited staff by checking five staff files. These showed that the appropriate checks and procedures were being followed.

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

The relatives told us that they felt confident that the manager and staff would make sure the service met people's needs. Relatives told us; "I have no complaints about the care my x is receiving", "Staff are hard working and committed", and "When there have been any issues they've been sorted out".

People told us that staff were flexible, and would give their care in the way that the person wanted. We were told the care is "lovely", and that the home is "very nice".

We received no complaints about the care. We were told that staff were respectful and caring towards the people living in the home,and listened to what they said.

People told us that staff were flexible, and would give their care in the way that the person wanted. One person told us, “The care is lovely, and the home is very nice”.

Another person told us, “I don’t have a wrong word to say about the place”.

We were told that staff were respectful and caring towards the people living in the home, and listened to what they said.

We asked people if they could think of any improvements that the home could make: no-one had any suggestions for improvement.

Most relatives we spoke to praised the staff highly and told us they thought the care in the home was very good.

People told us they felt safe in the home, and had their rights respected.

People told us staff listened to any suggestions they made and acted upon them.