Woodend Care Home is a purpose-built care home and can provide nursing and residential care for up to 79 older people. It is situated in a residential area of Altrincham, Cheshire. At the time of the inspection there were 75 people living in the home. People were supported over four floors. The Dunham and Stamford units provided residential and nursing care. The Tatton unit provided support to people living with dementia and the Arley unit provided nursing care. Each floor had a communal lounge and dining room, and a small kitchen area. The kitchen and laundry room were situated in the basement.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This inspection took place on 25, 26 and 31 October and was unannounced. The service was last inspected on 20 and 21 September 2017 and received an overall rating of requires improvement. The previous report found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, person centred care and good governance.

During this inspection we found that the provider had met some of the previously breached regulations. Although we found that improvements had been made we found three further breaches of the Health and Social Care Act 2008 (Regulated-Activities) Regulations 2014. These breaches were around safe care and treatment, staffing levels and good governance.

The service didn't have a registered manager at the time of our last inspection. A registered manager has now been in post since January 2018. 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.

At this inspection we found that there had been improvements to the service. Recruitment procedures were now being followed correctly and all the required checks had taken place in the files that we examined. Quality monitoring reports from Trafford Council and Woodend’s monthly and six-monthly audits demonstrated that there had been improvements since the last inspection.

Despite some improvement we still had concerns about how medication was being managed. We found one person whose PRN protocol was not in place. All annual medication competencies were now completed and up to date.

People who used the service, families, visiting professionals and the majority of staff raised concerns about the level of staffing in the home and the use of agency staff. Staff were visibly under pressure, during the inspection, to keep on top of their work. The use of agency staff had reduced by half compared to the same period 12 months ago and they had just recruited seven new carers and two new nurses who were due to start next month.

Staff were aware of their responsibilities to safeguard people from abuse and risks to people's safety were assessed with guidance on how to minimise the risks. The service also had a whistleblowing policy and staff reported feeling able to report poor practice if required.

Inspection of care records showed that risks to people's health and well-being had been assessed and that plans had been put into place to manage the identified risks.

Systems were in place to monitor the safety of equipment and all other required checks were up to date, including fire safety and gas safety checks. We saw infection prevention and control policies and procedures were in place and staff we spoke with understood the importance of infection control measures. On-site laundry facilities were well resourced and well managed.

We did find hazardous substances unattended in one of the bathrooms and a windo

We inspected Woodend Care Home on 20 and 21 September 2017. The first day of the inspection was unannounced. This meant the home did not know we were coming.

Woodend Care Home (known as 'Woodend' by the people who live and work there) can provide nursing and residential care for up to 79 older people. At the time of the inspection there were 52 people living in the home. People were supported over three floors and a basement floor had been renovated but nobody was currently living on this floor at the time of our inspection. The ground floor provided accommodation primarily for people requiring residential care. The first floor provided support to people living with dementia and the top floor provided nursing care. Each floor had a communal lounge and dining room, and a small kitchen area. The kitchen and laundry room were situated in the basement. There was a lift and stairs to all floors.

Our last inspection took place on 28 and 29 June 2016 when we rated the service as requires improvement overall. We also inspected the service on 17 and 18 November 2015. At that time we rated the service as requires improvement overall and inadequate in well-led.

At this inspection we found that although there had been improvements to some aspects of the service, we identified on-going concerns and continued breaches of the regulations. We found breaches of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, person centred care and good governance.

You can see what action we have told the provider to take at the back of the full version of this report. We are currently considering our options in relation to enforcement and will update this section once any enforcement action has concluded.

The service didn’t have a registered manager at the time of our inspection. The previous registered manager had resigned from this role in August 2017. The home was being managed by two interim registered managers from other locations connected to the provider until a new manager was recruited. 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.

At the last inspection in June 2016 we found recruitment files were not completed in line with the regulations. At this inspection we found the provider was still non-complaint in this area.

Medicines were stored safely, and staff kept accurate records of administration. However, we found one person had not received a pain relief medicine as prescribed as there had been delays in ordering the medicines. We also found 'as required' medicines (PRN) protocols were not in place for two people on the Tatton unit.

The registered provider had used a dependency tool to calculate staffing levels but we found this had not been reviewed for up to eight weeks. We observed that people's basic needs were met. People and care staff told us there were enough staff on duty.

Compliance with and staff knowledge of the Mental Capacity Act 2005 (MCA) had improved since the last inspection in June 2016. Staff sought consent from people they supported before providing care. Staff were aware of the principles of the MCA and Deprivation of Liberty Safeguards (DoLS) and how to support people effectively.

During the inspection we observed two people’s finger nails ingrained with dirt and spectacles which required cleaning. We viewed their care plans and bathing records and found the level of personal care had not always been clearly recorded.

At the last inspection in in June 2016 we found people's confidentiality was not respected as care staff discussed people's care and well-being in the presence of others living at Woodend. At this inspection we observed

We inspected Woodend Care Home on 28 and 29 June 2016. The first day of the inspection was unannounced. This meant the home did not know we were coming.

Woodend Care Home (known as ‘Woodend’ by the people who live and work there) can provide nursing and residential care for up to 79 older people. When we started the inspection 41 people were living in the home and there were admissions during the two days we were there. People were supported over three floors and a basement floor was being renovated at the time of our inspection. The ground floor provided accommodation primarily for people requiring residential care. The first floor provided support to people living with dementia and the top floor provided nursing care. Each floor had a communal lounge and dining room, and a small kitchen area. The kitchen and laundry room were situated in the basement. There was a lift and stairs to all floors.

Our last inspection took place on 17 and 18 November 2015. At that time we rated the service as requires improvement overall and inadequate in well-led. As the previous inspection in January 2015 had rated the service as inadequate overall, we placed the service into ‘Special Measures’ because it was inadequate for two consecutive inspections in one of the domains.

At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall with no inadequate domains. This meant the service could come out of special measures.

The service had a registered manager who had been in post since January 2016. 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.

Recruitment files we inspected were not complete. Not all files for recently recruited employees contained records of the interviews they had, completed health questionnaires or evidence of a full employment record.

We noted improvements in medicines management from the last inspection in November 2015 and some examples of good practice in dementia care in relation to medicines. However, we saw an out of date medicine being administered, a care worker administering medicines which involved touching people and not washing their hands afterwards and found an unlocked medicine trolley in a communal area.

People told us there were not enough staff. Care workers said there were enough staff if all those rostered came to work. The registered manager had used a dependency tool to calculate staffing levels but was not sure if the information it was based upon was accurate. We observed that people’s basic needs were met on fully staffed floors and care workers struggled on those that were not.

Compliance with and staff knowledge of the Mental Capacity Act 2005 had improved since the last inspection November 2015, however, we identified three people who were being deprived of their liberty without authorisation from the local authority.

People’s confidentiality was not respected as care staff discussed people’s care and well-being in the presence of others living at Woodend. Care files were also not stored securely.

We found breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Care assessments and plans had improved since the last inspection and were seen to be detailed and person-centred. However, we identified two people who at times displayed behaviours that may challenge others that did not have care plans to help guide staff when supporting them.

The registered manager had followed the home’s policies and procedures when responding to complaints, however, people’s relatives told us they did not fe

Two inspectors carried out the inspection. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found-

Is the service safe?

CQC has a statutory duty to monitor the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. We saw there were policies and procedures in place and training had been provided for staff in relation to the Mental Capacity Act and DoLS Codes of Practice.

We spoke with senior staff who showed an awareness of the process and were able to identify when an application might be required. There had been no applications made to deprive people living in the home of their liberty.

Where beds were fitted with safety rails protective bumpers were used. These were used to minimise the risk of entrapment and keep people safe.

There were contracts in place to demonstrate equipment was regularly maintained and serviced to minimise risks to people who lived at the home.

The recruitment practices were thorough and the required safety checks such as; a check with the Disclosure and Barring Services (DBS) was made before new staff started work.

The staff we spoke with were aware of safeguarding procedures and their responsibilities to report poor practice. However we saw evidence to demonstrate procedures were not being followed.

Care plans contained risk assessments in relation to people’s moving and handing requirements. Some of the care plans we looked at had not been updated to reflect the changing needs of the person. For example, one person’s risk assessment stated they required the assistance of two staff for transfers. We observed one member of staff transfer the person from a wheelchair to an armchair. We discussed this with senior staff who confirmed the person should be transferred with the assistance of two staff. Using inappropriate moving and handling techniques has the potential to place people at risk of harm.

Is the service effective?

Staff told us care plans were in place for each person. There was limited evidence that people had been involved in planning their care. Although care plans had been reviewed on a regular basis some of the information was outdated and gave incorrect information and some sections had not been signed or dated. This made it impossible for staff to know if the information contained was current and therefore followed.

Visitors we spoke with told us visiting times were flexible and they were welcomed by staff. We were told they were able to visit their relative in private.

Is the service caring?

We had received concerns that people were being woken early in the morning. We arrived at the home at 06:00 and walked around the building. We saw two people were up and dressed and the majority of people were asleep in their bedrooms. We spoke with the people who were up and they confirmed they preferred to get up early.

We spent time over the lunch service observing interactions between staff and the people they supported. People were offered a choice of meal and drinks. Staff were observed assisting people to eat. Staff were calm and patient explained what the meal was and encouraged the person to eat at their own pace.

We spoke with five people who lived at the home who told us staff were caring. Comments included: “They (staff) provide everything I need.” “They are all very considerate.” “They are lovely.”

Staff took time to talk with people when assisting them with their care needs. The people we spoke with told us: “It is nice here and they (staff) are very kind.” “I am quite happy.” “I have everything I need.” “I am very comfortable.” “I think they do look after us they are very good.”

We spent time observing interactions between staff and the people they cared for. We saw there was some really good practice, staff approached people with respect and worked at the person's own pace.

Is the service responsive?

There were a number of forums in place to gain people’s views and opinions about the care and support they received. The manager told us a questionnaire was sent to relatives on an annual basis but the most recently completed surveys could not be found on the day of our inspection. This meant it was difficult for us to establish if the manager considered peoples comments or opinions by making changes.

The people we spoke with told us if they had any concerns they would speak to their relatives or one of the nurses.

We looked at a sample of people's care plans and saw although they had been signed as reviewed on a regular basis, where there had been changes to a person’s support needs, some care plans had not been amended to record the changes.

Is the service well led?

There was a newly recruited manager in post who was registered with the Care Quality Commission (CQC). The quality manager was also visiting the home to offer support to the manager. The quality manager visited the home on a monthly basis to conduct audits and provide additional management oversight to the home.

Staff told us they were well supported and had access to training, supervision and annual appraisals. In addition the staff we spoke with told us the unit manager or registered manager were available to discuss any concerns or issues.

Staff meetings were taking place and there was a handover at the start of each shift. This was to ensure staff were aware of the most up to date information about the people they cared for. In addition there was a daily heads of department meeting where equipment and repairs were discussed and information about appointments and staffing handed over.

There was a system of audits in place that included; infection control, medication and mattresses. Although there were systems in place to support the delivery of good care we identified shortfalls in the care being provided which meant the systems in place were not properly implemented or acted upon.

Staff supervision was provided by unit managers and there was a daily heads of department meeting. The clinical lead was responsible for monitoring staff performance and quality of care.

A record of accidents and incidents was kept. We found there was conflicting information in accident reports. For example, one person had a fall resulting in bruising and a skin tear but the managers’ investigation summary stated there had been no injury.

This meant it was difficult for us to establish whether the accident had been investigated or what systems had been put in place to minimise the risks of future accidents.

We used a number of different methods to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

We looked at a sample of people’s care plans. We saw that they were detailed and gave enough information about the persons care needs and preferences.

We looked at how staff managed medicines. We saw that medication was dispensed in ‘blister packs’ and stored in lockable trolleys in locked rooms. We saw that regular audits of the medication systems were taking place.

We looked at the equipment provided and how this was maintained. We looked at maintenance records and saw records of safety checks.

We looked at the staffing levels to make sure there were enough staff on duty to care for people who lived at the home. Records showed staffing levels were consistent.

We spoke with people who lived at the home and their visitors. Comments included: “They are very good to X.” “The staff are always welcoming.” “X is very happy here.” “They keep us up to date with everything.” “They really do care.”

We carried out an unannounced unscheduled visit on 1 March 2103. We carried out the visit out of hours in response to concerns that had been raised in regard to people who used the service being woken at night and dressed. On arrival to the home we observed that the front of the property was illuminated inside. There were 8 staff on duty over 4 floors 3 of these were qualified staff members, 3 were agency staff.

We looked around the home and checked 68 people who used the service's bedrooms. We noted that 1 floor had 3 members of staff on duty. They told that they were all agency staff. These staff were unable to tell us how many people who used the service were located on this floor. This is important in the event of a fire and evacuation. Staff did not know the names of people who used the service and had to keep referring to a list’.

We spoke with people who used the service. 1 person told us that they were concerned about the “staffing levels” and that “standards had dropped over the last few months” and “was not as good as it had been”. They raised concerns over the lack of staff at the weekend. One person told us they were “happy”.

We saw in 1 person care file that a kosher diet had been specifically requested for religious reasons. Evidence was seen in the care files that dietary instructions related to only omitting specific meat. Staff told us that family had agreed with this diet plan, however there was no evidence of this documented in the care file.

During this unannounced visit to Woodend Nursing and Residential Centre we spoke with five visitors and four people who used the service.

Most people we spoke to were very positive about the service provided. One visitor was less enthusiastic but had no concerns about the nature of the care provided to their relative.

People told us they believed that they could influence the way in which their care was provided and that they got on well with the staff who were described as "first-class"; "very good" and "caring staff who treat you like a human". A visitor described their experience of the home as being "part of the family" and said that "[their relative] was looked after now more than I could do." Someone else we talked to said, about their relative, "if I didn't think it was suitable I would have taken her elsewhere".

People told us that they felt safe living at the home.

People described the building as being kept clean and tidy. One person told us "there are cleaners on each floor who are excellent, you can't fault them."

One person told us that ‘the staff are very kind and they are always very respectful’.

One person told us that she was involved in planning her care when she first came into the home. She said that she was very happy with the care she was receiving.

‘The food is extremely good and there is always a choice’.

for the essential standards of quality and safety

‘I feel safe and the staff are nice’.

‘The staff are lovely and very caring’.

‘Staffing is just adequate and they could have more’.

‘Some of the new staff don’t know what they are doing but the rest do’

One visitor said she is ‘confident in staff ability and they do a really, really good job’

We inspected Woodend Nursing and Residential Centre on 17 and 18 November 2015. The first day of the inspection was unannounced.

Woodend Nursing and Residential Centre provides nursing and residential care for up to 79 older people. At the time of our inspection there were 62 people living in the home. People are supported over four floors. The basement floor provides single sex residential accommodation. The ground floor provides accommodation to people requiring either nursing or residential care. The first floor provides support to people living with dementia and the top floor provides both nursing and residential care, although most people had higher dependency nursing needs at the time we inspected. Each floor has a communal lounge/dining room and a small kitchen for making snacks and hot drinks. The kitchen and laundry room are situated in the basement and the home is accessible by a lift and stairs to all floors.

The service is required to have 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this service is ‘Requires Improvement.’ However, we are placing the service in ‘Special Measures.’ We do this when services have been rated as ‘Inadequate’ in any key question over two consecutive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in Special Measures.

There had been no registered manager in post at Woodend Nursing and Residential Centre since January 2015. Since that time two further managers had been employed and then left the service. The current manager had been in post for six weeks and was in the process of applying to be the registered manager. Concerns relating to practice at Woodend Nursing and Residential Centre had led to a joint intervention by the Local Authority and Clinical Commissioning Group at the end of October 2015 whereby a 28 day suspension of admissions to the home had been agreed and a Service Improvement Plan imposed. At the time of our inspection officers from the Local Authority and Clinical Commissioning Group were working with the current home manager to ensure the improvements they had identified were being made. Since the inspection an extension to the suspension of admissions until 24 December 2015 had been agreed.

Our last inspection took place on 29, 30 January and 3 February 2015. At that time we rated the service as inadequate as there were breaches of the regulations relating to safeguarding people, the need for consent, person-centred care, good governance and the regulation which requires services to notify the Care Quality Commission (CQC) of certain types of incidents. We asked for and received an action plan telling us how they intended to make the improvements that were required.

The action plan was not comprehensive in terms of the breaches we had identified and whilst the provider had followed the plan to rectify some breaches, during this inspection we found other breaches had not been addressed fully. This failure meant a further breach of the regulation relating to good governance.

Medication administration records were not always completed properly or updated when changes were made, not all ‘as required’ medications had instructions for staff, some MAR charts were not easy to read and creams and lotions were not dated upon opening.

Assessments for people who might lack mental capacity were not consistent or comprehensive and staff lacked knowledge and understanding of the Deprivation of Liberty Safeguards. This was a finding from the last inspection and constituted an ongoing breach of the regulation relating to need for consent.

People and their relatives, where relevant, were not involved in the planning of their care to ensure their needs and wishes were considered. This was a finding from the last inspection and constituted an ongoing breach of the regulation relating to person-centred care.

Assessments and care plans were not comprehensive and had not been evaluated and reviewed monthly according to the home’s policy. This was a finding from the last inspection and constituted an ongoing breach of the regulation relating to person-centred care.

There was a lack of meaningful activities available for people living at the home for promoting and encouraging people’s involvement and enabling them to retain their independence.

There was a history of management changes at the home which resulted in poor leadership and governance of the service provided.

The provider had again failed to implement effective systems to monitor the safety and quality of the service so that people received a safe and effective service. This was a finding from the last inspection and constituted an ongoing breach of the regulation relating to good governance.

We found breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. You can see what action we have told the provider to take at the back of the full version of the report.

People, their relatives and staff told us that there were not enough staff to support all the people as they needed, especially at busy times. Our observations during the inspection supported this. The current manager was recruiting staff for a new twilight shift on one of the floors.

Systems were in place to ensure people being deprived of their liberty were done so lawfully, ensuring their rights were protected.

We identified issues with the fire safety systems in place at the home. Fire drills were not taking place and regular checks of equipment had not been carried out in accordance with the home’s policy. There was also outstanding action on the fire risk assessment. We raised this with the current manager who took immediate steps to address the issues.

People told us that they felt safe at the service. We saw that improvements had been made to the way safeguarding issues were recorded, investigated and reported and staff had received recent safeguarding training.

Staff were recruited safely; all the correct checks and documentation was in place. This included agency staff used by the home.

The home was clean and tidy and actions raised by a recent Infection Control Audit had been put in place.

Staff had received a comprehensive programme of training and had recently received supervision. A plan for ongoing supervision had been put in place to support staff in their work.

People enjoyed the food served at the home and we saw that a choice of meals was offered; kitchen staff were knowledgeable about people’s nutritional needs and preferences and had been trained appropriately.

People had access to a range of healthcare professionals; the service supported people to meet their holistic healthcare needs.

People and their relatives told us that the staff were caring and promoted their dignity and privacy. Interactions we observed between people and staff were mainly positive and people could exercise a choice over their daily routines.

Information on advocacy was available to people and their relatives and feedback on the end of life care from relatives was good.

A system had been put in place by the current manager for reporting and responding to complaints. We saw that all the relevant documentation was available and complete.