This inspection was carried out on 12 October 2017. Wykeham House is a purpose built care home providing nursing and residential care for up to 76 older people, some of whom are living with dementia. The service is separated into four units; two of the units are for people living with early to late dementia and the other two units are for people with greater nursing needs. At the time of our inspection there were 49 people were living at the service.

On this inspection we were following up on concerns that related to a lack of governance, a lack of supervision of staff, a lack of safe care and treatment, people not always being treated with dignity and respect, a lack of meaningful activities and that complaints were not always investigated. We found significant improvements in all of these areas.

Although there was no registered manager in post a new manager had started at the service and had submitted their applications. A registered manager is a person who has registered with the Care Quality Commission (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.

There were appropriate plans in place to ensure that risks to people were managed. Staff understood what to do to minimise risks in relation to people. Emergency evacuation plans were in place and staff understood what to do if an emergency occurred at the service. Where people had accidents and incidents actions were taken to reduce this risk of them reoccurring.

People told us that they felt safe with staff. Staff had received training in safeguarding people from abuse and they had a good knowledge of what they needed to do if they suspected abuse. Staff at the service had robust recruitment undertaken before they started work.

Although people and staff told us at times there were not enough staff this did not impact on care. The Provider assured us that staff levels were going to be maintained to ensure that people’s needs were met in a safe way. Other people and staff felt there were sufficient staff levels in other areas of the service and we confirmed this with our observations.

People understood the reason and purpose of the medicines they were given. The management of medicines was safe by staff who had the appropriate training.

People and relatives felt that staff were competent in their role. Staff received appropriate training and supervision and staff felt supported.

People’s rights were protected because staff acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Appropriate assessments had been completed where people’s capacity was in doubt and applications to the Local Authority were submitted if people were being restricted in their best interest.

People enjoyed the meals at the service and said they had sufficient choices. People’s health care needs were monitored included weight loss and any changes in their health. People had access to appropriate health care professionals where needed.

People and their relatives told us that staff were kind and caring and treated people in respectful and dignified way. This was confirmed through our observations. People had choices around their care and felt involved in their care planning. Relatives and friends were welcomed at the service to visit people. People and their relatives were given support when making decisions about their preferences for end of life care.

People had a range of activities that they could be involved in and trips out were arranged for people. People that were socially isolated in their rooms had one to one activities arranged for them.

Care plans were detailed and included specific guidance for staff to ensure that people’s needs were met. Staff communicated changes to each other about any changes in people’s care.

This inspection was carried out on 6 April 2017. Wykeham House is a purpose built care home providing nursing and residential care for up to 76 older people, some of whom are living with dementia. The service is separated into four units; two of the units are for people living with early to late dementia and the other two units are for people with greater nursing needs. At the time of our inspection there were 53 people living at the service.

There was a registered manager in post and present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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.

At our inspection in August 2016 we had identified a breach of regulation in relation to person centred care, dignity and respect, consent, safe care and treatment, the competency skills of staff, acting on complaints and lack of good governance. We issued warning notices in relation to the lack of competencies of staff and governance. The provider sent us an action plan in October 2016 that stated that they would meet these regulations by the 30 November 2016. However, we found at this inspection a systematic failure to identify and put right the shortcomings in the service as we found the warning notices had not been fully met and we identified further breaches of regulation.

People were not always protected from the risks of unsafe care. Risks to people had not always been identified and acted upon including risks around behaviours, lack of nutrition and bed rails. However there were other aspects to the risks to people that were addressed by staff including environmental risks. Personal evacuation plans were in place for every person and staff had received fire safety training.

Staff were not always suitably qualified, skilled and experienced to meet people's needs. This was particularly in relation to new staff and staff that did not have knowledge of people’s needs. Staff however had received appropriate support that promoted their professional development and had regular supervisions with their line manager.

There were times where staff did not treat people with dignity and respect and choices were not always offered. However people's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. We did see times where staff were kind and attentive to people’s needs.

People did not always have access to activities that were important and relevant to them.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided.

Complaints were not always investigated with the necessary action taken.

Although the provider actively sought, encouraged and supported people's involvement this was not always used to improve the quality of care. Although staff were encouraged to contribute to the improvement of the service staff did not always feel listened to or valued.

People’s records were not always up to date or accurate. People’s care plans did not always have the most up to date care needs recorded and food and fluid charts were not always completed accurately.

People told us that they felt safe and we found staff understood how to protect people from the risks of abuse. Recruitment practices were safe and relevant checks had been completed before staff started work. We found that there had been improvements made to staffing levels and there was now sufficient numbers of care staff deployed at the service to meet people's needs.

Staff understood how to support people to make decisions. Where people had restrictions placed on them there was evidence that these were done in their best interests. Staff had a clear understanding of Deprivation o

This inspection was carried out on the 26 and 30 August 2016. Wykeham House is a purpose built care home providing nursing and residential care for up to 76 older people, some of whom are living with dementia. The service is separated into four units; two of the units are for people living with early to late dementia and the other two units are for people with greater nursing needs. At the time of our inspection there were 74 people living at the service.

There was a registered manager in post and present on both days of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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.

There was insufficient numbers of care staff deployed at the service to meet people's needs. This resulted in people waiting for their care and for their meals.

Fire evacuation arrangements for people were not in place and there were risks to people in the environment that were not being managed well. However there were other aspects of the risks to people that were addressed by staff.

Medicines were not managed safely and there was a risk that people did not receive their medicines when they needed. Staff competencies with medicines was not being assessed.

Staff had not received appropriate clinical supervision that ensured the most appropriate clinical care was provided. However other staff were having one to one support with their manager that promoted their development. We found the staff team were knowledgeable about people's care needs. People told us they felt supported and staff knew what they were doing.

Staff were not knowledgeable about current guidance to support people to make decisions. Where people had restrictions placed on them there was not always evidence that these were done in their best interests or necessary. Staff did not always have a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) or their responsibilities in respect of this.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. However people were not always given choices of meals. The recording of what people ate and drank was not always being undertaken. People were supported to have access to healthcare services and were involved in the regular monitoring of their health.

There were times where staff did not treat people with kindness, dignity and respect. However people's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy was respected and promoted when personal care was undertaken.

People's needs were assessed when they entered the service and on a continuous basis to reflect changes in their needs. However care plans were not always updated with the changes to care.

Concerns and complaints were not always responded to appropriately and people did not always feel listened to.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided and to make improvements as a result. There were continued breaches from the previous inspection around the competencies of staff and people’s care plans not being updated that had still not been addressed.

Although the provider actively sought, encouraged and supported people's involvement this was not always used to improve the quality of care. People’s records were not always up to date or accurate.

People told us they were safe at the service. Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from harm.

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People's needs were assessed and care and treatment was planned and delivered in line with individual care plans.

People told us they liked living in the home and the staff were kind and caring. We saw staff spoke to people and explained what they were going to do prior to undertaking a procedure.

Relatives told us they were satisfied with the home and the care their relatives received. They said the home seemed welcoming when they were shown around. A relative said they felt the home met their relative's needs, but they had nothing to compare it to as it was their first experience of a nursing home.

We saw the home was clean and hygienic. Individual bedrooms were comfortable and communal areas were well decorated and nicely furnished.

Meals were well presented and we saw a high staff ratio available on Memory Lane to provide help and support for people who required this support during lunch.

Staff told us they liked working in the home and said they had the appropriate training and support to undertake their roles.

We saw there were appropriate systems in place to monitor the quality of service provision.

During our inspection we spoke with seven people in the privacy of their bedrooms to gain their views on the level of care and support they received. We also spent time talking with three relatives. All were positive about the staff and the quality of care they received. One person told us, “They (staff) look after me tremendously well…very kind.” One relative said, “I can’t fault it.”

We asked people if they would recommend Wykeham House to others, they told us they would. One person who lived in the service said, “Oh definitely.” A relative told us, “Oh yes dear, its got a very good reputation.”

People said that staff gave them their medication when they needed it, and confirmed that staff had never missed a dose.

People told us if they had any concerns, that they felt comfortable to tell staff. One person told us they, “Could talk to anyone, they (staff) would all listen to you, whatever is wrong they would put it right.”

Relatives shared with us that they had no concerns over the standard of hygiene and cleanliness. One relative said staff kept it, “Clean and tidy.” Another relative who described the standard of cleanliness as, “Very good,” said, "It always looks clean and tidy.”

People told us that they were happy living at Wykeham House and that the staff were caring and kind.

They told us that they were very satisfied with the facilities in the home and that they all like their rooms.

People told us that their rooms are cleaned every day and that everywhere always looked clean.

We had good comments regarding the standard of catering and we were told that people have three cooked meals every day, with a good choice of courses at each meal.

People felt that there was sufficient staff employed in the home to meet their needs.

People told us that there is plenty to do and that they enjoyed going out in the mini bus particularly to the garden centre at Christmas time and during the summer.

Relatives said they were satisfied with the standard of care provided and were kept informed of any changes.

We carried out an unannounced comprehensive inspection of this service on the 14 and 15 October 2014. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to staffing, people’s consent to care and treatment, requirements relating to the recruitment of staff, the cleanliness of the service, respecting and involving people and the care provided to people.

We undertook this inspection to check that they had followed their action plan and to confirm that they have now met legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Wykeham House on our website at www.cqc.org.uk.

On the day of our visit there was a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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.

Clinical staff were not able to tell us the most appropriate action to take in medical emergencies.

We spoke to the registered manager about this. Who said they would arrange for immediate training to ensure the staff knew what they should do in the event of an emergency.

There were some instances where staff did not effectively care for people. One relative said; “We have to ask the nurses to call the doctor for them (family member), I’m not sure if they always recognise the signs.” We were told by the registered manager that they recognised that staff did not always pick up on the signs of people being unwell and were taking steps to address it.

We saw examples where staff did provide effective care. One relative told us “Staff noticed that (their family members) feet were becoming inflamed and immediately called in the doctor.” One health care professional told us “They do a lot of in-house training here; I’m not worried about the clinical aspects of the care here.”

Not everyone had positive experiences in relation to meal times. People who were being supported to eat were hurried. There were no conversations between staff and people on one unit and some other people were not encouraged to eat their meals.

However people said that they enjoyed the food at the service. Comments included “The food is very good, I’ve suggested salmon and salad and it was lovely” and “They (staff) feed you well, the food tastes nice.”

There were enough staff deployed around the service to safely meet the needs of people. People had varying views on the levels of staff. One person told us “Staff are quick at answering call bells” whilst a visitor said “There are often no staff in the lounge.”

All new staff underwent a recruitment process before they started Where any gaps in records had been identified by us, for example evidence that previous convictions check had been obtained, these had been addressed by the registered manager. This ensured that only suitable people were recruited.

Staff were following best practice in relation to infection control and we found that all areas of the service was now clean.

Staff had knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. There was a safeguarding policy and staff received safeguarding training. Risk assessments were undertaken and reviewed every month or sooner if required.

Accidents and incidents with people were recorded with information of what happened and what actions were taken. In the event of an emergency such as a fire; each person had a personal evacuation plan and at each handover staff discussed these to make sure they reflected people’s current level of needs.

We observed that staff had developed very positive relationships with the people who used the service. Staff were kind and respectful, we saw that they were aware of how to respect people’s privacy and dignity. People told us that they made their own choices and decisions, which were respected by staff.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and the home

complied with these requirements.

The systems for the management of medicines were followed by staff and we found that people received their medicines safely.

People had good access to health and social care professionals when required. The local GP visited the service weekly and people were supported to see their GP at the local practice if they wanted to

The premises had been built to meet the needs of people living with dementia and various physical impairments.

Regular reviews were held and people were supported to attend appointments with various health and social care professionals, to ensure they received treatment and support as required.

Staff meetings took place on a regular basis. Minutes were taken and any actions required were recorded and acted on. People’s feedback was sought and used to improve the care. People knew how to make a complaint and complaints were managed in accordance with the provider’s complaints policy.

The registered manager and provider regularly assessed and monitored the quality of care to ensure standards were met and maintained. The registered manager understood the requirements of their registration with the commission.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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