mrs marjorie burnell and mrs jaqueline amanda mcdonald ... · mrs marjorie burnell and mrs...

1 Urmston Manor RH Inspection report 15 August 2017

Mrs Marjorie Burnell and Mrs Jaqueline Amanda McDonald-Downie

Urmston Manor RHInspection report

61-63 Church RoadUrmstonManchesterGreater ManchesterM41 9EJ

Tel: 01617476510Website: www.urmstonmanor.co.uk

Date of inspection visit:26 June 201727 June 2017

Date of publication:15 August 2017

Overall rating for this service Inadequate

Is the service safe? Inadequate

Is the service effective? Requires Improvement

Is the service caring? Requires Improvement

Is the service responsive? Requires Improvement

Is the service well-led? Inadequate

Ratings


Summary of findings

Overall summary

This inspection took place on 26 and 27 June 2017 and was unannounced.

We last inspected Urmston Manor on 24 August 2016 when we rated the home Requires Improvement overall. At that inspection new found breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, person centred care, recruitment, good governance and staff supervision and training. We issued three warning notices to the provider and former registered manager to formally inform them of the reasons they were in breach of the regulations and to tell them improvements must be made.

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

You can see what action we have told the provider to take at the back of the full version of this report. We arecurrently considering our options in relation to enforcement and will update this section once any enforcement action has concluded. As a result of our concerns, we requested and received an urgent action plan from the provider that detailed the immediate actions they would take ensure the safety of people living at the home.

We have made two recommendations. We have recommended the provider reviews their processes in relation to handling hazardous waste and that the provider reviews good practice guidance in relation to developing dementia friendly environments.

Urmston Manor RH is a residential care home registered to provide care to up to 24 older people, including people who may be living with dementia. The home has been operating since 1984. Accommodation is based over three floors and there is a passenger lift between the floors. At the time of our inspection there were 18 people living at the home.

There was not a registered manager in post at the time of the inspection. 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. The former registered manager who is also one of the partners of partnership who run Urmston Manor left the role of registered manager in March 2017. The main partner told us the former registered manager no longer had any active involvement in the management of the home. There was an interim manager in post who was overseeing the day to day management of the service. They told us they did not intend to register to managethe service, but would stay in post until a new registered manager could be recruited.


Prior to our inspection the fire service made us aware of shortfalls they had found in relation to fire safety at the premises. The fire service found that concerns identified in a fire risk assessment completed in 2012 by a third party risk assessor had not been acted upon by the provider. These shortfalls were unknown to the current manager and main partner until the risk assessment was located when the fire service was recently called out to a small suspected fire in the home. The manager had taken a number of immediate steps to help reduce risks including increasing staffing at night and stopping any new admissions to the home whilst works were underway to make improvements to the structure of the building. The required works were agreed to be completed by September 2017.

During this inspection, we found other issues effecting the safety of the environment. The provider did not have a risk assessment in relation to legionella, and was not undertaking routine checks to help control the risks of legionella. Legionella is a type of bacteria that can develop in water systems and cause Legionnaire'sdisease that can be dangerous, particularly to more vulnerable people such as older adults. There was also no call bell system in place, and instead an intercom system was used. This system was not effective and also had a potential impact on people's privacy.

Staff acted upon concerns to people's health and wellbeing. However, the measures in place to reduce risks were not always clearly documented in risk assessments. There were no recorded checks of equipment suchas bedrails taking place, and in one instance the use of bed rails had not been risk assessed. This would increase the risk that bedrails were not safe or suitable for use and that defects would not be recognised.

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 obtaining the medicine from the pharmacy. We also found accurate information on allergies was not always in place, and there was no evidence that staff had contacted a GP or pharmacist for advice when a person had repeatedly declined to take their medicines.

During our inspection we saw staff were attentive and responded to people who might need assistance in a timely way. There were sufficient numbers of staff on duty to provide people with the support they needed. We observed positive and caring interactions between staff and people living at the home. People were comfortable in the presence of staff and to request help if they needed it.

We saw limited activities taking place during the inspection and received mixed reports from people as to whether they had enough to keep them occupied. People told us trips out had increased since the new manager had started, although the manager acknowledged further work was required to develop the provision of activities.

The manager had introduced a new electronic care management system. All care plans had been transferred to this new system, which help with the organisation of records. Whilst staff were aware of people's care needs, preferences and social histories, we found this was recorded to variable degrees of detail in the electronic care records. We also found records were not always up to date, and did not always reflect the care the person was currently receiving.

We received positive feedback from people about the food provided. Kitchen staff were aware of people's dietary requirements, and they told us they devised menus based on what people had previously enjoyed.

The manager placed emphasis on the importance of supporting and training the staff team to build competence. Staff told us training had improved since the new manager had taken up post, although there were some continued gaps in training provision. The manager was providing regular supervision to staff,


and was enthusiastic about ensuring supervision was used as an effective tool to drive long-term improvements in the service.

The manager listened to both staff and people using the service and had acted on feedback they provided. Staff told us the manager had introduced quality training, supervision and had bought new moving and handling equipment they needed. The manager had arranged for the library to provide large print books in response to feedback from people using the service, and had supported a person to move bedrooms as a result of their request.

We received consistently positive feedback from people using the service and staff for the current manager. The manager had a clear vision for the continued improvements they wanted to see in the service. They alsotalked about a range of improvements they had already put in place, and this was reflected in large improvements in local authority assessments of the service since they had been in post.

Despite these improvements, we identified on-going breaches of the regulations. There was no effective monitoring of the quality or safety of the service in place, and no routine audits were being undertaken at the time of the inspection. This increased the risk that staff would not identify or be able to act on any areas where improvements were required. The manager told us their focus had been on the immediate issues such as fire safety and staff supervision, and that audits would be introduced in the near future. The providerdid not have effective oversight of the service, which had resulted in them failing to take effective action in relation to areas of known risk.The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varyingthe terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be nomore than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.


The five questions we ask about services and what we found

We always ask the following five questions of services.

Is the service safe? Inadequate

The service was not safe.

The provider had not acted promptly to address serious concerns in relation to fire safety.

A recently recruited member of staff had been allowed to start work without a criminal records check in place.

The provider was not ensuring reasonable steps were taken to ensure the safety of the premises, including in relation to controlling risks of legionella

Is the service effective? Requires Improvement

The service was not consistently effective.

There was no call bell system. An intercom system that continually monitored sound from people's rooms was used instead. The system did not help staff respect people's privacy and was not effective.

We received positive feedback about the food provided. Kitchen staff were aware of people's dietary requirements.

The manager placed high importance on quality supervision and training for staff. However, there continued to be gaps in training provision.

Is the service caring? Requires Improvement

The service was not consistently caring.

Staff knew people well and people told us they were treated withdignity and respect.

The intercom system in use did not help staff respect people's privacy. Some en-suites were separated from the bedrooms by only a curtain.

Staff were aware of the importance of supporting people's independence. People we spoke with confirmed staff


encouraged them to remain as independent as possible.

Is the service responsive? Requires Improvement

The service was not consistently responsive.

Staff were aware of people's care needs and preferences, although these were not consistently recorded in the new format electronic care plans.

People told us the provision of activities had improved. However,the home did not provide staff with any dedicated time to support activities and there was limited activity and stimulation during the inspection.

People told us they had not raised any complaints but would be confident to do so if required. The manager was able to demonstrate how they had listened to and acted upon feedback from people using the service.

Is the service well-led? Inadequate

The service was not well-led.

There were no processes in place at the time of the inspection to help monitor and improve the quality and safety of the service.

The provider did not have adequate oversight of the service and had not acted in relation to known risks in relation to fire safety.

We received consistently positive feedback from people using the service, staff and other professionals in relation to improvements being made by the current manager.


Urmston Manor RHDetailed findings

Background to this inspectionWe carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 26 and 27 June 2017 and the first day of the inspection was unannounced. Theinspection team consisted of one adult social care inspector, and a specialist advisor. The specialist advisor had previous experience of running a registered service and more recent experience relating to overseeing health and safety within a hospital setting.

Prior to the inspection we reviewed information we held about the service. This included any notifications the provider had sent to us in relation to safeguarding, serious injuries and other significant events that providers are required to inform us about. Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Due to technical problems a PIR was not available and we took this into account when we inspected the service and made the judgements in this report.

We had not received any feedback about the service via our website, email or through our contact centre since our last inspection. Prior to the inspection we contacted Trafford Healthwatch, the local authority quality and contracts team and the clinical commissioning group (CCG) medicines reviewer for feedback on the service. We used this feedback to help plan the inspection and have reported any significant findings in the main body of this report.

During the inspection we spoke with four people who were living at the home and one person's relative who was visiting on the day of the inspection. We spoke with one visiting professional, four care staff, the cook, the acting manager and the main partner of the business. We reviewed records relating to the care people were receiving including four people's care plans and risk assessments, daily records, accident records and four medication administration records (MARs). We also looked at records relating to the management of a residential care service including training records, staff supervision records, records of servicing and


maintenance, policies and procedures and staff recruitment records.

We carried out observations around the service, including staff interaction and support in communal areas. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.


Is the service safe?

Our findings At our last inspection in August 2016 we found there were gaps in checks required to help ensure staff employed were of suitable character for the role in which they were employed. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found sufficient improvements had not been sustained, and the provider remained in breach of this regulation.

The manager had asked a member of administrative staff to start scanning in staff recruitment documents. This would help provide an easily accessible record to check staff had the required checks in place. However, this process had not been completed at the time of the inspection. The personnel files we reviewed contained evidence that required checks including references from previous employers and proof of identity had been obtained. However, the personnel records that had not yet been scanned in were disorganised and this information was hard to locate. The provider had not yet carried out an audit of all staff recruitment records to provide reassurances that the required checks were in place.

The manager was aware, and informed us, that a recently recruited member of staff had started work without a disclosure and barring service (DBS) check in place. DBS checks provide evidence of previous convictions, and whether an applicant is barred from working with vulnerable adults or children. The manager told us they had agreed for the staff member to start work on the understanding that they would provide a copy of the DBS certificate from their previous workplace, but that they had been unable to find it. The manager acknowledged that a DBS check should have been completed prior to the member of staff starting work. By the second day of the inspection the manager had taken action to receive reassurances that the person's previous DBS was satisfactory. They also showed us evidence that they had requested a new DBS check along with an adult first check. An adult first check provides information on whether a person is barred from working with vulnerable people, and can be used to allow an employee to work without a DBS check, whilst supervised, in exceptional circumstances.

The provider had not consistently followed safe recruitment procedures. This was an ongoing breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection in August 2016 we identified concerns in relation to the safety of the premises. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found there were ongoing issues in relation to the safety of the premises, which were an ongoing breach of this regulation.

Prior to the inspection the fire service informed CQC that there had been a small electrical fire at the home. As a result the fire service had attended the home and carried out further checks in relation to fire safety at the premises. This had revealed that a fire risk assessment conducted by a third party contractor in 2012 hadfound significant improvements were required to adequately control fire risks at the home. There was no evidence that the former registered manager had acted on the findings of this risk assessment, and these risks had not been addressed.

Inadequate


When these concerns became apparent, the current manager took a number of immediate actions to help reduce risks in relation to fire safety, including increasing staffing levels to three at night, voluntarily suspending any new admissions to the home, having a regular recorded fire watch and refreshing staff training in fire safety. The fire service indicated they were satisfied that these measures helped adequately control potential risks as an interim measure whilst more substantial works required to the fabric of the building were completed. The completion date for all the required works agreed with the fire service was 19 September 2017. The Care Quality Commission (CQC) will continue to work closely with the fire service and local authority to monitor that adequate progress is made in relation to the fire safety improvements at the home.

During the inspection we saw evidence that three staff remained on duty at night, and that staff completed frequent fire checks. We also saw more significant works to the home were underway, including an electrical re-wire. The manager told us works to the structure of the building were due to start imminently. There was evidence that staff had received fire training from the manager. However, responses from two staff memberswe spoke with about the procedure they would follow in the event of a fire were not consistent. We also found the fire evacuation plans were not displayed or readily accessible, and there was no recorded evidence to indicate people's support needs as indicated in their personal emergency evacuation plans (PEEPs) had been considered as part of the evacuation strategy. This was of concern given the recently raised concerns in relation to fire safety. We also raised concerns that there was no clear plan in place in relation to the significant works due to take place, or evidence that potential risks arising from the completion of this work had been considered. For example, there was no risk assessment in relation to potential hazards caused by on-going building works or having contractors in the home. After the inspectionthe manager sent us a copy of the risk assessment they had produced, and told us works had been temporarily halted whilst the risk assessment had been completed.

We found two windows on the first floor of the home that led out to areas with flat roofs were not adequately restricted. This would pose a potential risk that people may access these areas and fall. We raised this with the manager who actioned the required works to make the windows safe during the inspection. We saw a radiator in the hallway of the home was not covered, which may present a risk of burning if someone were to fall against it. The manager informed us they had identified two additional radiators that were not covered and told us they had all been turned off until covers were in place.

Legionnaires' disease is a potentially fatal form of pneumonia caused by the legionella bacteria that can develop in water systems. We found the home was not taking reasonable measures to control the risk of legionella developing in the water system. There was no risk assessment in relation to legionella, and there was no evidence on any recent tests to confirm whether legionella bacteria was present in the water system.A common method of helping prevent legionella developing is by ensuring hot and cold water temperaturesare maintained within recommended limits. There was no evidence that any monitoring of the water temperatures had taken place. This meant the provider was not taking reasonable steps to help protect people from the risk of contracting Legionnaire's. We raised our concerns with the manager who purchased a water test kit, and asked for a competent person to undertake a risk assessment for the water system.

We found shortfalls in the assessment of risks relating to the use of the premises. The manager had recently put in place an emergency plan that provided some guidance for staff to follow in the event that the home had to be evacuated. The plan provided details of other nearby homes where agreements were in place to help provide temporary accommodation and support. However neither this plan, nor the previous plan contained details as to procedures that would be followed in the event of a high rate of staff absence and there were no recorded contact details for the providers of the home's utilities such as gas and electricity.


We looked at what steps the provider took to ensure equipment such as bedrails were safe for people to use.We saw there was a template to assess whether bedrails were safe and suitable for people to use. However, this had not been completed for one person's records we reviewed. There was also no regular recorded check that bedrails remained in a safe condition and that there were no unsafe gaps or sharp edges for example. Staff told us they had been briefed by the manager on how to assess whether bed rails were in a safe condition, and told us they did this on a regular basis.

The provider had not taken reasonable steps to ensure the premises and equipment were safe. This was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff had assessed potential risks to people's health and wellbeing in relation to a range of areas. This included risk assessments in relation to malnutrition, pressure sores, swallowing difficulties, mobility and falls. We saw staff had reviewed risk assessments on a regular monthly basis. The manager told us they were working with staff to improve the way they reviewed risk assessments to ensure this was not just done on a monthly basis, but also as required as any change in a person's needs became evident.

We saw staff followed plans in place to reduce potential risks to people. For example, we saw staff prepared food in accordance with guidance in people's care files, and carried out regular recorded observations to help reduce falls risk where care plans indicated this was required. However, we found risk assessments and care plans did not always accurately reflect the measures that staff were following to help keep people safe. For example, staff told us one person was being given thickened fluids when required to help reduce their risk of choking. Staff told us this was on the advice of a GP. However, this was not recorded in the care plan or anywhere in the care notes. Another person had a pressure sensor in place on their bed, and twenty minute observations in place to help reduce the risk of them falling. The risk assessment did not detail these measures, and there was only reference to the observations and not the pressure sensor in the rest of the care plan. This would increase the risk that staff would not be aware of, and would not follow these risk reduction measures.

The failure to keep accurate records in relation to people's care and to carry out adequate assessment of risks was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection in August 2016 we found two bedroom carpets had a malodour and considered this to be a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to preventing and controlling risks of infection. At this inspection we found that this issue had been resolved.

We found the home was clean and tidy, and did not find any malodours around the home. Personal protective equipment (PPE) such as gloves and aprons were readily available, and staff we spoke with were aware of how to maintain good hand hygiene. An external infection control audit was completed by Trafford's infection control lead in February 2017, which identified a number of areas requiring action. We checked a number of these action points and found improvements had been made, including the installation of soap and paper hand-towel dispensers. We checked the service contract the provider had in place for the removal of potentially hazardous waste. This referred to the use of a yellow bin for collections. However, we found there was no yellow bin outside the home, and waste in 'yellow bags' was kept in a box.

We recommend the provider reviews the arrangements for storage of clinical waste.


Medicines were stored securely in a locked medicines trolley or a lockable container in the kitchen fridge. Standard domestic refrigerators are not ideal for the storage of medicines. Medicines that require refrigeration should be stored at a consistent temperature of between two and eight degrees Celsius. The opening and closing of a domestic refrigerator can cause significant temperature fluctuations. We saw staff regularly monitored the temperature of the fridge, and staff told us they were currently looking to get a separate dedicated medicines fridge. Controlled drugs are certain medicines that due to their risks of misuseor abuse, are subject to more stringent legal requirements in relation to their storage, admiration and destruction. We saw controlled drugs were stored in a separate safe, although this did not appear to be bolted to the wall as required. Staff told us they did not think the safe met required standards and told us the home was currently sourcing a new controlled drugs cabinet. We saw all controlled drugs had been signed by two staff when administered or booked in, and a spot check of stocks did not find any discrepancies.

We saw every person had a profile sheet in the medicines folder, which included a recent photo and details of any allergies. We found one person's profile sheet stated they did not have any allergies, whilst the pharmacy produced medication administration record (MAR) indicated they had allergies to two different medicines. The manager told us the information on the profile sheets had been taken from people's old carerecords, and that they were requesting up to date medical profiles from everyone's GPs to address such potential issues. There was a risk in relation to this discrepancy that in an emergency, professionals may not receive accurate information about people's care needs.

Staff kept accurate records of the medicines they administered. However, we found known concerns in relation to people's medicines were not always acted upon promptly. For example, one person had run out of an evening dose of pain relief due to a change in their prescription, and had not received their prescribed evening dose for a period of five days. Staff had recorded the medicine was unavailable, but could not provide evidence that actions had been taken to obtain the missing medicine. We spoke with this person and they did not tell staff or us that they had experienced any increase in pain as a result of this error. A second person had declined to take their medicines for four days, and there was no evidence that a GP or other health professional had been consulted as to any potential adverse effects. The care plan stated staff should consider consulting a GP if this person repeatedly declined their medicines, although this was not specific as to the number of times the person would have to decline their medicines before such action was taken. Staff told us they would speak with the GP if the person refused their medicines again.

We found there were no plans, or 'when required' (PRN) protocols in place to inform staff when and how they should administer people medicines that were not required routinely. Whilst staff we spoke with understood what people's medicines were required for, this would increase the risk that people would not receive medicines as they needed them consistently. The manager told us they were in the process of developing PRN protocols and provided a copy of the template that they had developed.

These shortfalls in the safe management of medicines were a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

People told us they felt safe living at the home. One person told us; "Yes I feel safe, I keep my door open." Another person said; "I'm safe, they lock the doors at night." We saw staff were attentive and followed safe procedures when supporting people with equipment such as hoists. Staff were able to tell us how they would identify potential signs of abuse or neglect. Staff said they would feel confident raising any concerns with the manager, and were aware of external contacts they could approach if they felt unable to raise concerns within their normal management chain. We saw the manager had made appropriate referrals to the local authority safeguarding team, and had carried out further enquiries in relation to any allegations as


was necessary.

People living at the home told us they felt there were sufficient staff on duty to meet their needs. They told us they would not have to wait for extended periods to receive support when they required it. During the inspection, we observed there were always staff located in or close to communal areas, and people receivedsupport promptly when they required it.

Staff told us they found there were sufficient staff available to allow them to complete their duties. This was particularly the case given staffing at night had been increased, and as the home was not at maximum occupancy. Rotas showed, and staff confirmed that shifts were always covered either by existing staff, or if required, agency staff. The manager told us they had not used a dependency tool to help them determine staffing requirements, but that they would alter staffing levels based on consideration of people's needs andfeedback from staff.


Is the service effective?

Our findings At our last inspection in August 2016 we found staff had not received regular supervision, and there were gaps in the provision of training. This was found to be a breach of Regulation 18(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although improvements had been made in this area, we identified an on-going breach of this regulation as staff training was still in the process of being completed.

The manager placed emphasis on the importance of providing staff with the supervision and support they needed to help them develop, and to drive sustainable improvements within the service. The manager had introduced supervision contracts, which set out an agreement and expectations in relation to supervision between the staff member and supervisor. Staff told us, and records confirmed that supervisions took place on a regular basis. Staff told us they found supervision useful, and we saw discussion took place in relation to topics such as safeguarding, health and safety, training and any employment issues.

People told us they felt confident that the staff supporting them had the necessary skills and competence to meet their needs. Staff told us the training they received had improved, and the manager talked about wanting to ensure staff received training that was high quality and meaningful. One staff member told us; "I think the training's good, and you get tested on your understanding." The manager showed us examples of instances where they had asked staff to write reflective accounts of what they had learnt in training. This would help staff consolidate their learning, enable the manager to check their understanding and allow them to identify any further training needs. The manager showed us how they used the electronic care system to help monitor staff training. Required training courses were identified by the manager on the basis of staff members' roles, responsibilities and specific learning needs. For example, the manager discussed that they had identified concerns with how staff were effectively supporting people's continence, and we saw they had arranged training for staff in this area.

The manager told us they were still working towards ensuring all staff had up to date training, and we saw there were some gaps in training in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards, dementia and safeguarding training. Eleven of the 18 staff were still required to complete training in the Mental Capacity Act/Deprivation of Liberty Safeguards training, eight staff required dementia training, and six staff were still required to complete safeguarding training. However, we did not identify any concerns with staff practice in these areas. No staff had current first aid training, which was of concern given staff were assessing people following minor incidents and making decisions about whether further medical attention was required. The manager told us they were aware of this shortfall and that training had been booked for all staff between 18 July 2017 and 07 August 2017. They told us staff had previously only received basic life support training, and they felt more in-depth first aid training was required, and they had therefore cancelled the previously arranged training. The manager also acknowledged that few of the night staff had received medicines training. They told us that no-one required any routine or emergency medicines during the night, but they also felt this arrangement required review as at that time trained on-call staff would be required to attend the service if anyone required any 'when required' medicines such as pain relief.

Requires Improvement


The continued gaps in the provision of training was a continued breach of Regulation 18(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The care home is located in an older building that used to be two separate homes. The building has historically undergone a variety of alterations in adapting it to become a care home. The provider had stopped using one of the ground floor bedrooms after concerns were raised about its' use from a fire safety perspective, and due to it only having ventilation into the lounge area. The manager also made us aware that two of the ground floor bedrooms were very small, and they were concerned that equipment such as hoists may not fit in the rooms if required.

We recommend the provider reviews relevant guidance and seeks advice in relation to relevant building regulations, and considers the suitability of these rooms during any future potential developments and in relation to the occupancy of the home..

We did not notice any adaptations to the environment to make it more accessible to people living with dementia. For example, there was no pictorial or directional signage, use of contrasting colours on grab rails, and no use of memory boxes, photos or other ways to help people identify their rooms. Such adaptations would support people to remain independent for as long as possible. There were heavily patterned floor coverings throughout the home that can cause potential confusion to some people with visual impairments or who are living with dementia .

We recommend the provider reviews good practice guidance on developing dementia friendly environments and considers alterations to the environment in consultation with people living at the home.

There was no call-bell system in place at the home. The provider used an old intercom system that relayed sound from listening devices located in most rooms of the house, including the bathrooms, toilets and people's bedrooms, to a speaker located in a small office. From our observations of how this system worked we were concerned that this equipment would not be effective at allowing people to call for assistance when they required it. This was because there were not always staff present in the area where the speaker was located, so they may not hear if someone required assistance. The provider also told us the system was turned off in the day for privacy reasons, which would make it redundant if people needed assistance at this time. We also raised concerns that the system was intrusive, and did not support staff to respect people's privacy. The manager and staff agreed with these concerns, and the manager told us they had raised these concerns with the provider.

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as the intercom system was not adequate to meet people's needs, and compromised their privacy andconfidentiality.

We received positive feedback from people about the food provided. People told us they were given a choice of meal, and could request an alternative if they didn't like what the cook had prepared. Comments included; "The food is fantastic. Staff go round and take your choice before each meal," "The food is brilliant.The corned beef hash I love, or salads. I get plenty to eat and drink," and; "Dad eats well and enjoys the food."

We spoke with the cook who was aware of people's dietary requirements as detailed in their care plans. They told us there were no set menus, but meal choices were determined based on what people had enjoyed. Records showed people's weights and food or fluid intake had been monitored where a need had been identified. We saw staff had sought advice from other health professionals such as a GP or dietician


when they were concerned about a person's health. People using the service told us they were confident that staff would get in contact with their GP if they experienced any change in their health. We spoke briefly with a district nurse who was visiting the service. They told us they had no concerns in relation to the service,and that staff contacted them when required and followed any advice given.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the MCA. The authorisation procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met.

The manager had made applications to the supervisory body where they had identified this was required. The manager had introduced a tracking sheet to monitor when applications had been made, whether there were any conditions on the authorisation, and when the authorisations expired. This showed that one authorised DoLS had expired nine days prior to a re-application being made. This meant there was a risk that this person would be subject to restrictive practices that had not been lawfully authorised.

Staff we spoke with understood the principles of the MCA and DoLS. They were able to tell us people who had an authorised DoLS in place, and what this meant in relation to their care. Staff understood that people should be supported to make their own decisions whenever possible, and that when people lacked capacitythat any decisions taken should be in their best interests. People we spoke with told us staff always asked for their permission before providing care or support. One person told us; "They [the staff] always say, 'Do you mind?'". We saw people's capacity had been considered as part of their assessments. For example, one person's care file recorded that the person had capacity and that they should be fully involved in all decisions about their care. People or a person with relevant legal powers such as a lasting power of attorneyfor health and welfare had signed to consent to their planned care.


Is the service caring?

Our findings People told us the staff were kind, caring and treated them with respect. One person told us; "The staff makesure you're comfortable." Another person said; "You see things on the TV that make you nervous [in relation to care homes]. We observed that staff were attentive and made time to spend with people whenever possible. For example, we saw a member of staff walking through the lounge. One person living at the home started to wave slightly and look in the direction of the staff member. The staff member noticed this was a sign that the person wanted their attention and we saw they sat talking with this person and holding their hand to provide reassurance for some time following this.

Many of the staff at the home had worked there for a long time, with one staff member we spoke with havingworked at the home for 20 years. This consistency in staffing would help people living at the home and staff get to know each other. We saw people were comfortable in the presence of staff and were happy to requestsupport if they needed it. One person we spoke with pointed out a member of staff and told us; "That lady [staff name] is a load of fun!". Another person said; "I know the staff well. You can't go wrong. You can have a laugh and a joke."

Staff knew people well, and the staff we spoke with were able to tell us about people's preferences, social histories, routines, interests and things that were important to them. All staff we spoke with responded positively when we asked them if they would be happy for a friend or loved one to receive care at Urmston Manor. One staff member told us; "I feel like I have high standards, and treat people as I'd want to be treated."

People told us staff were respectful of their privacy. People said they could go to their rooms when they wanted and that staff would knock before entering. Staff told us they would ensure doors and curtains were shut when providing people support with personal care. We observed two staff members supporting a person using a hoist. We saw they communicated what they were doing clearly to the person and provided reassurances throughout the procedure. The staff were also mindful to respect the person's dignity by helping them rearrange their clothing as they were hoisted.

However, the facilities at the home presented barriers to staff being able to respect people's privacy and dignity as far as would otherwise have been possible. As discussed in the effective section of this report, there was no call-bell system. Instead, an intercom system that continually relayed sound from people's rooms and the toilets to a speaker in an office was used. Whilst there were 'privacy buttons' to mute the sound, in practice it would be impractical to use this routinely, and this system was intrusive. We also saw some bedrooms contained toilets that were separated from the rest of the bedroom by a curtain only, ratherthan by a wall and door due to the limited space available. There were no suitable locks on people's bedroom doors to use should they wish. This would have a potential impact on people's privacy.

People told us staff supported them to be as independent as possible. One person told us; "If you can do it, they let you." Staff said they would support independence by encouraging people to stay mobile where appropriate, and by encouraging them to take responsibility for aspects of their care. For example, one staff



member told us;" I encourage [Person] to walk a little bit, and ask people to help wash their face or brush their teeth. You have to allow time to support people to do things themselves, and they do appreciate it." People we spoke with told us they felt fully involved in decisions made in relation to their care.


Is the service responsive?

Our findings From our discussions with staff, it was apparent they had a good knowledge of people's preferences and care needs. We saw staff offered people routine choices throughout the inspection such as what they had to eat or drink, or where they sat. We received a variable response when we asked people if they were able to make choices such as when they went to bed or got up in the morning. Three people who were not dependent on staff assistance to go to bed told us they could go to bed when they wanted. However, another person we spoke with told us they needed staff to assist them to bed, and said due to the number ofstaff on the night shift that they had to be considerate and go to bed when staff asked them. The manager told us they had identified ingrained 'institutional' practices when they had started working at the home, and had worked with staff to help deliver care in more person centred ways.

At our last inspection in August 2016 we found care plans did not always contain up to date information in relation to the care and support people were receiving. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements had been made to the care planning processes. However, we identified ongoing issues in thisarea.

The current manager had introduced a new electronic care planning and management system to the home. Staff had transferred everyone's care plans to this new electronic format. Whilst this had made care plans easier to follow, we found the system was not yet being fully and effectively used. The manager acknowledged that there was on-going work to ensure staff had recorded all relevant information on the new system.

Information on people's preferences, social histories, likes and dislikes was recorded to variable degrees of detail. Two care plans we reviewed contained no social history and very little information on interests, likes and dislikes and preferences in relation to their care and support. One person's file stated, '[Person] likes to go to bed at [blank].' However, two other care plans we reviewed contained a greater level of detail in relation to those people's preferences. The manager told us some of this information would be contained in people's old care files and needed to be transferred to the new electronic format. The manager had assessed people's preferences when carrying out pre-admission assessments, and our conversations with staff showed they had a good awareness of people's care preferences, interests and social histories.

Care plans contained information about people's support needs in relation to a range of areas including mobility, health and social support needs. Whilst care plans had been regularly reviewed, we found they did not always contain accurate and up to date information. For example, as discussed in the safe section of the report, one person's care plan did not reflect the current use of thickener in their drinks as advised by a GP. Another person's care plan stated they did not take any 'when required' medicines, although their medication records showed they took three different when required medicines. We spoke with a staff member who had worked at the home for over one month who told us they had not yet looked at people's care plans. Some of the care plans we looked at contained generic information that was not personalised to the individual's needs. For example, we saw care plans stated to consider whether mirrors caused the



person distress in relation to dementia care. However, no information was provided on whether mirrors actually did or did not actually cause that person distress.

The lack of up to date, personalised information on people's support needs and preferences would increase the risk of staff providing care that was not person-centred, or was inconsistent or unsafe. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

The home did not employ an activities co-ordinator, and there was no dedicated time provided to staff to support activities. We received a mixed response from people when we asked them if they had enough to keep them occupied. One person told us; "I read and watch the TV. I help fold doilies and tidy things away." A relative we spoke with said; "I wish there was more going on. [My family member] has been out for a meal since the new manager started, and they arrange occasional card games and quizzes." During the inspectionwe saw little in the way of organised activity taking place other than staff setting up a card game on one day of the inspection. Staff and people living at the home told us there had been an increase in trips out arranged by the new manager. The manager told us they recognised the provision of activities was an area that required further attention.

People we spoke with told us they had not raised any complaints, but would feel confident doing so if they felt this was necessary. One person said; "I've not got anything to complaint about. I'd tell a member of staff who would sort any problems." People's care files documented whether the complaints procedure had been explained to the person, and what support they would need to raise a complaint. This would help staff ensure people were aware of how to raise a complaint, or that someone else could raise a complaint on their behalf if they were unable to do this themselves. Complaints were recorded in a complaints book held by the manager. We saw there had been one recorded complaint in the preceding year. Detail was given on the investigation and actions taken in response to the complaint.

The manager had held meetings for people using the service. Minutes from the most recent meeting in February 2017 showed discussions had included activities, complaints, concerns and safeguarding. We saw feedback from people attending the meeting had been sought, and the manager was able to discuss how they had acted on the feedback they received. For example, one person had requested to move bedrooms and this had been done. The manager had also arranged for the library service to visit and provide large print books for people to borrow as a result of feedback provided at the meeting.


Is the service well-led?

Our findings Urmston Manor is run by a partnership. Since our last inspection, the former registered manager, who is alsoone of the partners had de-registered as the manager of the service. The main partner told us the former registered manager no-longer had an active role in the business or management of the service. The provider had brought in a new manager in February 2017 who was also a registered manager at a different care home. The manager told us they would not be applying to register with CQC to manage Urmston Manor, but would continue to support the service until a permanent registered manager had been recruited and inducted. The manager told us the service was actively recruiting for a registered manager with support froma consultancy.

Staff and people living at the home gave consistently positive feedback on changes and improvements implemented by the current manager. Staff told us the manager listened to them and acted on their concerns. For example, staff told us the new manager had promptly purchased new moving and handling equipment when they identified this was required. There had also been improvements in training and supervision and people living at the home spoke about improvements in activities. The manager spoke with us about how they were managing change whilst supporting staff to bring about sustainable long-term improvements. The manager showed us copies of reports produced by the local authority quality team fromtheir monitoring visits. This showed the service had improved from an overall score of 51% and an amber RAG (red, amber, green) in January 2017, to a score of 83% and an overall green RAG rating in April 2017.

Whilst there was evidence of improvements in a range of areas, the manager acknowledged that the focus had been on addressing the most immediate concerns in relation to the safety and quality of the service. This including work on addressing fire safety concerns, training and supervision of staff. This meant in other areas there was limited evidence of improvements, resulting in the on-going breaches of regulations we have identified.

At our last inspection in August 2016 we found there were gaps in quality assurance processes, which we found to be a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found improvements had not been made in this area and there was an ongoing breach of this regulation.

The manager told us there were no formal audits of the quality or safety of the service. They told us this was due to prioritising other work that needed to be completed on an urgent basis. We saw there were a range ofaudit tools available that the manager planned to implement, although these had not been started at the time of our inspection. For instance, there was no audit of medicines, care plans, infection control or health and safety. There was also no analysis or overview of accidents and incidents occurring in the service to enable potential trends to be identified and actions taken to improve the safety of the service. The manager told us there had not been any surveys undertaken to gain the view of the quality of the service of people living at the home. The lack of adequate monitoring of the safety of the service meant that concerns and shortfalls were not consistently being proactively identified and acted upon.

Inadequate


The provider did not have adequate oversight of the service, and relied on trust that the managers in post had been performing adequately. The main partner we spoke with told us they had not previously been actively involved in the running of the home when the previous registered manager/partner was in post. Both partners had failed to ensure timely action was taken in relation to serious concerns identified in a fire risk assessment.

The provider did not have robust processes in place to ensure the safety and quality of the service was adequately monitored and improved, and to ensure known risks were acted upon. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they felt supported by the current manager and felt that positive progress was being made in improving the quality of the home. They told us they felt valued for the work they did. Comments from staff included; "[Manager] has turned it round. They have given us motivation, listened to us and solved out problems," "In the past few months it has improved 100%. We've been doing training and your understanding of the training gets tested," and; "[Manager] listens to us and any complaints or concerns. They will challenge the provider who used to come in and look at curtains rather than care."

At our last inspection in August 2016 we found the provider had not always submitted notifications to the Care Quality Commission (CQC) as was required, such as in relation to serious injuries and authorised deprivation of liberty safeguard applications. Improvements had been made and CQC were receiving notifications as required. Before our inspection we checked the provider's website. It is a legal requirement that provider's display the rating from their most recent CQC inspection on any websites they maintain or are maintained on their behalf. We found the rating was not displayed. We raised this with the provider who took action and updated the website to include the rating. The home's rating was displayed inside the homeas required.

The failure to display the home's rating on their website was a breach of regulation 20A (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection in August 2016 we found the provider's policies and procedures were not always current and had not been recently reviewed. The current manager had introduced a new set of policies that were provided by a third party and adapted to the requirements of the home. We saw that expected policies were in place and had been recently reviewed. However, it was apparent that the policies still needed to be embedded into day to day practice at the home. For example, a number of the policies provided standardised forms and audit tools that weren't in use at the time of the inspection. We also found the DBS policy stated that staff DBS checks would be renewed every three years when this was not the case in practice, as staff DBS checks were not renewed.


The table below shows where regulations were not being met and we have asked the provider to send us a report that says what action they are going to take.We will check that this action is taken by the provider.

Regulated activity RegulationAccommodation for persons who require nursing or personal care

Regulation 9 HSCA RA Regulations 2014 Person-centred care

Care plans were not always up to date and reflective of people's current needs and preferences.

Regulation 9(1)


Regulation 12 HSCA RA Regulations 2014 Safe care and treatment

The provider had not taken reasonable steps to ensure the premises and equipment were safe.

Medicines were not managed safely.

Regulation 12(1)


Regulation 15 HSCA RA Regulations 2014 Premises and equipment

The intercom system used at the home was not fit for purpose and infringed on people's privacy.

Regulation 15(1)


Regulation 17 HSCA RA Regulations 2014 Good governance

Accurate records of care had not been kept.

Action we have told the provider to take

This section is primarily information for the provider


The provider did not have robust processes in place to ensure the safety and quality of the service was adequately monitored and improved, and to ensure known risks were acted upon.

Regulation 17(1)


Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed

The provider had not consistently followed safestaff recruitment procedures.

Regulation 19(1)(2)


Regulation 18 HSCA RA Regulations 2014 Staffing

There were gaps in the provision of staff training.

Regulation 18(2)

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