Douglas Bank Nursing Home

Douglas Bank Nursing Home is a residential care home providing personal and nursing care to up to 40 people. The service provides support to people living with dementia, older people, younger adults, people with a physical disability and people with a sensory impairment. At the time of our inspection there were 37 people using the service.

Douglas Bank Nursing Home is set over 2 floors, with the ground floor dedicated to people with nursing needs and the first floor meeting the needs of people living with dementia. Both floors have good sized communal areas and people, and their relatives have access to a good-sized garden.

People’s experience of using this service and what we found

We have identified that improvements were required in the safe management of medicines, assessing risk regarding fire safety and the recording of risks to people’s health.

We identified improvements were required to assess, monitor and mitigate risks, and to improve quality.

People were kept safe from the risk of abuse. There were sufficient staffing levels with less reliance on agency staff compared to the previous inspection. The home was clean and comfortable, and people were protected from the risk of mistakes being repeated.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People living at the home benefitted from a positive culture and were supported by staff that enjoyed their jobs. The manager encouraged staff to develop knowledge and skills and worked well with other agencies.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 August 2022) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. Improvements have been made since the last inspection, however some changes are yet to be embedded and sustained, therefore the provider continues to be in breach of the regulation.

At our last inspection we recommended that the provider completed tasks to improve their health and safety systems, and to review their auditing processes to make sure issues were followed up. At this inspection we found that the provider had made improvements in these specific areas, however further improvements were required in other areas.

The service remains requires improvement. Although the service was rated good in 2021, it has previously been rated requires improvement in 7 consecutive inspections and inadequate in 1.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Douglas Bank Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safe management of medicines, fire safety, and governance of the service.

Please see what action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Douglas Bank Nursing Home is a residential care home providing personal and nursing care to up to 40 people. The service provides support to older people and people living with dementia, younger adults and people with a physical disability. At the time of our inspection there were 33 people using the service.

The home is set across two floors. One floor provides care to people with nursing needs. The home has communal areas and a good-size garden for people and their relatives to use.

People’s experience of using this service and what we found

Although we found no examples of harm, people were placed at risk as medicines were not always managed in a safe way, and we have made recommendations about the process for auditing medicines.

The home was clean and comfortable, and people told us they could decorate their rooms as they preferred. Some areas needed development and the provider had commenced work to update bathrooms. We have made recommendations about the management of health and safety requirements.

People were well cared for by staff that enjoyed their jobs. People felt safe and a relative said, “They know her quite well and know how to help her, she is kept safe.”

People benefitted from a positive culture within the home. People said the staff were friendly and caring and knew them well.

Staff and managers kept relatives up to date and informed them of any changes or issues. One person said, “We have lots of interaction with staff.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection

The last rating for this service was good (published 29 October 2021).

At our last inspection we recommended that the provider improved their recording and auditing processes of medicines. Although improvements were made, we found further development was still needed.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Douglas Bank Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to the safe management of medicines at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Douglas Bank Nursing Home is a residential care home providing personal and nursing care for up to 40 adults across two separate units. One of the units specialises in supporting people who are living with dementia. At the time of our inspection there were 31 people living at the home.

People’s experience of using this service and what we found

There had been some improvements in the management of medicines since the last inspection. However, further work was still required in order to ensure good medicine practices were adopted. We made a recommendation about this.

Staff were being supervised. However, the supervision records could have been more detailed and although training for staff had been provided this could have been expanded to ensure all staff completed the mandatory training modules. We were assured the manager would address this issue.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Recruitment practices were robust and at the time of our inspection there were enough staff on duty to meet people’s needs. However, two relatives felt there was a high turn-over of staff and not enough staff on duty at weekends. We were aware there had been high usage of agency staff, but a recent recruitment drive had filled all permanent staff vacancies.

Those we spoke with felt Douglas Bank was a safe place for people to live. The practices adopted by the home protected people from the risk of abuse. People looked relaxed in the company of staff and the new manager had implemented a system to ensure all staff received relevant training. One family member told us, “I am very pleased with the Home. I can sleep at night because I know my relative is safe, and staff are always about.”

Community health and social care professionals had been involved in the care and support of those who lived at the home and people's dietary needs were being fully met.

People received good care. Their preferences and wishes were respected by the staff team. People were treated with dignity and respect and were involved in the decision-making process. We observed some lovely interactions by staff members towards those who lived at the home and staff we spoke with were clearly committed to the people who lived at Douglas Bank. Independence was being promoted by the staff team. One family member told us, “My relative’s mobility has greatly improved since being at Douglas Bank. She walks with a zimmer and we know staff are on hand to make sure she uses it to prevent falls.”

The new manager was open and transparent during the inspection process. We received very positive comments about vast improvements made since his recent appointment.

The environment was clean throughout and infection control practices were good. A wide range of regular audits were evident. This helped to ensure the quality of service provided was of a good standard and any shortfalls identified were addressed without delay.

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

Why we inspected

This was a planned inspection based on the previous rating. However, the inspection was also conducted to follow up on action we told the provider to take at the last inspection.

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 February 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Douglas Bank Nursing Home is a residential care home providing personal and nursing care to 32 people aged 65 and over at the time of the inspection. The service can support up to 40 people across two separate units. One of the units specialises in supporting people who live with dementia.

People’s experience of using this service and what we found

People continued to be at risk of avoidable harm because the management of accidents and incidents was inconsistent. We found continued failings in relation to the management of people's medicines.

Staff did not always ensure people's care plans and risk assessments were in place or updated in a timely way, this meant we could not be sure people were being supported in a person-centred or safe way.

There were sufficient numbers of staff deployed. Staff were safely recruited and training had continued across the lockdown period. Some nursing staff told us they did not feel they had enough oversight or intervention with people who lived on the ground floor unit. We discussed this with the registered manager and they assured us further consideration would be made to ensure staff felt supported to undertake their roles and responsibilities.

Staff continued to follow task-based routines on the dementia care unit. Care and support was not always person-centred. People living with dementia were not suitably engaged or stimulated and had little communal space to carry out meaningful activities.

We made a recommendation for the provider to review and implement national good practice guidance in the delivery of care for people living with dementia.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their representatives told us staff were kind and empathic. We observed staff on the ground floor unit supporting people with kindness. However, some staff practices did always promote people's independence or protect their dignity.

There was a new registered manager who had been at the service for 10 weeks at the time of the inspection. We found the registered manager was committed to improving people’s experiences and aware of the failures and had started to make improvements. The registered manager was responsive to our feedback and provided assurances of immediate improvement.

We received positive feedback from professional stakeholders in health and social care about the improvements made in the home since the new manager arrived, and about the managers willingness to engage with them.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 May 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report. The provider has taken action to mitigate the risks identified at this inspection and voluntarily submitted their action plan outlining how immediate action would be taken to ensure people’s safety.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Douglas Bank Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified continued breaches in relation to medicines management, safe care and treatment, good governance and person-centred care at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Douglas Bank Nursing Home is a residential care home providing personal and nursing care to 32 people aged 65 and over at the time of the inspection. The service can support up to 40 people across two separate units. One of the units specialises in supporting people who live with dementia.

People’s experience of using this service and what we found

People were at risk of avoidable harm because the management of accidents and incidents was not always effective. Staff did not always follow safeguarding procedures. We found continued failings in relation to the management of people’s medicines.

People did not always receive person-centred care. We observed staff follow task-based routines on the dementia care unit and staff did not effectively support people to ensure they were stimulated or engaged. Staff did not always ensure people’s care plans were updated as their needs changed for example, after someone had sustained unexplained bruising or a skin tear.

The registered manager did not always ensure good governance. Failings identified at this inspection had not been identified by the registered manager. This inspection found continued breaches in Regulation 12 (Safe care and treatment), Regulation 9 (Person-centred care) and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and staff told us there were enough staff deployed. Staff recruitment was safe. The environment was clean and well maintained. The provider continued to refurbish areas of the environment. The registered manager failed to maintain good record keeping in relation to two outbreaks of infectious disease. At the time of the inspection we observed staff follow safe infection control procedures.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff received training. Staff told us they felt supported and listened to. People had access to a wide range of external health care professionals. There were procedures in place to promote equality, diversity and human rights.

We observed staff support people in a kind and respectful way on the ground floor unit, staff were responsive to people’s requests and it was clear staff and people had built positive relationships. Relatives provided positive feedback and told us they felt involved in the planning of their relative’s care.

We received positive feedback from visiting professionals who told us staff were responsive to people’s changing needs and good at asking for support. People’s care plans contained good detail about their needs and preferences should they be transferred to hospital. Staff supported people to maintain a healthy balanced diet. People had choice and control at meal times on the ground floor unit, the dining experience of the dementia care unit was not as positive because not enough staff were deployed to effectively support people.

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

Rating at last inspection and update

The last rating for this service was requires improvement (22 January 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

The last rating for this service was requires improvement (published 22 January 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to people’s safety, person-centred care and the way the service is governed at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because medicines were not managed safely. At this inspection we found that the management of medicines still required improvement and the home continued to be in breach of regulation 12. Improvements were needed for the reporting of medicine errors and the subsequent actions, the recording of topical medicine application and the storage of medicines.

We found that people who lived at the service were not always risk assessed in relation to their specific needs. We found an example were a person who required one to one support did not have a risk assessment in place to show why they needed this level of increased supervision. People who lived at the service were not always assessed for the risk of choking where it was required. This was also a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that people were assessed against the risk of malnutrition and de-hydration however, people did not always have access to quality food and the dining experience for people living with dementia was poor. Therefore, we found the provider to be in breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that people were not always engaged with in a dignified and person-centred way. We observed care and support on both units and found very little stimulating activity. People’s representatives told us that social activities and stimulation at the service was poor. We found that the service had collated person-centred information about people they supported. However, information was not always included in care plans or risk assessments. We found that care plans and observations of care were task focused. This meant that people did not always receive care and support in a person-centred way. The provider was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at audits undertaken by the registered manager and compliance team and found quality monitoring systems were in place however were not always effective. The provider was in breach of Regulation 17 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 the report.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive and well led to at least good. We found that improvements had been made in relation to environment safety, however medicines management still required improvement.

Douglas Bank Nursing Home (Douglas Bank) is a 'care home'. 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.

Douglas Bank is situated on the outskirts of Wigan. The service accommodates up to 40 adults, who need support with personal or nursing care, including people living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities.

Since our last inspection the legal directors for Douglas Bank had changed. However, the registered provider ‘Tudor Bank Limited’ had not changed. A legal director is a head of an organisation generally with certain powers and duties relating to management and administration. A registered provider is an individual person, partnership or organisation registered with CQC to carry on one or more regulated activities.

The service had a registered manager in post at the time of our 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 was run.

The service had a safeguarding policy and procedure. We found that staff understood what constituted to abuse, however people were not always safeguarded in relation to the management of their medicines. People who lived at the service were protected by safe recruitment practices.

Most accidents and incidents had been documented. There was a follow up procedure to check on injuries. However, we found failings around reporting medicine error incidents.

People who lived at the service, their representatives and staff told us that staffing levels were not always sufficient. The registered manager told us that staffing levels were being reviewed and times of the day and night that had been identified to require extra staffing would be fully considered in line with the provider's dependency risk assessment.

We saw that the provider had undertaken many areas of refurbishment, these included redecoration, resurfaced car park and new windows. The provider and registered manager showed us future refurbishment plans and we noted improved standards of cleanliness and environment safety throughout the service.

We found that staff did not always follow safe procedures when dealing with contaminated waste. Staff had access to protective clothing however, did not always use it.

People were assessed before they were admitted to ensure that the service could meet their needs.

The provider supported staff and provided training to make sure they had the skills and knowledge to care for the people who lived at Douglas Bank.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We found that the service had policies and procedures for supporting people at the end of life. However, people’s end of life care plans did not always reflect DNACPR decisions.

We received positive feedback about the registered manager and senior staff. The senior management team were co-operative throughout the inspection.

At the time of our inspection the registered manager was on duty. She was cooperative and helpful throughout the inspection process. 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.

This comprehensive inspection was conducted on 26 September 2017 and was unannounced. Our last comprehensive inspection of this service was conducted over two days on 23 January and 1 February 2017, where breaches of the regulations were found in respect of person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and notifications of other incidents. The service was rated inadequate overall and was placed into special measures. We took steps to ensure people were safe and the provider also submitted an action plan detailing the improvements they planned to make. Comments contained in the action plan were considered during this inspection. Since that inspection the directors of the registered provider’s limited company had changed.

During this inspection we found that Douglas Bank Nursing home had demonstrated improvements had been made and therefore as the overall rating for Douglas Bank Nursing Home is now Requires Improvement this service is no longer in special measures.

We did however find when we looked at the management of medicines that although some improvements had been made in this area, further improvements were required. Therefore, this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that risks to people’s health care had been appropriately managed and safety of the environment had significantly improved. However, we noted a small number of minor improvements, which could enhance the premises further. These were discussed with the registered manager of the home and a Director of the company, who assured us these areas would be addressed. We made a recommendation about this.

We looked at the quality assurance systems and saw a range of effective audits and surveys had been introduced and any issues identified had been addressed or were in the process of being rectified. However, the medicines audit could have been more thorough, so that any shortfalls could be identified and addressed in a timely manner. We made a recommendation about this.

People’s care had significantly improved. The plans of care we saw were, in general well written, person centred documents, providing staff with clear guidance about people’s assessed needs and how these needs were to be best met. We found that people’s privacy and dignity was respected throughout the day.

We saw that people were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service supported this practice and were in accordance with the principles of the Mental Capacity Act 2005 (MCA). However we have made one recommendation in respect of recording consent where the relevant person is unable to do so.

The system of required notifications had improved and the registered manager had notified us of any significant events, such as deaths, safeguarding referrals and serious incidents.

Meal times were pleasant and relaxed. We observed very positive interactions between people who used the service and staff. Staff members were seen to be kind, caring and compassionate.

The staff team had received training in safeguarding adults and whistle-blowing procedures. Staff members we spoke with were confident in making safeguarding referrals, should the need arise.

People who lived at Douglas Bank told us they felt safe there and we found that the recruitment practices were robust, which helped to protect people from harm. There were sufficient staff on duty on the day of our inspection and we saw staff were always present in the communal areas of the home. Records showed that although some agency staff were utilised, in order to cover staffing shortfalls, the agency staff used were usually the same ones in order to promote continuity of care.

At the time of our inspection the manager of the home had been in post for a very short period of time. Therefore, she had not submitted an application to the Care Quality Commission to become the registered manager of Douglas Bank Nursing Home. 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.

This comprehensive inspection was conducted over two days. The first day was unannounced. This was conducted on 23 January 2017. The provider was given short notice of the second day of our inspection, which took place on 1 February 2017.

The last comprehensive inspection of this service was conducted on 22 March 2016, when shortfalls were identified in relation to person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. The provider submitted an action plan, as requested. Comments contained in the action plan were considered during this inspection.

At our last inspection on 22 March 2016 we found the provider had not always ensured that the plans of care had been designed to reflect individual needs. Therefore, this area was in need of improvement to ensure that the health and social care needs of people were being appropriately met.

This was a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 1 January 2017.

At this inspection we found that the care plans were not always person centred and did not accurately reflect people’s needs. This constituted a continued breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that some risk assessments were not person-centred; as they did not accurately reflect people’s current needs.

At our last inspection on 22 March 2016 we found that the provider had not always ensured that people were treated with dignity and respect. Therefore, this area was in need of improvement to ensure that people who lived at Douglas Bank were treated in a proper manner. This was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions in this area had been completed.

At this inspection we observed two staff members preparing one person to be transferred in the hoist. This process did not promote dignity and respect for the person involved. Therefore, this was a continued breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found the provider had not always ensured that consent had been obtained from the relevant person before care and treatment was provided. Therefore, this area was in need of improvement to ensure that people who lived at Douglas Bank were in agreement with the care and support delivered to them. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 1 October 2016.

At this inspection we found that consent had not always been obtained before care and treatment was provided. Therefore, this was a continued breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found that the premises were not safe throughout and equipment used for providing care or treatment was not always safe for such use. We identified that risks associated with infection control had not always been appropriately assessed, in order to prevent, detect and control the spread of infections. We also found that the provider had not ensured systems were in place for the proper and safe management of medicines. Therefore, these areas were in need of improvement to ensure that people who lived at Douglas Bank were protected from harm. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed at various times, the latest being 1 January 2017.

At this inspection we found the management of medicines had significantly improved. Therefore, this part of regulation 12 had been appropriately met. However, although some environmental improvements had been made since our last inspection, we still identified many safety concerns, associated with the premises and the provision of care, which presented a risk of potential harm for those who lived at Douglas Bank. Although some improvements had also been made in relation to infection control, further improvements were still needed to the cleanliness of the environment. This constituted a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found that the provider had not always ensured that lawful authority had been granted in order to deprive someone of their liberty. Therefore, this area was in need of improvement to ensure that people who lived at Douglas Bank were not unlawfully restricted. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 1 January 2017.

At this inspection we found that the records of one person showed that they were unable to make safe decisions about their planned care and treatment. However, a mental capacity assessment had not been conducted and there was no evidence available to show that best interest decision meetings had been held, in order to ensure that care and treatment was provided in accordance with the best interests of this person.

The care records for one person, who lived at the home, indicated they were being gently restrained against their will. This represented a deprivation of liberty. There was no evidence to demonstrate that a Deprivation of Liberty Safeguards (DoLS) application had been submitted.

This constituted as a continued breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found the provider had not established and operated effective systems to assess, monitor and improve the quality and safety of the services provided or to mitigate risks relating to the health, safety and welfare of those who lived at the home and others who used the premises. Therefore, this area was in need of improvement to ensure that the services provided were sufficiently assessed and monitored to ensure any areas of risk were identified and mitigated as soon as possible. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions in this area were on-going.

At this inspection we found quality monitoring systems had been implemented, but these were not effective. Some documentation, such as care plans, falls risk assessments, dependency assessments and Personal Emergency Evacuation Plans (PEEPs) did not always reflect people’s current needs and some documents, such as dietary and fluid charts, were being inaccurately completed. These failings could have had a detrimental impact on the health and safety of those who lived at the home. Therefore, this constituted a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found that the provider had not ensured the premises throughout were being properly used or properly maintained. Therefore, this area was in need of improvement to ensure that all parts of the home used by residents were suitable for their use. This was a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 26 June 2016.

At this inspection we found that all parts of the home were suitable for the use of the people who lived there. Therefore, regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met on this occasion.

At our last inspection on 22 March 2016 we found that the provider had not ensured an effective system had been implemented for identifying, receiving, recording, handling and responding to complaints. Therefore, this area was in need of improvement to ensure that complaints were being appropriately managed. This was a breach of regulation 16 of the Health and Social Care Act 2008 (Regulated Activities)

Douglas Bank is situated on the outskirts of Wigan, in a semi-rural setting. The home enjoys panoramic views of scenic countryside and overlooks the picturesque village of Appley Bridge. The home accommodates up to 40 adults, who need help with personal or nursing care needs, including those who are living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities.

At the time of our inspection the manager of the home had been in post for a very short period of time. She was in the process of applying for registration with the Care Quality Commission. 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 last full scheduled inspection of this service was conducted on 04 August 2014, when some shortfalls were identified in relation to cleanliness and infection control protocols. A follow up inspection was conducted on 04 November 2014, when we found that action had been sufficiently taken to improve the cleanliness of the environment and therefore promote good infection control practices.

At this inspection we identified some areas where improvements needed to be made, which are detailed within each relevant section of the report.

People who lived at Douglas Bank told us they felt safe being there and we found that the recruitment practices were robust, which helped to protect people from harm. There seemed to be sufficient staff on duty on the day of our inspection and it was observed that staff were always present in the communal areas of the home. However, people told us that there were sometimes shortfalls in the staffing levels, particularly at night and records showed there was an excessive number of agency staff used over a short period of time.

The staff team had received training in safeguarding adults and whistle-blowing procedures. However, people’s Personal Emergency Evacuations Plans (PEEPs) were out of date and therefore did not provide current guidance. We made a recommendation about this.

The management of medicines was poor and there were areas of the environment and external grounds, where improvements to safety were needed.

Some areas of the home could have been cleaner and more hygienic. Infection control practices could have been better.

Care plans did not always reflect people’s assessed needs and some care records provided conflicting information. This did not give the staff team clear guidance about how people’s individual needs were to be best met.

Social care profiles were in place in each person's care file, which reflected people’s preferences and what they liked to do and needs assessments had been conducted before people moved into the home.

Deprivation of Liberty Safeguard (DoLS) applications had not always been submitted, in line with the requirements of the Mental Capacity Act. Records showed that people’s mental capacity had not always been considered when developing their plans of care and formal consent had not always been obtained from the relevant people before care and support was provided.

We observed that confidential records were sometimes left unattended on the nurses’ station, although there was always a member of staff in the vicinity. We have made a recommendation about this.

The provision of meals could have been better, although we saw people being supported with their meals in a sensitive manner. We have made a recommendation about this.

The majority of staff we spoke with had a good understanding of people in their care and were able to discuss their needs well. The staff team were well supported by the management of the home, through the provision of information, induction programmes and training. However, supervision and appraisal could have been more structured. We have made a recommendation about this.

Interaction by staff with those who lived at the home varied in quality. Some members of staff provided good, sensitive and caring approaches, whilst others failed to promote people’s dignity and respect.

Records showed that people's views about the quality of service provided were sought in the form of surveys and meetings. However, complaints were not always being managed well.

The provider had forwarded the required notifications to CQC, as and when required. The system for assessing and monitoring the quality and safety of the service provided was not always effective. This did not allow for shortfalls to be identified and improvements to be made.

We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for person centred care, dignity and respect, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance, need for consent, premises and equipment, receiving and acting on complaints and fit and proper persons employed.

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

The summary below is based on our observations during the inspection, speaking with people who lived at the home, the manager and staff members. We also toured the premises, viewing a random selection of private accommodation, as well as all communal areas and we looked at a variety of relevant records.

During our visit to Douglas Bank the manager of the home told us about the systems she had implemented to improve the area of non- compliance. We gathered evidence from a variety of sources and found improvements had been made since our last visit to this location, which enhanced the environment for the people who lived at Douglas Bank. Those we spoke with said they were satisfied with the overall standard of cleanliness of the home.

If you want to see the evidence supporting our summary please read our full report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with those who used the service, their relatives, support staff and the manager and from looking at records. We were able to speak with five people who lived at the home, who gave us positive responses to the questions we asked. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People we spoke with told us they felt safe living at Douglas Bank and their dignity was always respected. Safeguarding procedures had been implemented and staff understood how to safeguard people they supported. Systems were in place to help managers and the staff to learn from untoward incidents, such as safeguarding concerns. This helped the service to continually improve.

The home had proper policies and procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Applications were made, as was needed. This helped to ensure people were not being unnecessarily deprived of their liberty. People who lived at the home (or their relative) were involved in making decisions about the care and support they received.

At the time of our visit to this location, we toured the premises and found the home to be warm and friendly. However, the standard of cleanliness and attention to detail needed to be improved, so that people were provided with a hygienic and clutter free environment, in which to live. Equipment was well maintained and serviced regularly. This helped to protect people from unnecessary risk.

Is the service effective?

People were able to access an independent advocate for additional support, should they wish to do so. The health and personal care needs of those who used the service had been thoroughly assessed, with a range of people involved in their care and support. Records were maintained in an effective way, so that data protection guidelines were followed and personal information was appropriately protected.

Systems were in place to ensure the service was effectively assessed, so the quality of service provided could be consistently monitored. A broad range of training modules were provided for staff, with regular mandatory updates. This helped to ensure the staff team delivered effective care and support for those who lived at the home.

Is the service caring?

We asked those who lived at the home about the staff team. Feedback from them was very positive. They said staff were kind and caring towards them and helped them to meet their needs. When speaking with staff it was clear they genuinely cared for those they supported and were observed speaking with people in a respectful and friendly manner. People's preferences, choices and leisure interests had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

A wide range of daily activities were available both inside and outside the home on a regular basis. This supported people to maintain contact with their local community and encouraged people from outside to become involved with activities provided at Douglas Bank.

Staff were seen to be responding to people well by anticipating their needs appropriately. The service worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the manager of the service. One member of staff told us, "Coming to work at Douglas Bank is the best move I have ever made. I love it."

People who lived at Douglas Bank and their relatives completed annual satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately.

Comments received included:

"It is rather nice here. I like how comfortable it is and the staff are so friendly and helpful."

"I do think there are enough staff around, but sometimes they seem to be in a rush when doing things for me. Perhaps it is because they are very busy."

"This is a super place."

During our visit we looked at the management of meals and how people were supported to receive adequate nutrition. We also assessed outcome areas related to medications, staffing levels and quality assurance. We found appropriate action had been taken in each area and therefore we did not find any concerns on this occasion.

Comments received included:

"Pam, the activities organiser is brilliant. She really does some good things with us."

"I am very happy and the staff are smashing. They are considerate and always listen to what we have to say, even though they are always so busy. The young lads are super."

"They (the staff) are always on the go. They never have a minute to spare. There isn't enough of them."

"It's a lovely place here. The food is good and the staff are good and I've got a lovely bedroom. I'd sooner be at home, but I've got to stop here."

During our visit, we assessed standards relating to care and welfare and how people consented to care and treatment provided. We also looked at the management of medications and how people were supported to make complaints. Standards relating to monitoring the quality of service provision were also inspected. We identified concerns in some areas. Therefore, we also assessed areas in relation to nutrition, staffing and suitability of the premises.

The Registered Manager subsequently submitted an action plan to the Care Quality Commission outlining action the home was going to take to meet the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We asked for evidence to be forwarded to demonstrate the action plan had been followed and to show the area of none compliance had been addressed. This information was received within the agreed timescale. We found improvements had been made and relevant records had been completed.

We found staff to be well supported and appropriately trained and those living at Douglas Bank looked comfortable in their presence. We also spoke with several relatives who were all very complimentary about the staff team and the managers of the home.

Methods for monitoring the quality of service provided had been established and systems had been developed in order to protect the health and safety of those living at the home.

Comments from those living at the home and some relatives included:

"I cannot fault any of the staff. I am really 'pally' with them. They are so funny. We have a good laugh and I enjoy a bit of banter with them, it keeps me going."

"The young fellows who work here are marvellous. They seem to be really interested in their work. They talk to us all like ladies and gentlemen and don't brush us off because we are old folk."

"The staff are absolutely superb. The meals are excellent. The home is second to none. Everything is first class. I have not one complaint about this place."