Banksfield Nursing Home

Banksfield Nursing Home is a care home providing personal and nursing care for up to 42 people aged 65 and over. At the time of this inspection the service was supporting 27 people. The service provides dementia care on the ground floor and nursing care is provided on the upper floor.

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

The provider had not addressed all of the issues we found at the last inspection, we found the systems in place to manage and oversee people’s medicines were unsafe which placed them at risk of harm.

Safeguarding processes were in place to protect people from the risk of abuse. Staff were aware of procedures and had received training and knew what actions to take. Staff had been recruited in a safe way. The manager made sure enough staff were on duty throughout the day and night based on an assessment of people’s needs. However, some feedback we received indicated some people thought the home was short staffed at times.

We looked at infection prevention and control measures under the safe key question. We were assured the infection prevention and control practises were satisfactory.

People made decisions about their care and their rights were protected. 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.

Training records for staff showed they had completed the required training to meet people’s needs. Referrals to other professionals were being made to support people’s health needs. People and their relatives told us their health had improved while at the home. People were complimentary about the food they received and told us their individual needs were catered for.

People and their relatives told us they were satisfied with the care provided and they found staff were very caring, kind and respectful. There were a variety of activities available to people and these included activities for those, at risk of social isolation, when cared for in bed or who chose to stay in their rooms. Actions had been taken to respond to complaints and used to improve people's experiences.

The provider and manager had responded to and addressed most of the concerns we found at the last inspection. Various audits had been undertaken to monitor the quality and safety of the service. However, medicine audits and oversight did not identify the concerns we found during the inspection. Staff and people told us the improvements made since the last inspection of the service were making a positive difference.

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 8 September 2022) and there were breaches of regulations. At this inspection we found the provider remained in breach of those regulations.

At our last inspection we recommended that the provider ensured the call bell system was fully functional and reliable and oral hygiene assessments and oral care were consistently completed. At this inspection we found the provider had acted on improving oral care assessments and providing the necessary equipment to completed oral care. The recommendation made about the call bell system was partially completed as the provider had ensured the current call bell system was functioning. The provide was also in the process of identifying the most appropriate new system to install.

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 COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

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 breaches in relation to the safe management and oversight of medicines at this inspection.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Banksfield Nursing Home is a care home providing personal and nursing care for up to 42 people aged 65 and over. At the time of this inspection the service was supporting 18 people. The service accommodates people in one adapted building. Providing dementia care in a 20-bedded unit on the ground floor and on the first floor nursing care is provided to a maximum of 22 people.

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

The provider had made some improvements to the quality monitoring, governance and leadership arrangements which contributed to driving improvements at the home. However, we found some areas of the oversight of safety and quality monitoring in the home still required further improvements. The manager and regional manager recently appointed were still embedding the required improvements identified in the last inspection.

The provider and staff had worked hard to improve people's experiences and to address shortfalls found at the last inspection. The provider audited various areas of people's care however, they needed to sustain the changes they have made and continue to monitor areas of improvement including medicines management and governance. The service worked in partnership with a variety of agencies to ensure people received the support they needed. Staff were positive with how the service was managed and the culture and morale within the staff team had improved.

People and their relatives told us they felt the service was safe. While we saw some improvements had been made to the management of medicines, practices were not always safe and further improvements were still required.

Risk assessments were in place to monitor and minimise the potential risk of avoidable harm to people during the delivery of their care. The records for oversight and actions taken about risks in the environment were not always completed in a timely manner and we have made a recommendation about ensuring the call bell system is fully functional and reliable.

Staff had received training and guidance in the prevention and control of infections including COVID-19.

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's care and support had been planned in partnership with them and their relatives where possible. Staff had received training that was suitable to meet the needs of people in the home.

The provider had commenced a programme of redecoration and improvement works to the environment. There were improved systems to ensure people's clinical needs were identified, monitored and met including dietary and nutritional needs. However, we were not assured people always received the level of oral hygiene required. We have made a recommendation oral hygiene assessments and oral care is consistently completed.

People and their relatives made positive comments about the caring nature of the staff team. They said staff were kind and caring. We saw people were treated with dignity and respect and their right to privacy was upheld. Staff interactions seen demonstrated kindness and a good understanding of people’s needs.

People received person-centred care, which was responsive to their needs. Care records reflected people's needs and had been reviewed when people's needs changed. People could engage in regular activities. People's concerns and complaints were managed appropriately. People received dignified end of life care.

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 inadequate (published 26 October 2021) There were multiple breaches of regulation.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations 9 (Person-centred care),11(Need for consent),13(Safeguarding service users from abuse and improper treatment), 14(Meeting nutritional and hydration needs) and 18(Staffing). The provider remains in breach of regulations 12(Safe care and treatment) and 17 (Good governance).

This service has been in Special Measures since 26 October 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

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 COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection. We have found evidence that the provider still needs to make improvements. Please see the safe and well-led sections of this full report.

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

Enforcement and Recommendations

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 continued breaches in relation to the safe management of medicines and good governance.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Banksfield Nursing Home is a care home providing personal and nursing care to 31 people aged 65 and over at the time of the inspection. The service can support up to 42 people. The service consisted of a 20-bedded unit on the ground floor, providing general nursing care. On the first floor, nursing care is provided to a maximum of 22 people who live with dementia.

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

The provider failed to ensure people were consistently protected from the risk of avoidable harm. For example, the risk of choking, aspirating, malnutrition, dehydration, skin break down and clinical health deterioration. During the inspection the provider took steps to mitigate the risk people had been exposed to and assured us lessons would be learnt.

The provider failed to ensure safeguarding incidents were consistently identified or acted on. Recommendations made by the Local Safeguarding Authority were not always followed and lessons were not always learnt. Not all staff had received training in safeguarding adults. People’s representatives told us they were not always confident people were safeguarded because of incidents that has occurred including service user altercations and choking. During the inspection the provider took steps to improve staff responsiveness to safeguarding incidents and we received assurances that all incidents of risk and actual harm had been reported to the local safeguarding authority for their investigation.

People were not always supported to have maximum choice and control of their lives and staff did not consistently support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support best practice around use of the Mental Capacity Act (MCA), Best Interest Assessment (BIA) or Deprivation of Liberty Safeguards (DoLS).

Cleanliness throughout the dementia care unit on the first day of the inspection was poor. On the second and third day of the inspection we noted improvement however, the environment in some areas of the service remained worn and difficult to effectively clean.

Infection Prevention and Control (IPC) processes were not consistently effective. We asked the local IPC team to support the provider to improve their systems and processes to ensure people were effectively protected from the risk of COVID-19 and other infectious disease. The provider assured us they audited and actioned IPC shortfalls during the inspection and engaged with supporting external IPC professionals.

Relatives and staff complained to us about a lack of staff on duty. During the inspection staffing levels were increased. There was a dependency tool relied on to calculate numbers of staff required however, due to the high level of new and or agency staff deployed we found staffing levels at the start of the inspection did not ensure people’s needs were met in a timely or person-centred way.

Staff did not always ensure people’s medicines were managed in a safe and effective way. For example, we found failures in relation to the use of thickening agents to prevent people from choking and aspirating, application and recording of topical medicines, the availability of prescribed medicines and staff training.

There was a system in place to identify accidents and incidents however, the management of incidents and lessons learnt were not always recorded.

The provider did not always ensure people’s needs were assessed, evaluated or reviewed in a person-centred way. For example, a new service user was admitted their needs and preferences had not been assessed despite them displaying distressed reactions and changes in their physical health.

The provider failed to ensure all staff were suitably trained to undertake their roles and responsibilities. During the inspection we received assurances from the provider that training courses were scheduled.

We found the environment was not effective for people who lived with dementia. The service lacked soft furnishings and access to dementia friendly stimulus.

On the first day of inspection we observed staff failed to effectively acknowledge people’s non-verbal requests for support on the dementia care unit. On the second and third day of the inspection we noted improvement in staff presence in communal areas, staff were more attentive and recognised when people tried to communicate with them.

People did not have regular access to stimulating and meaningful activities.

Quality assurances processes were in place however did not identify some of the failures found at the inspection including; staff training, medicines management and environment. During the inspection a new manager and regional manager commenced in post and both demonstrated commitment to improvement. We were reassured by the regional managers risk mitigation and transparency throughout the inspection process.

Staff told us they felt the service had stabilised in the last few weeks since the previous manager had exited the business. Staff told us they felt able to raise ideas and involved in the running of the service.

People and their relatives told us they felt confident to raise their concerns/complaints some feedback identified relatives felt frustrated about delayed action being taken when they raised concerns.

We observed staff consider people’s dignity and respected their privacy. Staff discussed and assessed people’s end of life needs and preferences with them or their representatives when they were near to end of life.

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 25 March 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 enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding people from the risk of avoidable harm, management of the service, staffing levels and culture. A decision was made for us to inspect and examine those risks.

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.

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 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 breaches in relation to person-centred care, consent to care and treatment, keeping people safe, protected from avoidable harm, abuse and neglect, nutrition and hydration, governance and delegation of sufficient numbers of experienced, suitably trained staff at this inspection.

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 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 further concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more 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.

Banksfield Nursing Home is a care home providing personal and nursing care to 24 people aged 65 and over at the time of the inspection. The service can support up to 42 people. The service consisted of a 20-bedded unit on the ground floor, providing general nursing and residential care. On the first floor, nursing and personal care is provided to a maximum of 22 people who live with dementia.

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

Not all people consistently received safe care and treatment. Ways to manage risk were not always documented. This included the management of medicines. When supporting one person where restrictive practices were involved, best practice was not consistently followed. We observed some people failed to receive the support they required with their meals. Records and systems were not always accurate and sufficiently detailed to guide staff and protect people from the risk of avoidable harm.

There were times when some people required additional support or oversight, and this was not always available. We have made a recommendation about staff deployment. We noted concerns related to the cleanliness of some areas of the home. We have made a recommendation about this. We found two incidences when incidents had occurred, and the provider had not fully followed their regulatory responsibilities. We have made a recommendation about this.

Recruitment was carried out safely. The provider arranged police and reference checks and induction training when recruiting new staff. Staff were optimistic the new manager would bring positive changes within the home. People had access to health professionals and the opportunity to have any concerns or underlying health concerns investigated and reviewed. People and staff were supported to have COVID-19 vaccinations. Staff knew people very well. Interactions were familiar and sensitive. Staff listened and responded to people by observing what they said, changes in their body language and by monitoring their actions.

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 and update

The last rating for this service was requires improvement (published 24 June 2019) and there were multiple breaches of regulation. At this inspection enough improvement had not been sustained and the provider remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We received concerns about the safe care and treatment of people living with dementia, staffing levels and the lack of training related to moving and handling and managing some behaviours which challenged. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed from requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. The provider has taken action to lessen the risks and concerns identified.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Banksfield 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 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 breaches in relation to the management of risk, medicines management, nutrition and good governance 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 and meet with the provider following this report being published 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.

We found the following examples of good practice.

Staff received training in infection prevention and control. Staff had been supported to learn about safe and effective ways to put on and take off Personal Protective Equipment (PPE).

Staff and visitors had access to PPE. A strict risk assessment process was in place for all visitors including external health care professionals. This ensured people coming into the service were of good health and had no symptoms of Covid-19.

During the outbreak of Covid-19 staffing levels had been maintained by use of agency workers specifically allocated to the service. Agency workers were tested at the service weekly.

The provider had implemented an effective system for testing staff through a window which reduced the footfall within the service on allocated testing days.

A Covid-19 secure visiting pod was being developed at the time of the inspection, this meant people would be able to see their friends and family in a safe way with reduced risk of Covid-19 transmission. The manager told us the pod would be ready in time for visitations once the outbreak isolation period was complete.

At the time of the inspection the Covid-19 outbreak had been contained to one of two units. Staff were deployed solely to each unit and no cross over of staff was permitted other than the manager, who told us they took extra precautions to prevent transmission of Covid-19 during their once daily visit to the unit, the deputy manager was deployed solely to this unit during the outbreak.

People were supported to maintain contact with their family and friends. We observed one person talking to their relative on the telephone, staff supported them with the call and showed compassion when the person become upset and expressed how much they missed their family. People's closest relatives had been supported to safely visit in extenuating circumstances, primarily when a person was in the last hours of their life.

The manager maintained good records of infection control audits and action planning for improvement was undertaken. Assurances were in place to ensure increased cleaning processes were undertaken and a deep clean was scheduled to be undertaken in line with guidance provided by the infection prevention and control team at the Local Authority.

Further information is in the detailed findings below.

Banksfield Nursing Home (Banksfield) is a purpose-built care home registered to provide nursing and residential care to a maximum of 42 service users. The service consists of a 20-bedded unit on the ground floor, providing general nursing and residential care. On the first floor, nursing and personal care is provided to a maximum of 22 people who live with dementia. The service was providing personal and nursing care to 33 people at the time of the inspection.

The meal time experience had improved. However, we found the provider did not always ensure people had access to a range of snacks between their meals and at night time.

People’s experience of using this service:

The service failed to ensure people were consistently supported to maintain a good diet and fluid intake. People's records showed low fluid intake was not always considered or acted on and we could not be sure people were consistently offered food and fluids at night time. This placed them at risk of avoidable harm.

Staffing levels were not always consistent and this meant people were at risk of receiving a poor standard of care.

Communication at shift handover was not always effective for agency staff and this meant people were at risk of receiving inaccurate support.

Shortfalls found at this inspection had not already been identified by the provider therefore overall governance still required improvement. There had been some improvements made since the last inspection and areas which placed people at significant risk of avoidable harm had been addressed.

Staff were recruited in a safe way and checked for good character.

The recording and management of accidents and incidents had improved. The registered manager reported incidents to the local safeguarding authority and people's risk assessments were updated to show how further risk would be prevented. The service discussed lessons learnt with staff during shift handover however, this was not always recorded.

Staff had received training and development to enable them to undertake their role and responsibilities.

Staff told us they felt supported by the management team and had regular supervision.

People were asked to consent in line with principles of the Mental Capacity Act. Restrictive practices were considered and DoLS applications were made. Staffs awareness of the MCA and DoLS had improved.

People's care plans were written in a person-centred way and included information about their past hobbies and life experiences. People were encouraged to maintain relationships and build new friendships at Banksfield.

People had access to a wide range of external health and social care professionals and their advice was clearly recorded and acted on.

The service provided a good standard of end of life care and staff told us they felt confident and competent to support people with such needs.

The service considered ways to improve communication. This included easy read signage and experience surveys. People with visual and cognitive impairment had access to directional signage.

People were protected against bullying, harassment and abuse.

People were encouraged to be involved in decisions about the service and informed of change. Staff told us they were valued and could approach the registered manager if they had any concerns or ideas for improvement.

There was a new activity worker who had started to develop activity plans. People were encouraged to access the community and maintain links with local amenities.

The registered manager and nominated individual worked in a transparent way and understood their role and responsibilities.

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

Rating at last inspection:

At the last inspection the service was rated requires improvement (published 22 November 2018). The service has been rated requires improvement for the last two consecutive inspections.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection, we found the provider had made improvements in relation to the breaches of regulations we found at the last inspection. However, we found further breaches of regulations.

Why we inspected:

This was a scheduled inspection based on the previous rating.

Enforcement:

We have identified breaches in relation to staffing, nutrition and good governance at this inspection.

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 monitor the progress of the improvements working alongside the provider and local authority. We will return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Banksfield 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.

Banksfield Nursing Home is a detached, two storey, purpose built care home registered to provide Nursing and Residential Care to a maximum of 42 service users. The service consists of a 20-bedded unit on the ground floor, providing general nursing and residential care to male and female service users. On the first floor, nursing and personal care is provided to a maximum of 22 people who live with dementia.

There were 39 people who lived at the service at the time of the inspection.

During this inspection we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to safeguarding service users from abuse and improper treatment, safe care and treatment, staffing, need for consent, meeting nutritional and hydration needs, person centred care and good governance. We also found one breach of the Care Quality Commission (Registration) Regulations 2009, in relation to notification of other incidents.

Our last inspection of Banksfield Nursing Home was carried out on 8 December 2015. At that time we rated the service as overall 'good' with the effective domain being 'requires improvement'. There were no breaches of the regulations at that time. At this inspection the rating had deteriorated to overall 'requires improvement'.

This is the first time the service has been rated Requires Improvement.

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

The service had procedures in place for dealing with allegations of abuse and showed us the guidelines they followed from Lancashire County Council when they make a judgement in relation to raising a safeguarding alert. However, we found two incidents that had not been referred to the local authority in line with the providers policy for safeguarding.

We observed staff undertake unsafe practice in relation to dealing with behaviours that challenge and when we looked at the staff training matrix we saw that staff had not received suitable training to ensure that they could meet the needs of people who lived with dementia.

Staff told us that they felt confident to whistle-blow and we observed the management team engage with staff, people who lived at the service and visitors across both days of the inspection.

We looked at people's care records and found inconsistencies in how the service managed individuals' risk. For example, people at risk of choking were not always suitably risk assessed and this meant that people's personal safety was compromised.

We looked at the care records for a person who lived on the dementia care unit and found they had not been suitably assessed and care plans had not been completed to show the support they required. This placed the person at risk of receiving inadequate and unsafe care. We found that the providers admission procedure was not always fully carried out, one person had not been suitably risk assessed and care plans had not been formulated to reflect what care and support they required 13 days after they were admitted.

We found that medicine management was good in relation to stock control and recording when a person had been administered their medicines. We observed safe medicine administration. However, we found shortfalls in the way the service maintained records for 'as and when required' medicines and topical treatments.

We made a recommendation about how the service calculates its staffing levels in relation to people's dependency assessments.

We found four bedrooms on the dementia care unit were particularly cool and the heating system was not turned on. Some people who lived on the dementia care unit appeared cold and had not been provided with duvets, we found them in bed with a thin sheet or thin fleece blanket. At 8.00am we informed the deputy manager who took immediate action to provide all people with suitable bedding. Maintenance checks were undertaken during the first day of the inspection to turn on radiators. We found that this issue was isolated to the dementia care unit.

We found that maintenance work around the service had not been always been planned or completed. For example: there were holes in two bedroom walls, a toilet in a locked store cupboard that had not been disconnected and this meant that it collected stagnant water, we found a sharp screw in a person's bedroom furniture that meant the person was at risk of injury and several fire doors that did not fully close. The registered manager took immediate steps to rectify the issues we found.

We analysed training statistics for the service and found gaps in compliance for training courses the provider stipulated should be mandatory. For example, only two employed nurses [one being the registered manager] had undertaken first aid training in the previous 12 months and no other staff members had undertaken first aid training. This meant that staff had not received adequate training to ensure that people were provided safe and correct care in the event of an accident/injury.

During the course of our inspection we looked at the personnel records for three members of staff. We found that staff were safely recruited and checks were undertaken before they started to work at the service. Staff were inducted inline with the providers induction policy.

At this inspection we found staff knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) was not sufficient and this had lead to inappropriate restrictive practices. For example, we found that one person used restrictive seating (a bean bag) and this had not been considered in line with the MCA. The same person was given covert medicines and again the service had failed to assess the person to ensure that their rights were not infringed upon.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice

We undertook a Short Observation Framework For Inspection [SOFI] during lunch time meal service on the dementia care unit, this allowed us to observe the care provided and to help us understand the experience of people who used the service who could not talk with us. We found that people were not always assisted in a person-centred way and this meant that they did not always receive a nutritious meal because of the lack of assistance. We received positive feedback from people who lived at the service about the meals provided and observed a better standard of dining on the general nursing unit.

People were assessed on an individual basis against the risk of malnutrition and nutrition care planning was undertaken, however we found significant shortfalls in the accuracy of nutrition planning.

People were supported to access external health care professionals. We found evidence within care records that showed people had been reviewed by multi-agency health care professionals including dentist, optician, mental health teams and podiatry. Staff told us that they understood referral pathways for external health agencies such as tissue viability and dietetic.

We found that the environment on the dementia care unit was not ‘dementia friendly’. The registered manager told us that refurbishment throughout the unit had been planned.

We have made a recommendation about adaptation of the dementia care unit.

People who lived at the service and their representatives told us that they felt involved in their care and had been provided with the opportunity to read their care plans.

We found that staff approach to people who lived at the service was not consistent. We observed some positive interactions and also some instances when people's needs were not responded to.

We have made a recommendation about staff training in relation to providing specialist dementia care.

We looked at minutes for 'resident and relative' meetings and found that the registered manager held meetings on a regular basis.

We found a significant difference in the standard of care plan writing and risk management when we compared records from the general nursing unit and dementia care unit. Across the two care files we looked at on the general nursing unit we found a good standard of person centred care planning, with the exception of nutritional assessment. People's needs and preferences had been assessed thoroughly prior to admission and detailed admission assessments had been undertaken when the person arrived at the service. We also found that people's life stories, hobbies and interests had been recorded and staff understood the holistic needs of the people we pathway tracked from the general nursing unit.

When we looked at care records on the dementia care unit, we found a significant difference in the quality of care planning and saw that care plans were not always reflective of the person's current needs.

We observed people on the general nursing unit to be dressed in clean and personalised clothing. People appeared to have been supported to maintain good personal hygiene. We found that this standard of personalised care was not always provid

The feedback we received from people was very positive. Everyone we spoke with felt that there had been significant improvements in all aspects of the service. One relative said, 'The place is unrecognisable. There seems to be more staff and it's much cleaner.' A professional commented, 'The manager has worked very hard and really turned things around. I find them very responsive and keen to move forward.'

As part of the inspection we consulted the Local Authority contracts monitoring department, who told us that they had been monitoring standards closely at the home and were satisfied that all the improvements they had previously requested of the home, had been made.

Residents and relatives that we consulted expressed satisfaction with their (or their loved one's) care. Their comments included:

'This is a good place, they are doing a good job!'

'They have been great! Absolutely great! I visit every day and I feel like they are my family.'

'I have had a very difficult year. I couldn't have got through it without Val (the manager) and the staff here. They have been a huge source of support for me.'

We consulted a number of people who lived at the home, some relatives and also some visiting professionals. The majority of people we spoke with told us they had seen a number of improvements at the home in various areas. People told us that they had seen particular improvements in recent weeks.

Comments we received included;

'There have been some great improvements. There are lots of new faces and I think that it is a good thing.'

'The place had sharpened up a lot.'

'I went to a meeting with the new manager, these are going to be every month now. I think that is a good idea.'

'I am thrilled. I am so pleased with the way things are progressing.'

'The manager definitely seems to know what she's doing. She's bringing people in that do as well. They've brought three new nurses in, who seem very good.'

'I cannot believe the difference in this home in the last four weeks.'

We found evidence that there were a number of improvements in the areas we inspected. However, we also noted that there were further areas still to be addressed.

During this inspection we assessed the progress made by the provider in relation to the warning notices. We found that some minor improvements had been made, but that there were a number of issues still outstanding that had not been addressed.

During our visit we spoke with a number of residents and some visiting relatives. We received some positive feedback from people about the service. These comments included;

'(Name removed) has come on in leaps and bounds since she came here. We are really pleased!'

'I think that they really care here. That is the difference.'

'There are some great carers. They are very kind.'

We saw some examples of improvements that had been made since the last inspection. These included increased efforts on the part of the new manager to involve residents and families in the running of the home and the resurrection of an activities programme for residents.

Whilst the feedback we received during our visit was generally positive, we had also received a number of concerns from other professionals and relatives since the last inspection.

During this inspection we found evidence that the service had failed to take action to meet compliance actions that we set in all the areas we inspected.