Bryher Court Nursing Home

Bryher Court Nursing Home is a residential care home providing regulated activities personal and nursing care to up to 45 people. The service provides support to people who were living with a range of health care needs associated with their age and physical health conditions. At the time of our inspection there were 34 people using the service.

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

Improvements were needed to some aspects of risk management. Systems were not robust enough to demonstrate safety was always managed effectively. Improvements were needed to recruitment procedures to ensure there was a full employment history for each staff member.

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

Care plans and records did not always contain all the information staff needed to support people. An audit system was in place but this had not identified all the shortfalls we found. The manager and provider had oversight of the service and had implemented improvements which needed further time to be embedded into everyday practice. This included training, quality assurance feedback and accident and incident monitoring.

The home was clean and tidy throughout. Systems were in place to help ensure people were protected from the risk of infection. Staff understood safeguarding risks and procedures and knew what to do if concerns were raised. People were supported to receive their medicines when they needed them. There were enough staff working in the service to meet people’s needs.

People told us they were happy living at the home and we observed an open and friendly relationship between staff and people. Staff knew people well; they understood peoples care and support needs and were committed to providing good care. One staff member said, “We always try to do our best for people.” We identified areas that suggested care and support was not always person-centred. The provider and manager addressed this immediately. People, relatives and staff told us there was a positive culture at the home. They said the manager was approachable and they could speak with them at any time.

People were supported to maintain and improve their health with support from health care professionals. People were supported to have enough to eat and drink throughout the day to meet their nutritional and health needs, individual choices and preferences.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic. The service provided care and support to 2 people with learning disabilities and autism. The manager was aware of the principles of RSRCRC. At the time of the inspection these people’s needs required care from nurses due to their health needs .

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

We undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

Rating at last inspection

The last rating for this service was Good (published 17 November 2017).

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.

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 changed from Good to Requires Improvement based on the findings of this inspection.

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 Bryher Court Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to Safe care and treatment, Need for consent and Good governance.

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.

We found the following examples of good practice.

Staff were provided with adequate supplies of personal protective equipment (PPE) and were seen to be wearing this appropriately. At the start of the outbreak staff had started to wear visors in addition to the recommended PPE. They continued to wear these as additional protection.

Staff had received specific Covid-19 training and this included guidance for staff about how to put on and take off PPE safely. They were seen to be following correct infection prevention and control (IPC) practices. Hand sanitiser was readily available throughout the home. Regular testing for people and staff was taking place.

During the outbreak people remained in their bedrooms. Some people did not always like their bedroom doors closed. Therefore, staff repositioned people’s beds as far from the door as possible, but also positioned people so they could see outside of the door and still feel part of the home.

As far as possible staff maintained social distancing from each other. For example, limited numbers of staff in the staff room or on breaks together. Although people were now able to leave their rooms most people had chosen not to. Therefore, social distancing for people who used the lounge was managed with ease. We heard staff engaging with people both in their bedrooms and the lounge throughout our time at the home.

In March 2016 and December 2016 the overall rating for this service was Inadequate and we took enforcement action against the provider and placed the service into Special Measures. Special Measures means a service is kept under review and if needed urgent enforcement action can be taken. The local authority put a restriction on admissions to prevent the service from admitting people until improvements were made. On the 3 and 4 July 2017 we inspected to see if improvements had taken place. The service was rated as Requires Improvement with enforcement action still in place whilst we continued to monitor the service to ensure that improvements continued and became part of the integral systems and processes. At this inspection we found improvements had been made and we have withdrawn the enforcement action previously issued. The provider is now meeting all regulations. We will continue to monitor the service to ensure this level of service is maintained.

The registered manager had left employment at the home but was currently still registered with CQC. The deputy manager had been acting as manager supported by a consultant employed by the provider and the provider, who was present at the home on an almost daily basis. A new manager had been recruited and they had started work the week prior to this inspection. We were told by the provider the newly recruited manager would be registering with CQC. 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 and associated regulations about how the service is run.

Documentation had been greatly improved with new care plan formats introduced. Care plans were detailed and person centred. Staff had information that enabled them to provide support in line with people’s wishes. Personal and environmental risk assessments took place to ensure people’s safety was maintained. These included risks assessments for people’s specific individual risks and regular maintenance and safety checks for services and equipment. Monitoring and documentation of accidents, incidents and falls was robust. Staff had a good understanding of safeguarding and were able to tell us how they would report a safeguarding concern.

There were systems to assess quality and identify any potential improvements to the service. This included a robust programme of audits completed on a regular basis. All audits included analysis and actions and had been signed and dated when actions had been addressed. Safe medicine procedures made sure people received their medicines consistently and safely. Systems were in place to ensure medicines were ordered, stored and disposed of appropriately. People’s nutrition and health was monitored. Meal choices were available and we received good feedback regarding the meals provided. People's weights were monitored and any changes reported.

Relatives felt that communication was good and they were always contacted if needed.

There was a complaints policy and procedure at the home. People were aware how to raise any complaints or concerns and told us they would be happy to do this if needed. Staff told us they supported people to discuss any issues.

People were supported by staff who were kind and caring. Staff respected people's dignity and right to privacy and knew people well. People were encouraged to participate in meaningful activities and to continue with hobbies that they had previously enjoyed. Staff were aware of how people they liked their care to be provided. Decisions regarding people’s consent and capacity had been assessed and recorded. Staff understood the importance of involving people in decisions and encouraging and supporting people’s independence when possible. People were supported to attend appointments and referrals were made to other health professionals when needed.

Recruitment processes were being followed to make sure required checks took place before people began work at the home. Staff received appropriate training and training was monitored to ensure it was kept up to date. Staff competencies were assessed and there was an on-going programme for staff to receive supervision. Regular meetings took place for staff to ensure they were kept informed of changes and developments. Residents, relatives and visiting professionals also provided meaningful feedback all of which was analysed and used to take the service forward and encourage improvement. People, relatives and staff spoke positively about Bryher Court Nursing Home and the on-going improvements.

At the previous comprehensive inspection in March 2016 the overall rating for this service was Inadequate. Six breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified and we took enforcement action against the provider and we placed the service into Special Measures. Special Measures means a service will be kept under review and if needed could be escalated to urgent enforcement action. The local authority put an embargo in place to prevent the service from admitting people until improvements were made.

A further inspection was carried out in December 2016 where we found there was not enough improvement to take the provider out of special measures. We found a number of continued breaches of the of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating remained as inadequate and the service stayed in special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found. This inspection on the 3 and 4 July 2017 was to see what improvements had taken place. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The registered manager had recently left employment at the home but was currently still registered with CQC. The deputy manager was acting as manager supported by a consultant employed by the provider and the provider. 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 and associated regulations about how the service is run.

There were a number of planned improvements and action plans which had not yet been introduced. Therefore we were unable to make a judgment on how effective these were. This is why the rating is Requires Improvement and there is a continued breach on Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. A further timescale has been agreed for these improvements to be made. All areas will be reviewed at the next inspection to ensure they are fully implemented and embedded into practice.

People’s care documentation was not accurate, complete and contemporaneous. Care plans for specific health needs were not detailed and some care plans and records had not been written in a timely manner. Documentation needed to be more robust. Systems to assess and monitor the quality of service needed further improvement. Changes to the way the service was audited were being introduced but were still in their infancy. Some audits had been completed but improvements needed to continue with management and provider oversight to ensure that robust measures are introduced and maintained. We have asked the provider to make improvements in these areas within a set timescale.

There were on-going improvements to ensure the service was safe. Medicines processes had been audited and reviewed. Registered Nurses (RN’s) had competencies assessed to ensure that appropriate standards were maintained. A training programme was now overseen by the administrator who ensured that training was booked and attended by staff when required.

Fire safety training and checks were in place to ensure peoples safety. This included fire drills and equipment available around the building for staff to use in the event of an emergency evacuation being required.

Recruitment processes were being followed to make sure required checks took place before staff began work at the home. Information had been sought from agencies regarding staff training and experience before they worked at Bryher Court Nursing Home. An agency profile folder was available so staff booking agency cover had access to information about the staff member. Improvements were being implemented to ensure staff received a thorough induction period when they began work at the home. There was an on-going programme for staff to receive regular one to one and group supervision.

Staff had a good understanding of adult safeguarding and were able to tell us how they would report a safeguarding concern. People told us they felt safe and well cared for. The maintenance employee had robust records to demonstrate maintenance and safety checks for services and equipment had been completed.

Management and staff had an understanding of the mental capacity act (MCA) 2005 and deprivation of liberty safeguards (DoLS) and understood this was decision specific. Information was recorded to inform staff who was legally entitled to be involved in decisions made about people’s care. Staff understood the importance of involving people in all day to day choices. People were able to spend their time how they chose and told us they felt involved in decisions. An activity programme was available, this included arts, crafts, music and entertainment. People had been asked for their feedback and involved in choosing what activities were planned in the future.

People were supported by staff who were patient, kind and caring. We saw staff had a good rapport with people and clearly knew them well. Staff respected people's dignity and right to privacy.

People’s nutritional needs were met. Staff were aware of people’s specific dietary needs, including those who required pureed or fortified meals. Meal choices were provided and people’s weights were monitored to identify any issues or concerns. Referrals were made to other health professionals if needed.

People’s feedback had been sought. Meetings had taken place and further staff meetings were scheduled. People, relatives and staff spoke positively about the values and culture at Bryher Court Nursing Home and the on-going improvements. Relatives gave positive feedback about the home and felt welcome to visit at all times. A complaints procedure was displayed in the main entrance area. People told us they would speak to the staff or management if they had any concerns. Relatives who had complained in the past felt that this had been responded to and the issue addressed.

Improvements were required to ensure Bryher Court Nursing Home met all areas of Regulation. Further improvements are needed and those already introduced need to be maintained to ensure the changes continued long term and systems and processes became fully embedded into practice. We found a breach of Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of the report.

Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two lifts.

This was an unannounced inspection which took place on 12 and 14 December 2016.

At a comprehensive inspection in March 2016 the overall rating for this service was Inadequate. We placed the service into special measures. Six breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found the provider did not have systems in place to continually assess and monitor the quality of service provided. People’s safety had not been maintained as maintenance checks including water safety and risk assessments had not been completed. Electrical testing had not taken place and fire risk assessments and personal emergency evacuation plans (PEEPS) were not completed. New staff had not received an adequate induction; staff competencies including Registered Nurses (RN) had not been completed. Training records had not been updated and mandatory training had not taken place for many staff before they worked unsupervised. People’s care records were not up to date and accurate and did not reflect changes to care needs. Records were task orientated and did not evidence person centred care. Some records were not written respecting people’s privacy and dignity. Medicine procedures needed to be improved to ensure they followed best practice guidelines and people received their medicines in a safe consistent manner.

The provider had not ensured that service users were protected. We issued Warning Notices for Regulation 9, Person-centred care, Regulation 15, Premises and Equipment, Regulation 17, Good Governance and Regulation 18, Staffing. We also identified two further breaches for Regulation 10, Dignity and Respect and Regulation 12, Safe Care and Treatment. The service was rated as inadequate and placed into Special Measures. Special Measures means a service will be kept under review and if needed could be escalated to urgent enforcement action.

The local authority put an embargo in place to prevent the service from admitting people until improvements were made.

The service was required to address the enforcement actions within a designated timescale. This inspection was to check that this had taken place.

The provider sent us an action plan stating they would have addressed the further breaches of regulation by June 2016.

At this inspection we found although improvements had been made in relation to the premises, dignity, respect and person centred care. Areas identified in Warning Notices for Regulation 17 and 18 had not been addressed. This included basic staff training for all staff being kept up to date and staff competency assessments. Some Registered Nurses (RN) did not have any training and competencies completed and had been working unsupervised at night. Training and competency assessments had not been carried out before agency staff worked at Bryher Court, this included RNs who worked unsupervised at night.

Further concerns were identified with regards to Regulation 12 for unsafe medicine procedures. People’s medicines were not stored safely and in line with legal requirements. People did not always receive their medicines as prescribed. There had been medicine errors and some medicines were found with no documentation or information in place to show when or why they had been prescribed. Despite some initial action taken by the provider to monitor and update staff regarding safe medication procedures, this had not been robust or effective. Medicine competencies had taken place for some RNs but not all RNS working unsupervised had been assessed. Competency documentation did not include full detail to show what had been checked and discussed. A number of issues relating to medicine procedure and documentation were found during this inspection. As required’ (PRN) medication procedures were not being followed. PRN guidance had not been updated in all MAR charts or recorded accurately. Medications were not being stored safely, dated on opening or monitored to ensure they were still within their safe shelf life. We found medications which expired in 2015. We also found unexplained gaps in the recording of topical cream application.

There was a registered manager in post. 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 and associated regulations about how the service is run. The registered manager had the job title of matron, some people and relatives referred to them as the manager and others referred to them as matron.

Changes to the care plan format and records meant they were more person centred and showed regard for people’s privacy and dignity. Information was no longer displayed on walls and in communal areas. Further improvement were still required to ensure that all care documentation corresponded to ensure staff were aware of peoples individual care needs.

People’s safety was still being compromised in a number of areas. The provider had not made adequate improvements to address areas identified in the Warning Notice for Regulation 17. Documentation was still not accurate or up to date in people’s care files specifically in relation to skin integrity, pressure ulcer monitoring and wound documentation processes. Repositioning guidance that had been updated in care plans had not been updated in room folders or included on people’s skin integrity documentation. This meant that documentation for staff was conflicting. Repositioning timescales were not clear and repositioning had not always taken place in the designated timescales. This could impact on appropriate care delivery and put people at further risk of developing pressure damage. We found one incident where a wound was documented on a wound assessment form but no other documentation completed and staff were not aware of the outcome. It was unclear what treatment had taken place, how the wound had been monitored or the initial cause.

We had previously identified concerns regarding quality assurance. Quality assurance systems were in place but had not still identified the shortfalls in training which we identified at the previous inspection. Issues had been identified with regards to the PRN guidance and medicine improvements, however these had not been actioned and addressed in a timely manner. Documentation inconsistencies although mentioned in audits had not been appropriately addressed to ensure all information for staff was accurate and up to date. The registered provider and manager lacked oversight of all the systems and processes in place to ensure safe standards were maintained. The provider although visiting the home regularly did not carry out any reviews of auditing, assessments of care provision or monitoring to ensure the home was meeting regulatory requirements. Auditing processes needed further work to ensure they were detailed, actioned and reviewed. New processes were yet to become fully embedded into everyday practice and a number of issues identified at the last inspection had not been addressed sufficiently to meet the Warning Notice for Regulation 17.

People and visitors we spoke with were complimentary about the caring nature of some of the staff but many were unaware who the registered manager was. People told us if they had concerns they would raise them with the activity person or nursing and care staff. Care staff were kind and caring however staff needed to be aware that discussions regarding people’s health and welfare should not take place in front of others in communal areas.

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people’s health.

Recruitment was on going. People had safety checks completed and checks were made to ensure RNs had appropriate registration in place, However recruitment records lacked detail. Interview questions were not clear, so it was difficult to determine what had been discussed. When people had gaps in employment history or references were not detailed there was no information to show how this had been explored.

The overall rating for this provider is 'Inadequate'. At the last comprehensive inspection this provider was placed into special measures by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

At this inspection there was not enough improvement to take the provider out of special measures. We found a number of continued breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

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

Accommodation is arranged over three floors, and access to each floor can be gained via stairs or the two passenger lifts.

This was an unannounced inspection which took place on 21, 22 and 23 March 2016.

Bryher Court did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

An acting manager had been appointed and had worked at the service since December 2015. The acting manager told us they would be starting their application to register as manager in the near future.

This inspection took place to follow up on previous breaches identified at the inspection in March 2015. Two regulations which were in breach at the last inspection had been met at this inspection; however, we found four continued breaches and two new further breaches of regulation.

The provider sent us an action plan following the previous inspection telling us the actions they would take to ensure they met regulations. However, we found that these had not been completed to ensure the provider met all registration requirements.

The provider did not have a system in place to continually assess and monitor the quality of service provided. A number of areas identified in the last inspection had not been addressed by the provider to ensure the service met regulations. People’s safety had not been maintained as a number of required checks and risk assessments had not been completed. This included water temperature checks to all areas of the home, legionella risk assessments completed by an appropriately trained professional to access and monitor the risk of water borne infection. Personal appliance testing (PAT) testing was not up to date and some electrical items had no evidence of ever being checked to ensure they did not present a safety or fire risk to people. Fire risk assessments and personal emergency evacuation plans (PEEPS) were not in place for everyone living at Bryher Court. This meant people’s safety had not been maintained.

Although recruitment systems were in place. Induction information for trained staff had not been completed. There was no evidence to show how RNs competencies had been assessed and reviewed. Some staff had not received required ‘in-house’ training before working unsupervised. This included fire training, which had not taken place since 2013. Training records had not been maintained and it was not possible to get a clear picture of when staff had attended or training needed to be updated.

People’s care plans and other care related documentation, including charts and risk assessments had not been completed consistently to ensure information about people was current and accurate. When incidents had occurred these had not been documented in people’s care files to ensure all staff were aware of wounds and treatment required. Care plans currently in place for people did not reflect recent changes to care and people’s daily notes were task orientated, and did not evidence person centred care. Information about people’s care and nutritional needs were displayed on bedroom walls and in public areas. We found that some wording used did not take into consideration people’s privacy or refer to their care needs in a dignified manner.

Medicine procedures needed to be reviewed to ensure they were following best practice guidelines and ensure people received their medicine in a safe and consistent manner; documentation around the application of topical creams was not consistent.

A system of supervision had been introduced and staff told us they felt supported. The acting manager was also in the process of introducing a variety of staff meetings to ensure staff were kept informed of any changes. We saw that staff knew people well and displayed kindness and compassion when providing care. Relatives felt informed when changes had occurred and told us they felt welcome to visit at any time.

A complaints procedure had been implemented since the last inspection. People felt able to talk to staff and told us they would speak to any of the staff if they had any concerns.

People were encouraged to spend their time how they chose. A varied activity programme was available for people and we saw people walking around the service, accessing the garden or sitting in their room as they chose.

Meals were well presented and people told us that meals provided were of a good standard, with alternatives available if they did not like what was on the menu that day. People’s weights were regularly monitored, with a weights tracker in place to identify any changes and people were referred to other health professionals if required.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, our observations during the inspection and the records we looked at. We spoke with 14 service users, a visiting relative, most care staff, each registered nurse and the manager.

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

Is the service safe?

Bryher Court Nursing Home provides accommodation over four floors. Although some areas of the service had recently been redecorated, we found that other areas required repair, renewal and redecoration. One person told us 'Some parts of the building look quite knocked about and I don't like the sticky tape repairs on the stair carpets'. We found that there was no clear oversight or structure to address required work. People were not cared for in a safe and suitable environment because there was insufficient planning and activity to ensure that maintenance and remedial work was carried out. A compliance action has been set for this and the provider must tell us how they plan to improve.

Care plans had recently been reviewed and transferred to a new system. We found that care documents and risk assessments were incomplete for one person and their previous care plan was not available for staff to refer to. An incorrect care plan had been used for a person on respite care and their required risk assessments had not been completed. This meant that people were not protected from the risks of inappropriate or unsafe care because care planning did not identify how people should be safely supported. A compliance action has been set for this and the provider must tell us how they plan to improve.

We found that some records were confusing and difficult to follow because some staff had entered incorrect dates, they were incomplete or there was no clear reason why some records were in place. This meant that these records were not fit for purpose because they did not accurately or fully record the information they were intended to contain. A compliance action has been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty safeguards (DoLS) which apply to care homes. This is where restrictions may be placed on some people to help keep them safe. While no DoLS applications had needed to be submitted, suitable policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

The service had taken appropriate steps to improve the way medicines were managed. Medicines were administered when they should have been, administration charts were checked and people received medicine from staff who had been appropriately trained and competency assessed. One person told us 'I've never had any problems with getting my medicines, the staff have been very good'.

Is the service effective?

People we spoke with told us they were happy with the care delivered and that their needs had mostly been met. One person told us 'On the whole I'm happy with the care I've received, but I have needed to speak to staff about how they do a few things when they support me'.

Most people's health and care needs were initially assessed, but because some care plans were incomplete, it was not possible to confirm that all people's ongoing needs were being met.

Is the service caring?

People spoke positively about the staff. They said staff were kind and attentive. People said that staff spoke with them respectfully and felt that their privacy and dignity was respected. People's preferred names were recorded in their care plans and people told us that staff always used these names. We saw that people were dressed in clean clothes appropriate to the care and support they received. Our observation found that staff usually knocked on people's door before entering their bedroom. However, we discussed with the manager we had seen an isolated occasion during this inspection when this was not the case.

Is the service responsive?

People's admission needs had been assessed before they moved to Bryher Court Nursing Home. This meant that the service knew the support and facilities needed to meet people's identified needs. Regular monitoring of people's health, associated risks and their social needs identified when particular measures were required to help keep people safe. However, we saw that reviews and risk assessment processes did not happen in all cases. This meant that the service could not demonstrate that it was responsive to each person's individual needs.

Is the service well-led?

We saw that the service had a range of measures in place intended to monitor the quality of the service provided. However, some checks had not taken place. For example, walk around safety checks of the service environment, although in place, were not completed. This meant that there was not an oversight of the quality and safety of the service provided. We found that although the provider visited the service regularly, there was no record of planned, preventative or ongoing building maintenance. Records of quality surveys and minutes of resident and relative meetings, completed in March 2014, were not available to be seen. A compliance action has been set about how the service assessed and monitored the quality of the service it provides. The provider must tell us how they plan to improve.

Staff told us and discussion with them found that they were clear about their roles and responsibilities. During the inspection we received positive feedback form residents about the manager and staff. Staff felt that the manager was hardworking, approachable and supportive and felt that recent changes introduced to the service were positive.

We saw that staff gained people’s consent before they undertook any care or treatment.

We looked at the systems and processes in place for the safe management of medicines and found that there were shortfalls in the recording of medicines.

Although it was busy at the home we saw that there were sufficient staff to meet the care needs of people who lived there.

We found that staff knew people well, and the care people received was good. However, not all of the records were fully completed.

We found that there were plans in place to look after people safely and in a way that met each person's specific needs. We observed staff speak to people with kindness and respect.

Two members of staff that we spoke with told us that the manager was always available and they felt well supported.