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Harewood Court Nursing Home Good

We are carrying out a review of quality at Harewood Court Nursing Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Reports


Inspection carried out on 12 December 2019

During a routine inspection

About the service

Harewood Court Nursing Home provides nursing and personal care for a maximum of 40 older people, some of whom are living with dementia. At the time of our inspection there were 32 people living at the service.

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

Overall, the provider maintained appropriate staffing levels to ensure people's needs could be met safely. We have made a recommendation that the provider continues to monitor sufficiency of staffing. Robust recruitment procedures ensured suitable staff were employed. People were supported by staff who understood how to identify and report potential abuse. Medicines were managed so people received their medicines as prescribed. People told us they felt safe and risks to people’s health and safety were managed well. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again.

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. People had the support they needed to maintain a balanced diet and good health. Staff received training and support to give them the knowledge and skills needed to care for people safely and effectively.

Staff promoted positive, caring relationships with the people who lived at the service. They knew how people preferred their care and support to be provided. Staff respected people’s privacy and dignity and promoted independence, equality and diversity. People and their relatives were involved in the planning and delivery of their care.

People had access to a good range of activities and told us they enjoyed these. People's care plans were individualised and supported a person-centred approach. Staff said they read and followed these. People's wishes regarding their end of life care were established, so these could be addressed at the appropriate time. People and relatives were confident to raise issues and concerns. Complaints procedures were effective.

There was positive leadership in the service. People and their relatives spoke highly of the provider and registered manager. They were described as approachable. Audits and monitoring procedures were used effectively to manage the service and to make improvements where needed.

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 6 December 2018) with one breach 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.

Why we inspected

This was a planned inspection based on the previous rating.

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.

Inspection carried out on 3 October 2018

During a routine inspection

This comprehensive unannounced inspection took place on 3 and 10 October 2018.

Harewood Court Nursing Home 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. Harewood Court Nursing Home provides nursing and personal care for a maximum of 40 older people, some of whom are living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with 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.

We last inspected this service in August 2017. At that time, we found, improvements had been made to the service following our previous inspections when we had identified a number of concerns. We rated the service Requires improvement. We completed this comprehensive inspection to check whether the improvements had been sustained. We found that not all of them had and there were some shortfalls within the service.

On this inspection, the service has been rated as Requires Improvement. Providers should be aiming to achieve and sustain a rating of 'Good' or 'Outstanding'. Good care is the minimum that people receiving services should expect and deserve to receive; we found systems in place to ensure improvements were made and sustained had not been not fully effective.

We found some concerns relating to the records of management of medicines. Although the provider took swift action at the time of the inspection; quality assurance systems had not ensured on-going improvements around medicines management were sustained.

We received mixed views from people who used the service, relatives and staff about staffing levels. This related to the supervision of communal areas and night staffing sufficiency. We have recommended that the provider reviews the deployment and organisation of staff to ensure there are always sufficient staff at the times they are needed.

People were protected from abuse and told us they felt safe. Staff were recruited safely. Risk assessments contained enough detail to enable staff to keep people safe from harm. Risk assessments were reviewed regularly, and any changes were incorporated into people's care plans.

People lived in an environment that was cleaned daily. The home and equipment were maintained to minimise the risk of cross infection. Health and safety checks were undertaken and there were

appropriate procedures in place in the event of an emergency.

People told us they enjoyed the food at the service. There was a varied menu available to people and specialist diets were catered for. People were supported to maintain their health. They received consistent care and had access to health professionals as required.

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. People were supported to make choices and retain their independence.

Staff felt well supported and received appropriate training which was updated when needed. Staff said they enjoyed working for the service. We were told there was good teamwork and a positive culture within the service.

People we spoke with told us they were happy with the care they received and were complimentary about the staff who supported them. Overall, we saw individualised caring interactions between staff and people who used the service. People were treated with dignity and respect.

People received support from staff that understood their needs and preferences. Care plans were comprehensive to make sure staff had all the information required to support people as they wished. Staff

Inspection carried out on 1 August 2017

During a routine inspection

This was an unannounced inspection carried out on the 1 August 2017.

At the last inspection in November/December 2016 we found the provider had breached five regulations associated with the Health and Social Care Act 2008.

At this inspection, we found improvements had been made with regard to these breaches and the provider is now compliant with the regulations.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who may be living with dementia.

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.

At this inspection, we found medicines were better organised and managed. Medicines were stored correctly and medication administration records (MARs) showed people received their medicines as prescribed. Staff were trained and competent to administer and manage medicines.

Systems for assisting people to make decisions in line with the requirements of the Mental Capacity Act 2005 (MCA) had improved. There were policies and procedures in place in relation to MCA. Staff were trained in the principles of MCA and could describe how people were supported to make decisions. Where people did not have capacity decisions were made in their best interests.

Recruitment was now managed safely. Recruitment procedures were robust enough to ensure staff were suitable and fit to be employed at the service. Staff showed a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe from abuse

Staffing arrangements had improved; we saw staff worked as a team and each unit had a manager. Senior staff had also been trained to administer medication, which meant the nurse on duty each day had more time to attend to people’s nursing needs.

Systems had now been established and were operated effectively to assess, monitor and improve the service. Staff and relatives we spoke with told us the management team led the service well and had driven improvements. A range of checks and audits were undertaken to ensure people's care and the environment of the home were safe and effective.

Overall, staff were trained and supervised appropriately which meant they were able to carry out their role effectively. Staff received support to help them understand how to deliver good care and meet people’s individual needs. We recommended the provider reviews how staff accessed training to ensure all staff were enabled to complete their training in a timely way, as we were told this was completed by staff in their own time.

Support plans covered what was important to people; what their interests were and how they wished to be supported. Staff understood people's individual needs in relation to their care and showed they had developed positive relationships with people. There were systems which ensured risk was well managed. Staff were aware of the risks people faced and what they could do to manage these.

People were provided with the food and drink they liked to eat. There were choices available on the menus and alternatives if people didn't like what was on offer. Nutritional risk was assessed and people’s weight was monitored. Health, care and support needs were assessed and met by prompt and regular contact with health professionals.

There were systems in place to ensure complaints and concerns were fully investigated. We saw the manager and provider had dealt appropriately with any complaints received.

Inspection carried out on 29 November 2016

During a routine inspection

This inspection took place on 29 November 2016, 1 and 7 December 2016. Days one and two were unannounced and day three was announced. At the last inspection in February 2016 we found the provider was in breach of four regulations related to medicines and the premises, the need for consent, person centred care and quality assurance. We also issued a fixed penalty notice as the provider did not have the current CQC rating of the home on display.

At this inspection in November/December 2016 we found the provider was still in breach of three of these regulations and was in breach of an additional two regulations related to staffing and fit and proper persons employed. The provider had made improvements in some areas; care plans were more informative on people’s care needs and gave guidance for staff on care needs. The certificates to show the home was maintained safely were available and in date. We also saw the current CQC rating for the home was on display.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who are living with dementia.

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.

Medicines management was not safe and we found some issues we identified at our last inspection in February 2016 had not been addressed. This continued to put people at risk of not receiving their medication as prescribed.

One person told us there were not enough staff and one person said staff did not come when they needed them. They also said they sometimes received their medication late. We found people were not always cared for, or supported by, enough skilled and experienced staff to meet their needs. There was only one nurse on duty at all times; to cover two floors of the home. The registered manager calculated staffing requirements on people’s level of funding and not their individual assessed needs.

Recruitment procedures were in place. However, for one staff member we found their Disclosure and Barring Service (DBS) check had not been checked for their employment at this home. The DBS checks assist employers in making safer recruitment decisions by checking prospective staff members are not barred from working with vulnerable people. For another staff member, their DBS had an error within it which could have affected the validity of the DBS.

The provider’s disciplinary procedures had not always been followed when concerns had been raised about staff member’s fitness and ability to carry out their duties. Systems in place were not robust and records did not clearly show the actions taken in these circumstances to ensure staff’s practice was safe.

Care plans we looked at contained risk assessments associated with people’s care and support needs which staff understood and followed to keep people safe. We saw there was a positive atmosphere in the service and people who used the service had developed good relationships with the staff team. Staff could recognise abuse and knew what action to take to ensure people’s safety.

We found the service was not fully meeting the legal requirements relating to the Mental Capacity Act 2005 (MCA) and these were the same concerns we raised at our inspection in February 2016. Mental capacity assessments were not specific to the decisions being assessed and there was conflicting information within capacity assessments which made it unclear as to whether people had capacity to make their own decisions. Mental capacity assessments undertaken were confusing and contradictory and showed a lack of understanding of the principles of the MCA.

Where people lacked capacity, relatives

Inspection carried out on 9 February 2016

During a routine inspection

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who are living with dementia.

This was an unannounced inspection carried out on 09 February 2016. At the last inspection in April 2015 we found the provider had breached two regulations associated with the Health and Social Care Act 2008. We found the provider did not have systems and processes in place to fully ensure the safety of the premises and assure compliance with national guidance. Where people did not have the capacity to consent, the provider did not always act in accordance with the legal requirements of the MCA 2005. At this inspection we found this was still the case with MCA.

At the time of the inspection there was no registered manager in post. However, there was a manager in post who had overall day to day control of the home. 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.

We looked at a sample of medicines and records for people living at the home as well as systems for the storage, ordering, administering, safekeeping, reviewing and disposing of medicines. We found the provider had not protected people against the risk of not receiving their medication as prescribed.

The gas certificate for the premises had expired on 03 January 2016. We were told by staff they were waiting for the provider to authorise the expenditure. We asked the manager to send us information when the gas check has been completed and a copy of the certificate. The information we requested was sent to us in a timely manner. However, we found the provider had not protected people against the risk of premises and equipment.

There were systems in place to make sure people were not deprived of their liberty unlawfully. However, we found mental capacity assessments were not specific to the decisions being assessed and did not show how decisions were made as required by the Mental Capacity Act 2005.

Care plans did not show how people who used the service would like to be cared for. There were no evidence individuals or their relatives were involved in the care planning process. We found the registered person had not protected people against the risk of not receiving person centred care.

We found the previous CQC inspection rating was not displayed in the home. The manager was unaware this had to be displayed.

We found the quality assurance monitoring systems in place were not robust as shortfalls in the service highlighted in the body of this report had not been identified through the audits carried out by the manager or provider.

We saw staff were patient and caring toward people in their care. People who were able told us they were happy living at Harewood Court and were complimentary about the staff.

We saw people were offered a choice of what to eat and given assistance, if they required it. The food was well presented and looked appetising. People were offered a choice of hot or cold drinks to go with their meal. A person who used the service told us, “The food is nice, very nice.” Another person said, “The food’s good, not bad.”

Robust recruitment procedures were in place and appropriate checks had been undertaken before staff began work. Staff demonstrated a good understanding of protecting vulnerable adults. They told us they were aware of how to detect signs of abuse and were aware of external agencies they could contact. They told us they knew how to contact the local safeguarding authority and the CQC if they had any concerns. They also told us they were aware of the whistle blowing policy and felt able to raise any concerns.

There was a complaints procedure available which en

Inspection carried out on To Be Confirmed

During a routine inspection

This was an unannounced inspection carried out on the 22 April 2015. At the last inspection in July 2014 we found the provider had breached four regulations associated with the Health and Social Care Act 2008.

We found there were not sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity and that medicines were not managed safely. We saw there were not suitable arrangements in place to ensure the dignity, privacy and independence of people who used the service and that people were not protected against the risks of unsafe or inappropriate care or treatment arising from a lack of proper information about them by means of the maintenance of accurate records. We also found that the systems in place to monitor the quality of service delivery were not effective.

We told the provider they needed to take action and we received a report in December 2014 setting out the action they would take to meet the regulations. At this inspection we found improvements had been made with regard to these breaches. However, we found other areas where improvements were needed.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who are living with dementia.

At the time of the inspection there was no 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.

We looked around the premises and found there were safety concerns regarding the premises. Window restrictors were not in place on windows that opened wide enough for people to fall out of and risk assessments had not been undertaken regarding the use of them. This was a breach of Regulation 12 (1) (d) Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the end of this report.

There were systems in place to make sure people were not deprived of their liberty unlawfully. However, we found that mental capacity assessments were not specific to the decisions being assessed and did not show who had been involved in the assessments as is required by the Mental Capacity Act 2005. This was a breach of Regulation 11 (1) (3) Need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the end of this report.

Although staffing levels were provided as the home’s dependency assessment indicated, we found staff were not deployed efficiently at all times to ensure the needs of the people who used the service were fully met. We saw people had to wait for periods of time for their meals to be served and there were times when communal areas of the home were left unsupervised.

People who used the service told us they were overall, happy living at the service. They said they felt safe and overall, staff treated them well. We saw care practices were good. Staff respected people’s choices and treated them with dignity and respect. We noted however, that people were not always involved in decisions affecting their care and support and care plans did not show how people had been involved in developing their plans of care.

People were encouraged to maintain good health and received the support they needed to do this. Overall, medication was managed safely and people received their medication when they needed it. People’s views on food and menus in the home were mixed. We saw people received regular drinks and snacks to make sure their nutrition and hydration needs were met.

Robust recruitment procedures were in place and appropriate checks had been undertaken before staff began work. Staff said they felt well supported in their role and received the training and supervision they needed. Records we looked at showed a number of staff needed to update or complete their mandatory training. The manager had a plan in place to ensure this was done and staff’s practice was up to date.

People who used the service were involved in a wide range of activities within the home. Most people we spoke with said they enjoyed these. However, some people said they would like to get out more often.

Staff spoke positively about the manager of the home saying they were approachable. They said they had confidence in the manager.

There were systems in place to assess and monitor the quality of the service; which included regular audits of the home. These were not always fully effective. Some of the records we looked at did not show evidence that improvements identified through audit were always completed.

Inspection carried out on 22 and 28 July 2014

During a routine inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2012 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2012, and to pilot a new process being introduced by CQC which looks at the overall quality of the service.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who were living with dementia. At the time of our visit there were 34 people living at Harewood Court.

This inspection was unannounced. At our last inspection in January 2014 we had identified breaches of regulations related to care and welfare, the management of medicines and staffing levels. Following this visit the provider sent us an action plan telling us the improvements they were going to make. During this inspection we looked to see if these improvements had been made. We found improvements still needed to be made in each of the areas where we had previously raised our concerns.

The Registered Manager, who was also a director of the provider group who own Harewood Court, had been in post since 2012.  A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People were not always protected against the risks associated with the unsafe use and management of medicines, particularly following admission or readmission to the service. Although a new medicines system had been introduced, the service’s policy and procedure had not been updated to provide staff with the necessary guidance.

People who used the service, their relatives and staff all told us there were not enough staff at the service. We saw this had led to some routines that focussed on tasks rather than the person when supporting people who required additional support.

Although we found a lack of information related to the requirements of the Mental Capacity Act 2005, referrals had been made to the local authority where people required their support to be authorised as it restricted their freedom.  We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards.

We had raised concerns at our first visit regarding aspects of cleanliness and infection control and fire evacuation procedures; however, these had been addressed for our return visit.

Staff received training and supervision to assist them in undertaking their role. We raised concerns about the lack of support and guidance provided to volunteers.

People were supported to maintain a balanced diet. Where people were at risk of malnutrition appropriate risk assessments were in place and people were supported to maintain a good nutritional intake. Catering staff worked with care staff to identify those people requiring fortified diets.

People were supported to access appropriate health professionals where they experienced a change in their health and well-being.

Care was not always delivered in a way that was responsive to people’s individual needs. Some practice was task oriented and lacked compassion. Some care records did not reflect people’s current needs and had not been updated.

People who had not had reason to complain told us they were aware of how to make a complaint if necessary. However, two people who had cause to complain had poor responses to the concerns they raised.  The wording of the provider’s whistleblowing policy and response to complaints actively discouraged people from raising concerns.

People had access to in-house activities that were run by staff at the service, external activity organisers and volunteers.

The management arrangements made it difficult to be clear about individual’s roles and responsibilities. The leadership team did not always act in a way that set a positive example to more junior staff.

Quality monitoring processes did not always identify shortfalls in quality. Where shortfalls had been identified these had not always been addressed.

We found different breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.  You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 20 January 2014

During an inspection in response to concerns

We revisited Harewood Court because we had received further concerns about the number of staff on duty and the standards of care and treatment people received.

During our visit we spoke with three people living at the home, three visitors, 15 members of staff, including the nurses on the day and night shifts and the Registered Manager.

We saw the staff were busy but appeared well organised and supportive of each other. The atmosphere was calm and staff were observed interacting warmly with people. There were no signs that anyone living at the home was in distress or unable to obtain timely support from the staff.

People�s needs were assessed but care and treatment was not always delivered in line with their individual care plan. We were unable to establish whether people�s wishes were being respected. Records about people who had asked to have a weekly bath or shower were incomplete and we were unable to determine if or when people had received their bath or shower.

Care and treatment was not always delivered in a way which ensured their safety and welfare. There was evidence in people�s care records to show that risk assessments had been completed. Where a risk had been identified, there was a plan in place to manage the risk. However, we found; plans which did not reflect the level of risk, delays in addressing the risk, lack of sufficient detail to manage the risk and the absence of records to show the requirements of the risk plan had been followed by staff.

Arrangements in relation to obtaining, recording, handling, administering, storing and the disposal of medicines were not always adequate. One person was left without sufficient medication. Medicines were not kept securely and there were several examples of people�s medicine not being accurately recorded.

There were not enough qualified, skilled and experienced staff to meet people�s needs. The staff and visitors we spoke with on the day of our visit told us they had no major concerns about the number of staff at the home. However, we found the one nurse on duty was called upon to deal with other issues whilst administering medication. Care staff were predominantly occupied meeting people�s essential needs and they had little time to spend with people and engage them in activities which enriched their experience of living at the home.

Inspection carried out on 16, 17 July 2013

During an inspection in response to concerns

We carried out this inspection because we had received anonymous concerns about the number of staff available and how some staff spoke to people who lived at the home.

We visited the home over two consecutive days, observing how people were cared for during the morning, afternoon and evening shifts.

We spoke with the Registered Manager and 12 members of staff. None of the staff we spoke with had observed people who used the service being spoken to or treated inappropriately. They told us that they would report any concerns to a manager and were confident they would be dealt with.

We observed the morning and evening routines and how well the staff were able to meet people�s needs. We saw that the staff were fully occupied meeting people�s essential needs, assisting people with their personal care and serving breakfast. All but one of the members of staff we spoke with expressed concerns about the number of staff on duty. However, the staff we spoke with were all confident that people's needs had been met and none could recall an occasion when a person had been neglected or harmed.

We found the home was calm and the staff well organised. Requests for assistance were met promptly. Staff spoke warmly and respectfully to people who in the main appeared relaxed and to enjoy the company of the staff.

Inspection carried out on 3 April 2013

During a routine inspection

On the day of our visit we found that Harewood Court Nursing Home was clean and well maintained. Carpets, furnishings and decorations were in good condition and there were no unpleasant odours. The people we saw looked clean, well dressed and cared for. We saw that the staff were attentive to people's needs and spoke to them respectfully. A person who used the service said �I get on well with all the staff, I feel safe here�

The visitors we spoke with told us that they were generally happy with the care their relatives received. One said �I�m quite satisfied that they are doing their best for mum�. Another relative said that the home was �Better now there are some activities.�

People who used the service had personalised care plans which were regularly reviewed an updated. The staff we spoke with understood the needs of the people they cared for and were involved in decisions about their care needs. The staff were clear about their personal responsibility to keep people safe. They understood how to protect vulnerable adults, the signs of abuse and how to report concerns. The staff had access to supervision and felt they could ask for advice or support from more senior colleagues at any time.

The manager had put in place systems to monitor the quality of the service. Quality information was regularly reviewed. The views of people who used the service and their relatives were used to identify areas for improvement.

Inspection carried out on 28 June 2012

During an inspection in response to concerns

We did not speak with any people who use the service as part of this inspection because we spent time talking with staff and observing infection control procedures within the home.

How ever we used a number of different methods to help us understand the experiences of people using the service. We gathered evidence of people�s experiences of the service by observing and talking with staff, reviewing care plans, policies and procedures for infection control. We found that the provider was meeting the standards we reviewed.

Inspection carried out on 5 April 2012

During an inspection looking at part of the service

We used a number of different methods to help us understand the experiences of people using the service because some people using the service had complex needs and they were not able to tell us their experiences. Other people using the service were able to tell us about their experiences.

The people we spoke with told us they were satisfied with their care. One person said, �I think the care is excellent.� Another person said, �I�m well looked after and have no problems.�

People who use the service told us they were asked about their care and able to make decisions. One person said, �I choose what I�m doing but let the staff know so they know I�m ok. Staff understand that somethings are my business.� Another person said, �They ask me when I want to get up and if I�m ready to go to bed. The staff talk to my family when they visit me.�

We spoke with two relatives of people who use the service who told us that they were very happy with the home. One relative said, "The home was very accommodating�. They had sent several letters to the home complementing them on the care that their relative received. Another relative said, �Mum is very comfortable here, and always looks clean. There was a problem before but they resolved it.�

Staff we spoke with told us people received appropriate care and their needs were met. They said people get good support with their healthcare needs and other professionals were consulted when appropriate.

Staff told us how they worked with people with differing needs. Most staff were unable to tell us how they sought agreement to the care and support that was offered to a person who was not able to communicate verbally. If people were not able to give consent due to lack of verbal communication, staff we spoke with were not able to explain how they knew if people were consenting to care.

Inspection carried out on 12 December 2011

During an inspection looking at part of the service

People who use the service were generally complimentary about staff and said they were well cared for. One person said, �The staff are nice. I like it here.� We asked people if they were being properly looked after. One person said, �Yes, we are.� Another person said, �They do alright.�

One visitor spoke with us about their relative and told us they did not have any concerns about the care. They said their relative had recently put weight on and were pleased with the support they had received. They said the �staff do their best�.

People told us the meals were satisfactory and they had enough to eat and drink.

People who required assistance generally told us they did not have to wait long for staff support. One person said, �The staff are nice. I like it here.� Another person said, �They do their best for me. Everything�s ok.�

Staff said the increased staffing levels have improved the quality of service for people and the staffing arrangements were adequate. Staff said the new arrangements for managing staff absences had made a big difference and they had dramatically reduced.

The nominated individual who was managing the service at the time of our inspection told us they would be submitting an application to register as manager shortly.

Inspection carried out on 30 August 2011

During an inspection looking at part of the service

Concerns were raised about staffing levels and management. Several people told us that there were not enough staff to meet people�s needs. Some people also raised concerns about the overall management of the service and did not think they were approachable.

One visitor said �It�s a very good service, we�re very happy. Staff work very, very, very hard. It�s the way staff treat people, it�s their attitude, it�s very good. And they have good surroundings. There�s not always enough staff, normally three sometimes four, and only one nurse. They are good and follow up on things. We will help out and feed (name of relative) and others if they�re pushed.� Another visitor said, �It�s improved. Staffing is better.�

One person who uses the service was upset and told us that they had not been able to have a cigarette. We observed the person asking on several occasions if they could go for a cigarette. We brought the matter to the attention of the staff who then supported the person. The person�s care plan and daily records did not show how many cigarettes they were smoking. The person�s preferences were not being met and their records did not contain enough information about the planning and delivery of support.

We were informed that the home had run out of bread so people could not have toast straight after their cereal. Bread was purchased from a local shop and was brought onto the units. Part way through breakfast they ran out of milk so then people were only offered juice. When staff offered people drinks in between breakfast and lunch, they were only given the choice of juice. The manager said they had run out of the provisions because the usual delivery of bread and milk had not arrived.

Inspection carried out on 21 June 2011

During an inspection in response to concerns

One person who uses the service was very complimentary about the care they receive. They said, �I do my own thing, and am able to do what I want. They let me go to Tesco on my own, I have my own kettle to make my drinks. I send my clothes to the laundry, shower myself. I don�t go into the communal rooms. I like my own company and watch my own programmes.�

One person who uses the service raised concerns and told us they do not receive care at the time they want it. They said, �It�s terrible, I sometimes call them and they don�t come. I try and do things for myself. We want more staff, if we had more staff I would have help with feeding me.� We asked the person how the service could improve. The person said, �When I want to go to the toilet then they would come. I don�t want them to lose their job. I need two people to help me. I have to wait, sometimes one comes but I need two.�

There were mixed responses when we spoke to people about the quality of meals and choice of food. Some people said the food was good quality, other people said they thought this was an area that could improve. One person who uses the service said, �Meals are satisfying.� Some people said there is always enough to eat; other people said there was sometimes a shortage of food. Some people said the menu should be reviewed because people don�t like some of the options. One person who uses the service said a staff member had recently been checking what people like to eat and had been writing it down.

People were generally complimentary about the staff. One person who uses the service said, �I have fun with the staff, I reckon there is enough staff.� Another person who uses the service said, �The old ones are lovely, the young ones give me the problem.� A visitor said, �The staff don�t have enough time for caring. They try their best, the staff are good but don�t have time. People just sit there; they used to have staff coming in to do things. They always seem to do things then it fades out.�

Staff raised concerns that on occasions there had not been enough staff to meet the care needs of people using the service. Some staff said there were occasions where only two care staff had worked in a unit.

Inspection carried out on 10 February 2011

During a routine inspection

People who use the service and visitors told us they are satisfied with the service they receive and their dignity and privacy is respected. People we spoke to said if they have any concerns they are happy to raise them with the staff or management and are confident they will be dealt with appropriately. People said the environment is always clean and pleasant. People who use the service and visitors made the following comments;

� I go to bed when I want, get up when I want, I'm satisfied but it's not like home.

� You can get involved as much as you want to.

� I didn't really want to come here but I've found they are good people, they try

to help in many ways.

� Staff do what they can and know what to do. They give us time on our own

when we want it.

� I am very happy living here and the staff are most helpful.

� My family come and they see I�m all right.

� I feel I have settled very well, the place is new and the standard is good.

� I have been coming to this home to visit people for years, if I thought the care

people was getting was not good I would not still be here.

� We get plenty to eat but it's not always a good choice.

� The breakfasts alright but sometimes other choices are not as good.

� The place is always clean.

� They look after people well. They pop in to my room and check I'm ok.

� There has been an improvement in the number of staff over the past few

months.

� The staff are good, helpful and you can talk to them.

� I'm not afraid to say what I want and think and they listen.

� Staff are polite and respectful. I get on well with them.

� You tell the staff. They look after you.

� I just say what I think and they do something about it.

Staff told us that people receive a good service and they can make decisions about their care. They said people can choose what time to get up and go to bed, depending on their preferred routines. They knew which people liked to get up early and those who preferred a �lie-in�. Staff said they are confident that the management of the home would deal with safeguarding issues or concerns appropriately and systems are in place to make sure people are safe. Staff told us there are generally enough staff and they receive appropriate training to help them understand how to do their job properly.

We received a mixed response from health and social care professionals. They said the manager and staff cooperate when they have other professionals involved in the care packages. Some professionals said they have observed very good care practice at the home; other professionals said they have sometimes observed practices that do not show respect towards people who use the service. Professionals made the following comments;

� I have always found the staff and management very pleasant, professional and very approachable. When I have visited the staff are very respectful to the residents but always very personable and pleasant. When I have spoken to both the service user and their family they have always been happy with the quality of care that is being provided and they have always felt that if they had any concerns they would feel able to address this with the staff rather that contacting myself.

� I have noticed an improvement in the past few months in terms of organisation. I have no concerns for patients there and the new charge nurse seems to have had a good influence on their overall care.

� Hip-hop type music was playing in the bedroom of someone who was being nursed in bed and it didn�t feel right.

� Staff were storing their coats and bags in one person�s bedroom.

� One person was eating their meal in their room and staff had put a plastic apron on but the strap was over their ear.

� One member of staff was observed pushing a person in a wheelchair, without being strapped in, and with no foot plates, and had tipped the chair back on to its rear wheels.

� One staff member was observed doing the medication round, she put each person's tablets on a spoon and put them in their mouths without speaking to them.

� They are very good at catering for different cultural diets and they try and cater for people�s individuals diets/preferences. When I have visited the home and it has been meal time the meals have always looked appetising, and presented well.

� When I have visited I have always found the home to be clean and tidy, it has always smelt fresh as we know nursing home�s can sometimes have an odour to them. The resident�s rooms have always looked tidy and clean and their laundry has always been washed regularly.

� I visit on a regular basis and have never had any concerns about the home. It's a very clean and pleasant environment

� The home is very pleasant decorated and has always been tidy and clean when I have visited. The front door is locked which is appropriate and I have never had to wait at the front door for very long before someone has responded to the bell. If there has been no one in reception I have not had to wait very long for a response via an intercom system. I have always been asked who I am and who I am visiting which is reassuring because of safety it is reassuring that the home do not let people in without asking who they are and who they are visiting.

� When certain equipment has been required such as a profiling bed the home have always contacted the appropriate department and have requested this equipment.

� There have always been plenty of staff available when I have visited and they have always been interacting with the residents in a friendly but respectful manner.

� When I have visited and have asked to look through the nursing documentation they have been available and always seemed quite detailed and up to date.

Reports under our old system of regulation (including those from before CQC was created)