This inspection took place on 13 and 15 June 2017 and was unannounced. This meant the provider and staff did not know we would be visiting. The service was last inspected on 28 January and 10 February 2015 and was meeting the regulations we inspected at that time.

Ascot Nursing Home is located in Linthorpe on the outskirts of Middlesbrough, in close proximity to public amenities. It provides nursing and personal care to people, including people living with a dementia. The home has a number of communal areas including three lounges, a large dining area and a conservatory leading out to the garden. There are bedrooms and bathrooms on all three floors for which there is lift access. It provides care and accommodation for up to 34 people. At the time of our inspection 32 people were using the service.

At the last inspection on 28 January and 10 February 2015 the service was rated Good. At this inspection we found the service remained Good.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives told us the service kept people safe. Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. The safety of equipment and the premises were monitored to ensure they were safe for people to use. Medicines were managed safely. Procedures were in place to safeguard people from abuse. The provider and registered manager regularly reviewed staffing levels to ensure enough staff were deployed to support people safely. The provider’s recruitment procedures minimised the risk of unsuitable staff being employed.

People and their relatives told us staff had the training and knowledge needed to provide effective support. Staff received training and updates the provider deemed mandatory to support people safely. Staff were also supported through regular supervisions and appraisals. People’s rights under the Mental Capacity Act 2005 (MCA) were protected. People were supported to maintain a healthy diet and to maintain and promote their health by accessing external professionals.

Without exception people and their relatives spoke positively about the care and support they received, describing staff as kind and caring. Staff worked hard to create a welcoming and homely atmosphere and people told us they felt at home at the service. People were treated with dignity and respect. Staff understood the importance of promoting people’s independence. We saw numerous examples of kind and caring support being delivered throughout the inspection. The provider and staff were committed to enhancing people’s quality of life. People were supported to access advocacy service and end of life care when needed.

During our last inspection in 2015 we found the service to be outstanding in responsive. When we returned for this inspection we found it continued to be outstanding in this area. People and their relatives told us the service was extremely responsive to their needs and that staff accommodated their wishes as much as possible. Personalised, individual care was the highest priority of the provider, registered manager and staff. People received personalised support. Care plans were regularly reviewed to ensure they reflected people’s current needs and preferences. People were supported to access a wide range of personalised activities. Policies and procedures were in place to respond to complaints.

Staff spoke positively about the culture and values of the service. People, their relatives and staff spoke positively about the provider and registered manager. Feedback was sought from people, relatives and visiting external professionals. The provider and reg

We spoke with three people who used the service. One person said, “It is good here, if I pull my buzzer two carers come and I don’t have to wait too long.” Another person said, “The nurses and staff are helpful, they are nice and they try to cheer me up, I like them.” We spoke with two relatives of a person who used the service and they said, “We are really pleased with the care and support provided” and “They (staff) all work hard, the whole team are great.”

Throughout the inspection we saw staff interacting with people in a kind and respectful way. We did however find that the level of detail within people’s care plans was not detailed enough and did not give staff sufficient information to enable them to provide people with the care they needed.

We found that the service had not fully protected people against the risks associated with the unsafe use and management of medication. This was because the home did not have appropriate arrangements for the recording, handling and use of medicines.

We found that staff were receiving regular appraisals and supervision sessions, were up to date with training and were working in a supportive environment.

We found that people were not protected from the risks of unsafe or inappropriate care and treatment because care records were not always completed properly.

We spoke with eleven people who lived at Ascot Nursing home and four relatives during our inspection. We also received information from two people anonymously. We received mixed comments from people about the service and found that some of the individuals living at the home felt some improvements could be made whilst others were happy and content with the support they received.

A number of people told us they felt the care was meeting their needs. They said “I’m well looked after, I don’t need much and I’m safe here, it’s OK”. “Staff are wonderful, I’m safe enough here, everything is looked after and I have a bath every day but I don’t need much help for that’’ and “They really look after you, there are the odd times they (staff) can be a bit off but they’ll do anything for you. They look after some really poorly people in here. I never have to ask twice for anything”.

Other people told us that staff did not always attend to their needs in a way they would like and said; “I asked them to wake me up later than usual this morning. Sometimes they wake me up early and get me up”, “Sometimes I have to wait ages for somebody to answer my buzzer” and “The girls work hard and are always busy but they don’t seem to have time to sit and chat for five minutes”. Another person complained of boredom; “I wish there was more to do, I sometimes get bored just watching films or the television”.

Three people found that the staff did not always respond to requests as quickly as they would have liked. One said “I’m waiting for a jug of water. They took my jug away to clean it and didn’t bring another one back” another added, “They don’t always bring me drinks when I ask”.

One person told us that they sometimes found the staff attitude to be unhelpful. They said “Staff can be a bit patronising sometimes so I spoke with the manager about it, they weren’t explaining things to me and I wasn’t happy about it. I think she spoke with them about it as they seem to be better”, “Sometimes staff talk about other residents behind their backs, they don’t think that other people might be listening, it’s not very nice”. However another person told us that staff were, “Wonderful”.

Two people told us about the way staff assisted people to mobilise. They said ”I’ve seen them (staff) lift people up by their arms, I think they were in a hurry” and “Staff sometimes lift people up on their own, that can’t be good for their back”.

Mixed views were expressed about the quality of the food. People said “I’m well fed, they do what I ask. I do get a choice if I don’t like what’s on the menu” and “Care staff are marvellous but the food isn’t great, breakfast is ok, I get what I want but the rest is just alright and there isn’t always much choice, sometimes the portions are a bit small”.

The relatives we spoke with told us that on the whole they were happy with the care their family member received. One person told us, “The majority of staff look after most of the residents quite well, but my mum is looked after well”. They added that staff always seemed to be busy. A second relative told us, “The staff love my mum and they look after her so well. Staff here are very good and yes they give mum choices.” They added, “I’m always let know if she’s unwell”.

We carried out this inspection on the 28 January and 10 February 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

Ascot Nursing Home is located in Linthorpe on the outskirts of Middlesbrough, in close proximity to public amenities. The home has a number of communal areas including three lounges, a large dining area and a conservatory leading out to the garden. There are bedrooms and bathrooms on all three floors for which there is lift access. In September 2014 the number of registered places increased from 33 to 34.

A registered manager has been post since the service opened. The provider has always ensured a registered manager was in post. Thus, when the registered manager retired a new manager was appointed and they became registered in November 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People who used the service and relatives we spoke with told us they felt the staff did a wonderful job and felt the home provided an outstanding service. People told us that they made their own choices and decisions, which were respected by staff but they found staff provided really helpful advice. We observed that staff had developed very positive relationships with the people who used the service. The interactions between people and staff were jovial and supportive. Staff were kind and respectful, we saw that they were aware of how to respect people’s privacy and dignity.

People we spoke with were positive about the care they received and said that they felt safe. Staff were trained and understood the principles and processes of safeguarding, as well as how to raise a safeguarding alert with the local authority. Staff said they would be confident to whistle blow (raise concerns about the home, staff practices or provider) if the need ever arose. Staff ensured people were kept safe from abuse and avoidable harm.

We found that the activity coordinator and provider proactively ensured a wide range of opportunities were available for people to engage in meaningful occupation. This was in the form of an internal activities programme, which included social activity, pet therapy and sensory stimulation as well as external activities, such as going out for trips and meals.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training. The provider had organised additional training on this subject for all of the staff to complete. The majority of people were able to make decisions but the home were following guidance from the supervisory body which suggested all the people needed to be subject to DoLS authorisations. The guidance we looked at had not clearly outlined that only people who had been assessed as lacking capacity would need to be subject to DoLS. We discussed how people with capacity to make decisions can agree to restrictions being in place. We found that people do go out when they want to and the staff have used assistive technology, for example trackers, to help individuals who become a little confused to go out independently and find their way back to the home.

Where people had difficulty making decisions we saw that staff helped them to work out what they felt was best. We saw that when people lacked the capacity to make decisions staff routinely used the ‘Best Interests’ framework to ensure the support they provided was appropriate. This meant staff worked within the law to support people who may lack capacity to make their own decisions. The provider was completing more work with staff to ensure they understood all aspects of the MCA. The registered manager had requested information to demonstrate that relatives had enacted lasting powers for care and welfare before they became decision makers for the person.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. The care plans contained comprehensive and detailed information about how each person should be supported. We found that risk assessments were very detailed. They contained person specific actions to reduce or prevent the highlighted risk.

Accidents and incidents were monitored each month to identify trends. We found that when trends were found action was taken. For example certain times of the day were highlighted as being high risk, so the provider ensured extra staff were on duty to cover these times.

We reviewed the systems for the management of medicines and found that people received their medicines safely.

People and the staff we spoke with told us that there were enough staff on duty to meet people’s needs. They found the staff worked very hard and were always busy supporting people. Throughout the week a nurse, five care staff, a cook, kitchen assistant and domestic staff were on duty during the day and a nurse and four staff were on duty overnight. During the week days the registered manager, head of care, administrator and maintenance staff were on duty. One of the providers visits most days and we heard from relatives that they often assist staff with care tasks.

Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. This included obtaining references from previous employers and we saw evidence that a Disclosure and Barring Service (DBS) check had been completed before they started work in the home. The Disclosure and Barring Service carry out a criminal record and barring check on individuals who intend to work with children and vulnerable adults. This helps employers make safer recruiting decisions and also to prevent unsuitable people from working with children and vulnerable adults.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as dementia, strokes and diabetes. We found that the provider and registered manager ensured staff received regular refresher training. They also routinely checked that staff understood how to put this training into practice at supervision sessions and staff meetings.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. A designated infection control champion was in post and we found that all relevant infection control procedures were followed by the staff at the home. We saw that audits of infection control practices were completed.

The provider had developed a range of systems to monitor and improve the quality of the service provided. We saw that the provider and registered manager had implemented these and used them to critically review the service. This had led to the systems being extremely effective and the service being well-led.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. The registered manager had ensured people were supported to access independent advocates when needed. People we spoke with told us that they knew how to complain and felt confident that staff would respond and take action to support them. People we spoke with did not raise any complaints or concerns about the service.

Regular surveys and resident and relative meetings were held. We found that the analysis of the surveys showed the majority of people believed the home delivered an excellent service and this view was echoed in our discussions with people during the visit.