This inspection took place on 30 May 2017 and was unannounced. This meant the provider and staff did not know we would be visiting. A second day of inspection took place on 7 June 2017 and was announced.

Astune Rise Nursing Home is located in purpose built premises and can accommodate up to 38 people. The home is situated in Eston, and accommodation for people using the service is provided over two floors. At the time of the inspection 24 people were using the service, some of whom were living with a dementia.

The service was last inspected in April 2016. During that visit we identified three breaches of our regulations. A pre-admission assessment for one person contained limited information and did not mention some specific health and support needs they had. Care plans and daily care checks were not always consistently recorded. Medicines were not always managed safely, and staffing levels were not effectively reviewed and staff did not have time to engage in meaningful activities with people. We took action by requiring the provider to send us action plans setting out how they would make improvements. When we returned for out latest inspection we found this action had been taken and improvements had been made.

The service had a registered manager. 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. Medicines were managed safely. The registered manager assessed people’s dependency levels on a monthly basis to ensure enough staff were deployed to support them safely. The provider’s recruitment processes minimised the risk of unsuitable staff being employed. Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. Emergency plans were in place to keep people safe and provide a continuity of care in emergency situations. Policies and procedures were in place to safeguard people from abuse.

People and their relatives said staff were effective at meeting people’s needs. Staff received mandatory training in a number of areas to support people effectively. Staff were 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 access external professionals to maintain and promote their health.

People spoke positively about the support they received from staff, describing it as kind and caring. Relatives we spoke with also described staff as kind and caring. Staff treated people with dignity and respect. People also told us staff encouraged and supported them to maintain their independence. We saw numerous examples of kind and caring support during our inspection. People were supported to access advocacy services and end of life care where required.

People and their relatives told us they received personalised care based on their needs and preferences. Care plans were regularly reviewed to ensure they reflected people’s current needs and preferences. People were supported to access activities they enjoyed. Procedures were in place to investigate and respond to complaints.

Staff spoke positively about the culture and values of the service. People and their relatives described the service as well run and spoke positively about the registered manager and deputy manager. The registered manager and deputy manager carried out a number of quality assurance audits to monitor and improve standards at the service. Staff meetings took place regularly, which staff said were useful opportunities for them to raise any issues they had. Feedback was sought from people who used the service and their relatives. The registe

This inspection took place on 4 April 2016 and was unannounced. This meant the registered provider did not know we would be visiting. The service was previously inspected in April 2015 and was meeting the regulations we inspected.

Astune Rise Nursing Home is located in purpose built premises and can accommodate up to 38 people. The home is situated in Eston, and accommodation for people using the service is provided over two floors. At the time of the inspection 28 people were using the service, some of whom were living with a dementia.

The service had a registered manager. 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.

Medicines were not always managed safely. Consistent records were not kept on how people should be supported with ‘as and when required’ medicines, the storage temperature of medicines was not effectively monitored, controlled drug stocks were not regularly checked, medicine records for the same person did not always match and some supplements lacked prescription labels. Care plans were not always consistently completed or followed.

Staffing levels had not been effectively reviewed since January 2016, and during the inspection there were periods when there was little or no staff presence in communal areas as they were busy helping people in their rooms. Staff did not have time to engage in meaningful activities with people.

The service’s recruitment process minimised the risk of unsuitable staff being employed, including seeking references and carrying our Disclosure and Barring Service (DBS) checks.

Risks to people were assessed and plans put in place to reduce the chances of them occurring. These covered risks arising from the person’s individual support needs and the physical environment of the service. The registered manager monitored accidents and took remedial action to reduce the risk of them being repeated. Safety checks of the building and equipment were regularly undertaken.

Plans were in place to safely evacuate people from the building in case of emergency and to provide a continuity of care should the service be disrupted.

Staff were familiar with safeguarding issues and the types of abuse that can occur in care settings. Staff said they were confident to raise any concerns they had, and the registered manager understood how to raise these with the relevant authorities.

Staff received regular training in the areas needed to support people effectively. Staff felt confident to request any additional or specialist training they needed, and could give examples of where this had been arrange in the past. Staff felt supported by regular supervisions and appraisals at which they could raise any issues they had.

Policies were in place to ensure people’s rights under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards were protected. Where appropriate, the service worked collaboratively with other professionals to act in the best interests of people who could not make decisions for themselves.

People were supported to maintain their health through access to food and drinks. Appropriate tools were used to monitor people’s weight and nutritional health. People spoke positively about the food on offer.

The service worked with various healthcare and social care agencies and sought professional advice, to ensure that the individual needs of the people were being met.

People and their relatives spoke positively about the care they received. Throughout the inspection we saw people being treated with dignity and respect and observed caring interactions. Staff enjoyed getting to know the people they supported, though they did not think they always had time to do so.

The service supp

We used the information we gathered under the outcomes we inspected to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they were listened to and that they felt safe. Safeguarding procedures were robust and staff understood their role in safeguarding the people they supported. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards and staff had recently received Mental Capacity Act training.

There was no system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This increased the risk of harm to people and failed to ensure that lessons are learned from mistakes. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events that affect people’s safety.

The service was safe and clean. However we did find rooms used for storage and the handyman’s tool cupboard left open. This was putting people at risk of harm.

Is the service effective?

People’s health and care needs were assessed and reviewed monthly and this was documented in their care plans. However the care plan for one person who used the service stated they had to have two members of staff to turn them on an hourly basis, we asked the manager if we could see the positional change chart. The manager could not produce one and said the person no longer needed hourly turns. The person's care plan did not reflect this.

People's care plans provided information on the care they needed but they were not person centred. There was no information about a person’s life history, their likes or dislikes.

We looked at how nutritional needs were taken into account; people who used the service were very complimentary about the food. One person who used the service said, “The food is brilliant and lunch was gorgeous.” We sat in the dining room at lunch time and tea time, and everyone we asked had no idea what they were going to eat. There were no menu’s available however, we saw a white board in the corner of the dining room that detailed what was for lunch. People we spoke with also said they were not provided with a choice of food. The manager and staff said there was always a choice and they just have to ask.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person who used the service said, “I feel safe and cared for, you could not wish for better staff.”

People who used the service, their relatives and staff completed a satisfaction survey; these were not dated so we could not confirm when they were last done. The main concern raised in these surveys was the lack of activities. No action plan had been prepared to overcome this concern. We did see a whiteboard stating what activities were taking place on each day, but this was not displayed in a prominent position or in an attractive way. One person who used the service said, “We had a big Easter raffle and a member of staff bought everyone an Easter egg.” There were no photographs on display to show people enjoying this event.

Is the service responsive?

People who used the service said they knew how to make a complaint if needed. We asked to see the complaints file but the manager did not have one to show us. There was no information on the walls to say how someone could make a complaint. The manager said that they were in the process of making a welcome book to put in each room, this will include how to make a complaint. Until this is up and running, people were at risk of not having their concerns and needs properly taken into account. Staff we spoke to had a good understanding of how to raise concerns and felt able to raise these with the manager.

We did see an accident and incident file which included a monthly accident and incident monitoring form; this had not been completed since November 2013. Therefore we could not see evidence of any trends or learning as a result.

Is the service well-led?

We asked to see the cleaning rota and mattress audits. Although there was a cleaning rota this had not been completed since January 2014 and there were no mattress audits.

We looked at the finance records for the people who used the service’s personal allowance system. We looked at the finance records for 32 people and found that there were discrepancies with four of them. Each of these four people had more money than was recorded in the finance file.

The service did not have any records of quality assurance systems in place. Therefore the registered manager was not protecting the people who used the service and others against the risks of inappropriate or unsafe care and treatment.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance and record keeping.

During the visit, we spoke with nine people who used the service and four relatives. As this was a routine visit we asked people about the choices on offer; what the care was like; and what people thought about the staff. People told us that they found the staff delivered good quality care and the home met their needs. Relatives thought the staff were good at their jobs and their loved ones were being appropriately supported.

People said, “They are a good bunch and really know how to look after us’’, ‘‘The staff are fantastic and really like helping me’’ and ‘’I have no complaints at all it is a good service, before needing care myself I worked voluntarily for Age Concern so know what is expected.’’ Relatives said, ‘’I am delighted with the care, the staff are always at hand and the food is excellent,’’ and ‘’I looked after my relative for 14 years and must say the staff here do a much better job.’’ One person said they would like there to be more activities on during the day but all the other people we spoke with said there was plenty to do and told us about entertainers, trips out , bingo sessions and the regular sing a-longs they joined in.

People told us that the service was run well and that the manager was very committed to making sure everything operated smoothly. All of the relatives said they felt the home was well run. They said, ‘’I would recommend this home to anyone it is excellent,’’ It is a marvellous home and I don’t know what I would have done without it’’, and ‘’I’m very satisfied with the service.’’

The review was completed because some very specific concerns had been raised around how staff dealt with people's personal and intimate care needs. People at the home can have difficulty communicating either because of their physical health conditions or dementia type illnesses. Also some people find it hard to remember recent events but can give their opinion about how they are feeling. The visit established peoples' dignity was being maintained.

This inspection took place on 21 and 23 April 2015. The first day was unannounced which meant the staff and registered provider did not know we would be visiting. The registered provider knew we would be returning for the second day of inspection.

Astune Rise is a 38 bedded nursing home, which provides residential and nursing care for predominantly older people. Three beds are used as winter pressure beds, these help with discharge from hospital much quicker and provide an opportunity for assessment prior to going home versus permanent care. On the day of our inspection there were 32 people who used the service.

The home had a registered manager in place who started working there in September 2011. 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.

At the last inspection in April 2014 we found the registered provider did not meet regulations related to assessing and monitoring the quality of service provision and records. The registered provider sent us an action plan that detailed how they intended to take action to ensure compliance with these two regulations.

Since the inspection of the service in April 2014 the provider had developed a robust quality assurance system and gathered information about the quality of their service from a variety of sources.

Records had also improved. Accidents and incidents were now recorded with a monthly monitoring form to identify trends or patterns. Finance records were all updated and correct and care plan review records were all complete. There were still some issues around the completion of room records and some medication records such as cream charts and when required (PRN) medication protocols. We discussed this with the registered manager who was putting a check list in place that would audit these records.

Medicines were managed safely although there were some concerns. For example we observed the nurse signed the medication administration record (MAR) before they had observed people take their medicines and MAR records were not fully up to date.

We saw that people were involved in activities. However activities for people were limited. This meant that some people were provided with limited stimulus during the day.

People’s nutritional needs were met and the records held on people's nutritional needs were improved on the second day of inspection.

Staff we spoke with understood the principles and processes of safeguarding, as well as how to raise a safeguarding alert with the local authority. Staff had received training in safeguarding. Staff said they would be confident to whistle blow (raise concerns about the home, staff practices or provider) if the need ever arose.

Assessments were undertaken to identify people’s health and support needs and any risks to people who used the service and others. Plans were in place to reduce the risks identified. Care plans provided evidence of access to healthcare professionals and services.

There were sufficient numbers of staff on duty in order to meet the needs of people using the service. The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.

Although staff training was up to date, the registered manager needed to make sure nurses were able to update their skills through regular training. Staff received regular supervisions and appraisals, which meant that staff were properly supported to provide care to people who used the service.

All of the care records we looked at contained consent for example consent to photographs and bed rails.

The home was clean, spacious and suitable for the people who used the service.

We saw safety checks and certificates that were all within the last twelve months for items that had been serviced such as fire equipment and water temperature checks.

The registered manager had knowledge of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager understood when an application should be made, and how to submit one. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We discussed DoLS with the registered manager and looked at records. We found the provider was following the requirements in the DoLS.

People who used the service, and family members, were complimentary about the standard of care. Staff told us that the home had an open, inclusive and positive culture.

Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible..

Care records showed that people’s needs were assessed before they moved into the service and care plans were starting to be written in a person centred way.

The registered provider had a complaints policy and procedure in place and complaints were fully investigated.