The inspection took place on 18 July 2018 and was unannounced. The service was last inspected on 28 July 2016 when we rated the service good overall and in all the five key questions. At the comprehensive inspection on 18 July 2018 we rated the service ‘good’ overall but we made a recommendation in relation to the environment.

Blakesley House 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.

Blakesley House Nursing Home provides accommodation and nursing care for up to 22. At the time of our inspection there were 11 people living at the home.

The provider is registered as an Individual and as such is not required to have 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. The provider runs and manages the service.

Not all the environment was suitable for people living at the service, particularly those living with dementia. The garden was bare and uninviting, not easily accessible and people were unable to use it appropriately.

The service was clean and had systems to protect people by the prevention and control of infection, however, liquid soap and hand gel were not topped up in the staff toilet and entrance hall so these would be readily available when needed.

There were systems and processes in place to protect people from the risk of harm. There were enough staff on duty to meet people’s needs.

Checks were carried out during the recruitment process to ensure only suitable staff were employed.

There were arrangements in place for the safe management of people’s medicines and regular checks were undertaken.

The provider was aware of their responsibilities and had acted in accordance with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People’s nutritional and healthcare needs had been assessed and were met.

People were supported by staff who were suitably trained, supervised and appraised.

Staff were caring and treated people with dignity and respect. Care plans addressed each person’s individual needs, including what was important to them, and how they wanted to be supported.

People were able to take part in a range of activities. They were cared for in a way that took account of their diversity, values and human rights.

People’s end of life wishes were discussed and recorded.

People living at the home, their relatives and stakeholders told us that the manager and senior team were approachable and supportive. People and their relatives were supported to raise concerns and make suggestions about where improvements could be made.

The provider had effective systems in place to monitor the quality of the service and ensure that areas for improvement were identified and addressed.

The manager kept themselves informed of developments within the social care sector and cascaded important information to the rest of the staff team.

The inspection took place on 28 July 2016 and was unannounced. The service was last inspected on 13 August 2015 when we found seven breaches of the Health and Social Care Act 2008 and associated regulations. Following the inspection the provider sent us an action plan detailing how they would make improvements. At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements had been made.

Blakesley House Nursing Home is registered to provide accommodation for up to 22 people. At the time of our inspection, 12 people were living at the service. The provider is registered as an Individual and as such is not required to have a registered manager in place. The provider runs and manages the service.

A range of activities were organised and external entertainers visited twice a week to provide an activity program to people who used the service, however there was a lack of person centred activities for people who were living with the experience of dementia. We have made a recommendation around this person-centred activity provision.

The provider was aware of their responsibilities and had acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and they consented to their care and support.

Improvements had been made to the training of staff, and we saw that all staff had received training in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).

Improvements had been made in relation to the management of risk. The risks to people’s safety were identified and managed appropriately. The provider had processes in place for the recording and investigation of incidents and accidents.

The provider had put systems in place to ensure people lived in a safe environment. We saw a variety of health and safety checks were conducted on a regular basis by staff and external agencies.

Improvements had been made to fire safety, and we saw that the provider carried out regular fire checks and fire drills. All people using the service had personal emergency evacuation plans (PEEPs) in place.

Improvements had been made to the recruitment procedures and systems were in place to ensure that only suitable staff were appointed to work with people who used the service.

There were enough staff on duty to keep people safe and meet their needs, and there were contingency plans in place in the event of staff absence.

There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.

There was a procedure for the recording, storing and administering people’s medicines and the staff were aware of this. Staff received regular training in the administration of medicines.

Staff treated people with kindness and dignity and took into account their human rights and diverse needs.

People’s nutritional and healthcare needs had been assessed and were being met.

Assessments were carried out before people were admitted to the service to ensure the service could provide appropriate care. Care plans were developed from the assessments and reviewed regularly.

There was a complaints procedure in place and people and their relatives knew how to make a complaint. They felt confident that their concerns would be addressed. People and their relatives were sent questionnaires to gain their feedback on the quality of the care provided.

There were regular staff meetings, and these were recorded. Staff told us that communication was good and they had regular handover meetings.

People, relatives and professionals we spoke with thought the home was well-led and the staff and senior team were approachable and worked well as a team. The staff told us they felt supported by the provider and there was a culture of openness and transparency within the service.

We inspected Blakesley House Nursing Home on 13 August 2015, the inspection was unannounced. There had been a previous inspection of this service on 25 July 2014 where the Regulations we inspected were met.

Blakesley House Nursing Home is registered to provide accommodation and personal care as well as nursing care for up to 22 older people. At the time of the inspection, 13 people were living at the home. The provider is not required to have a registered manager in place and the provider runs and manages the service.

Staff were not always following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. The provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for at least one person for whom bedrails were being used.

We found evidence that staff did not always understand the need to obtain consent from people. For example we found photographs of bruising to a person’s body part for which consent had not been sought.

Risk assessments gave little or no information on how risk was managed. Although people had individual fire risk assessments in their care plans, they did not have any Personal Emergency Evacuation Plans (PEEPS). We found that the information in the fire risk assessment did not always reflect the information in the care plans. For example, a person’s risk assessment stated that they would need the assistance of one carer to evacuate in the event of a fire, but the care plan said that they needed the assistance of two carers to mobilise.

Not all the recruitment records we checked were thorough and complete, although the provider had ensured that staff had a Disclosure and Barring Service (DBS) check prior to starting work.

Training records were inconsistent, and the provider was unable to locate the record for all staff training. The staff did not have regular individual supervision meetings with the provider. The staff did not receive an appraisal.

We found two cleaning products (which could have been hazardous) in an unlocked cupboard on the first floor and made the provider aware of it. They did not lock the cupboard or remove the products.

Although the provider told us that they had regular staff meetings, they were unable to locate the minutes. However, the staff told us that communication was good and they had regular handover meetings but these were not recorded. The staff said that they felt supported and that the provider was always around.

Care plans were in place, and people had their needs assessed. The care plans contained a lot of information but did not always reflect the needs and wishes of the individual. There were regular reviews of the assessments and care plans for some people but not for others. Important information was not always followed up and recorded. For example, we saw information about a bruise sustained by a person living at the home. This was correctly recorded on the day it was noticed, but there was no follow up in the daily notes.

There were no organised activities on the day of the inspection and we observed people sitting in the lounge with nothing to do apart from listening to music in the morning and watching TV in the afternoon. Although most of the people were living with dementia, we did not see any evidence of a dementia friendly environment or activities.

The building appeared clean and checks on infection control and health and safety were recorded.

There was a procedure for recording, storing and administering medication and that the staff were aware of this and received regular training in administration of medicines.

People gave positive feedback about the food and we observed people being offered choice at the point of service. People had nutritional assessments in place. People had access to health care professionals as they needed, and the visits were recorded in their care plans.

People had good relationships with staff. The staff were kind, attentive and had a gentle manner. The relatives we spoke with praised the staff’s kindness and the care their relatives received.

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

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask: 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?

Systems were in place to make sure that staff reported events such as accidents and incidents, complaints and other concerns although there was little evidence to demonstrate these systems were always used effectively as there were no records of complaints or of action following accidents or other incidents.

There were procedures for managing emergencies. Staff had received appropriate training to their roles and were aware of relevant procedures and contacts to access help and support.

The home had proper policies and procedures to protect people who used the service from abuse and staff had suitable training. Staff were aware of the procedure to follow in the event of a safeguarding concern.

Recruitment practice was safe and thorough and ensured that suitable checks were in place with regard to qualifications, employment history, identity, health declarations and criminal records. There was suitable induction training for new staff.to ensure that staff carried out their duties safely.

Is the service effective?

People using the service experienced care that was planned and scheduled to meet their needs and reduce any risks. People using the service and their relatives were involved in the development of their care plans. A statement of agreement was signed by people using the service or their representatives to indicate agreement to the care they received.

Daily records were maintained to ensure the care delivered reflected the care plan and allowed the provider to identify concerns or changes to people’s needs enabling them to respond promptly.

Is the service caring?

People were supported by kind and attentive staff. We observed staff providing kind and empathetic support to people living in the home. Staff offered people choices and respected their rights to dignity and privacy. The provider took account of people's equality and diversity and this was reflected in people’s care plans.

People using the service and their relatives completed an annual satisfaction survey. The latest report showed a good level of satisfaction with the care provided. People we spoke to were happy with the care and support they experienced. A family member of one resident told us, “They’re very good. I have no complaints.” Another person commented, “I’m happy here, the staff are kind and I have information on how to make a complaint.”

Is the service responsive?

Care plans were reviewed on a monthly basis to ensure that the care provided reflected current needs. Observation of the care provided on the day of our visit showed that staff were aware of people’s preferences and routines and could therefore support people effectively.

There was a program of activities and to help to keep people involved in the daily life of the home and interact with others. People were supported to attend outside visits and appointments although there were no organised outings for people living at the home.

People knew how to make a complaint if they were unhappy although there was no evidence of recorded complaints.

Is the service well-led?

The provider had a variety of systems to monitor the quality of service provided and audit their performance. People using the service and their relatives had regular opportunities to provide feedback on their care and express their views. There were appropriate procedures for dealing with complaints and reporting accidents and incidents.

We spoke with 5 people using the service, 2 relatives and 4 staff working in the home. People mostly told us they were happy with the care and support they received. One person said “the staff are very caring.”

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. Where people were not able to make decisions about their care the provider carried out assessments and involved people’s relatives and other professionals.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Care plans and risk assessments were completed but people did tell us that they sometimes had to wait for support. One person said “the staff do their best but they are very busy.”

People were supported to be able to eat and drink sufficient amounts to meet their needs but the food was not always enjoyed by some people. One person said “the food is a bit boring but it’s alright.” Another person said “I enjoy the food, it’s the highlight of the day.”

Appropriate arrangements were in place to make sure people received the medicines they needed.

There were enough qualified, skilled and experienced staff to meet people’s needs.

Most people’s personal records, including medical records, were accurate and fit for purpose. Health care records for one person were not adequately maintained and this was discussed with the deputy manager and staff during the inspection.

We spoke with four people using the service, two members of care staff and the provider to get information about the quality of services provided in the home.

Four people we spoke with told us that they were not being restrained and that they liked their table close to them and this allowed them to place their drinks and newspapers on them. Three people showed us how they were able to move the table away when they wanted too and stand up by themselves. One person said “of course I can move my own table, I am not a prisoner”.

Three people told us that staff cut their nails in the privacy of their bedroom. One person commented that they had seen staff cutting other people’s nails in the lounge but that this was not a regular occurrence.

A GP had commented in a recent satisfaction survey that “generally the home has improved” and “the staff are very helpful”.

People indicated to us that they were happy living in the home. One person told us “they (staff) are nice and friendly”. A visitor told us their relative was “well cared for” and that although at times they were bored as there was little to do in the home, they were not concerned about the welfare of the person. We observed staff supporting people appropriately with daily living tasks, including personal care and assistance with meals. We observed interactions between the staff and the people using the service and saw that staff were friendly and respectful to the people they supported, we saw that choices were offered and decisions respected. A visitor told us they believed their relative was safe living in the home.

People told us that they had not seen their care plan and therefore had not been involved in the planning of the care they would want to receive. We saw that staff did not always explain what care they were going to carry out. People also told us that ‘I’m pretty well settled, I’m comfortable here’

We found that people experienced care that did not uphold their dignity, privacy and their human rights. People are not enabled to make choices about how they wish to live their lives.

People are not supported to make informed decisions about their care. Choices are limited and people’s individual preferences are not respected.

The provider and staff do not understand issues related to consent and how this can be affected when people have limited capacity.

People are not involved in the development and review of their care plan.

People do not receive individualised care that meets their individual needs and choices.

People do not receive the food that they choose. People’s individual preferences are not taken into account. Staff were taking time to assist people with meals in an unhurried manner.

The provider does not understand the processes that need to be followed in relation to signs and allegations of abuse.

We spoke with people who live at the home and asked their views about their home and how it was run.

People that we met and observed showed some signs of well being such as being dressed in clean clothes and looked as though their personal care needs had been met. We saw that the men using the service had been shaved. A relative told us that their loved one was “clean and well fed”.

We saw that people were offered a choice of food and drink.

We saw that a person had been moved to share a bedroom with another person; we could not find evidence that they had been assessed and involved to make this decision.

We saw that very few activities were being provided for people that met their needs. A relative told us that they had not seen any activities apart from the television being on. Another relative told us that no activities took place with their loved one as they had limited understanding. We saw that where people were confined to their bedrooms no activities took place with them.

One person living at the home told us that they had “not seen a care plan”. Another said that they had “no problem with staff, they respect my wishes”. One person told us that they had nobody to talk to and that they could not understand what a lot of staff said.

People who were able to speak for themselves said that they felt safe and could raise concerns.