The inspection took place on 14 and 19 November 2018 and was unannounced on both days, so no-one connected to the home knew we were visiting the home. The home was previously inspected in September 2017 when we judged the overall rating of the service to be 'Requires Improvement’. This was because records did not always reflect the changes in needs in people’s care or actions taken. At this inspection we found improvements had been made, [and were still ongoing] in the nursing unit and records fully reflected people’s care, treatment and any risks associated with that care.

Carr Gate is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Carr Gate provides personal care and support for up to 65 people in three units, this includes people living with dementia. At the time of our inspection there were 51 people using the service.

The service had a registered manager in post at the time of our inspection. 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.

We saw improvements to the care plans on all three units of the home. We spoke to the registered manager around ongoing improvements in the nursing unit. The registered manager had just recruited a clinical lead to continue with these improvements. Staff supported people in a compassionate, caring, responsive and friendly manner. They encouraged them to be as independent as possible, while taking into consideration their abilities and any risks associated with their care. Most people we spoke with made positive comments about how staff delivered care and said they were mostly happy with the way the home was managed.

Systems were in place to safeguard people from abuse.

Care and support was planned and delivered in a way that ensured people were safe. Where possible, people had been involved in planning their care. Care plans outlined peoples’ needs and risks associated with their care, as well as their abilities and preferences. Since our last inspection the information in care plans about how to support people had improved. However, work was still needed in relation to the care plans around people’s capacity and end of life care.

We made a recommendation to the registered manager to ensure all end of life plans were in place for people in the home, if they chose this.

We looked at the medicine management in the home on all three units. We saw charts used to record when staff had applied topical creams were not always in place. We saw some topical creams did not have a used by labels in place. However, these had been picked up in the audits at the end of each month.

We made a recommendation to the registered manager to complete weekly medication audits on all three units instead of completing these monthly to ensure these were picked up and addressed earlier.

Recruitment procedures aimed to make sure staff employed were suitable to work with vulnerable people. Staff were trained and supported to develop their skills, so they could provide people with the standard of care they required. There was enough staff on duty to meet the needs of the people living at the home at the time of our inspection.

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. Since the last inspection the care plans we looked at we saw decisions made in people’s best interest had been followed and the correct procedure were accurately recorded.

People received a varied and heal

The inspection of Carr Gate Nursing Home took place on 27 September and 2 October 2017 and was unannounced on both days. The previous inspection, which had taken place on 26 April 2016 found the service was in breach of two regulations. Safe care and treatment and safeguarding service users from abuse and improper treatment. The provider sent us an action plan in relation to how they would address these issues. At this inspection we found sufficient improvements had been made in each of these areas. However we did find at this inspection the provider was in breach of two regulations in relation to person centred care and governance.

Carr Gate Nursing Home provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. The home is on two floors and there are three units; Cherry (nursing care), Cliffe (residential care) and Holly (dementia care). At the time of the inspection 17 people were living on Holly, 14 people were living on Cliffe and 19 people were living on Cherry.

There was a registered manager, who had been registered with the Care Quality Commission to manage the service since July 2015. 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 were provided with care and support in line with the principles of the Mental Capacity Act (2005). One person, who remained in bed however, had no clear recording of any best interest decision around this and the rationale for them staying in bed continuously was not evident or understood by staff around this person.

Care records we looked at contained individual risk assessments although we found some conflicting information in relation to weight checks. We spoke to the registered manager who told us this should be completed monthly unless a risk is present.

People and relatives we spoke with told us people felt safe at Carr Gate Nursing Home.

Staff had received training in relation to safeguarding people and staff were aware of relevant procedures to help keep people safe in the home. Staff received appropriate induction, training, supervision and support to enable them to perform their role.

Staff were recruited safely. Staffing numbers were determined by the use of a dependency tool. However there were mixed views about staffing levels across the service in relation to staff having quality time to interact with people in the home. Whilst we felt there were adequate staff to meet people's care needs, we observed sometimes the deployment of staff was not effective in some areas of the home. We spoke to the registered manager about this.

We saw some examples of good care practice. Staff were observed to be caring and kind in their interactions with people.

We saw accident and incident records completed across the three units. The registered manager had a good insight to these and lessons learnt were consistently addressed at team meetings. The registered manager held regular meetings with people, staff and relatives and engaged with other

agencies. Audits were in place around the governance of the home. However some areas around care plans would have been picked up sooner if these had been more robust and effective.

We made a recommendation the registered manager looks at all repositioning records to ensure these are all up to date around the frequency for the repositioning of the person.

You can see the action we have told the provider to take at the end of this report.

The inspection of Carr Gate Nursing Home took place on 26 April 2016 and was unannounced. The previous inspection, which had taken place during July 2015, had found the service was in breach of specific regulations. We had issued warning notices to the registered provider which meant they were required to take immediate action with regard to people’s privacy and dignity, risks associated with medicines management, audit and quality assurance systems and staffing levels. We had issued requirement notices and received action plans from the registered provider to show how they would address other breaches we found with regard to providing meaningful activities, acting in accordance with the Mental Capacity Act 2005, meeting nutritional and hydration needs and suitability of premises.

This inspection found improvements had been made in each of these areas. However, there was a continued breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, because the registered manager had not reported a safeguarding incident in line with safeguarding procedures and a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were not always protected from assessed risks.

Carr Gate Nursing Home provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. The home is on two floors and there are three units; Cherry (nursing care), Cliffe (residential care) and Holly (dementia care). At the time of the inspection 13 people were living on Holly, 14 people were living on Cliffe and 11 people were living on Cherry.

There was a registered manager, who had been registered with the Care Quality Commission to manage the service since July 2015. 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.

Most people told us they felt safe living at Carr Gate and the family members we spoke with on the day of the inspection also told us they felt their relatives were safe. One person, however, indicated they did not feel safe.

Staff had received training in relation to safeguarding people and staff were aware of relevant procedures to help keep people safe. However, on the day of the inspection, we identified a safeguarding concern that had not been reported and investigated.

Staff were recruited safely. Staffing numbers were determined by the use of a dependency tool and staff and people told us they felt staffing levels across the home were adequate. Whilst there were enough staff to meet people’s needs, we observed sometimes the deployment of staff was not effective.

Staff received appropriate induction, training, supervision and support to enable them to perform their role effectively.

People were provided with care and support in line with the principles of the Mental Capacity Act (2005) and staff demonstrated knowledge and understanding of the relevance of this when providing effective care to people.

People across the home were supported to have their nutrition and hydration needs met. However, the lunchtime experience on the Holly unit was not as well organised as other units, resulting in people having to wait longer for assistance.

Support was provided to people by caring staff. We observed many positive, caring interactions between staff and people.

Care plans were person centred and included people’s choices and preferences, although one care plan we sampled contained contradictory information. Care plans were were reviewed regularly.

Although we observed some activities taking place, we felt there was a lack of meaningful activities. However, a new activities coordinator had been appointed and w

During our previous inspection of this service in September 2013 we found the provider was not compliant with Outcome 4 (Care and Welfare of People), Outcome 9 (Management of Medicines), Outcome 13 (staffing) and Outcome 14 (Supporting Workers). We judged non-compliance with these outcomes had a minor impact on people who lived in the home and issued compliance actions. Following that inspection the provider sent us an action plan telling us what they would do to achieve compliance. During this inspection we checked to make sure the required improvements had been made.

At this inspection we were informed the registered manager had resigned and there was an acting manager in place. The home has three units, Cherry (nursing unit), Cliff (residential unit) and Holly (dementia unit) and we visited all three during the inspection.

We spoke with the acting manager, the Quality Assurance Manager, seven staff, ten people who lived in the home and three relatives.

We found improvements had been made in the care documentation. People told us they were generally satisfied with the care they received and were positive about the staff. They described staff as "very good" and "lovely". One person said about one staff member: “He’s a nice lad”. Another person told us: “The staff do a good job, I’m well looked after”.

We found improvements in the management of medicines. The home had changed its pharmacy supplier and staff we spoke with who were responsible for medicines told us they much preferred the new system. They said the systems and records were clearer and easier to follow.

We found staffing levels were sufficient to meet people’s needs. Additional staff had been recruited and recruitment was ongoing. We observed people’s needs were being met and staff responded promptly to requests for assistance.

Staff were receiving regular supervision and training updates as required.

We spoke with five people living at Carr Gate. We carried out this inspection to follow up on a compliance action that had been made at a previous inspection in November 2012. We were also responding to information of concern we received. The information alleged that there were insufficient staff on duty in the evening and at night to meet people's needs.

People we spoke with said they felt well cared for and made positive comments about the staff. One person said; “It’s good here, I like it.” Another person said; ”It’s grand and the staff are lovely.” Another person told us; “The staff are nice.”

We saw a good rapport between staff and people living in the home. For example, we observed one person laughing with a staff member. This person said to us that the staff member “always makes me smile”.

People said they enjoyed the food. We saw there was a choice of food and people were offered more.

We saw staff maintained people’s privacy and dignity at all times and maintained confidentiality when speaking to people and other staff. We found that care and treatment was planned and delivered in a way that ensured people’s safety and welfare.

We found there were enough qualified, skilled and experienced staff to meet people’s needs.

You can see our judgements on the front page of this report.

At the time of our visit there were 42 people living at Carr Gate. We spoke with six of the people living at the home and three relatives.

The people we spoke with told us their needs were being met and they were very positive about the staff. One person said; “I can have my hair done anytime I want.” Another person commented; “They are very kind. They know me and look after me.” Another person told us; “I like it here. They are all so kind. It makes all the difference.”

The relatives we spoke with told us they were happy with the care their family members received, and they felt involved in their care. One relative told us; “Both my parents have been in here. The staff are really good I can’t fault them. They let me know as soon as anything happens.” Another relative said; “They really look after [my relative] and they are kind and caring.”

Other comments included:

“The staff keep me updated about my dad’s care.”

“The staff are fantastic.”

We asked people if they have ever had to make a complaint. People told us that they had not had to complain but if they did they knew to speak to the manager.

The inspection of Carr Gate Nursing Home took place on 23 and 27 July 2015 and was unannounced. There was a manager who was new in post and had applied for registration, but this was not yet complete.

The service was last inspected in January 2014 and found to be compliant with regulations.

Carr Gate Nursing Home is in a quiet residential area on the outskirts of Wakefield. The home provides accommodation and nursing for up to 65 people, some of whom are living with dementia. The home is on two floors and there are three units; Cherry (nursing care), Cliff (residential care) and Holly (dementia care).

Staff had a good knowledge of how to ensure people were safeguarded from abuse and understood safeguarding and whistleblowing procedures.

Staff recruitment systems were thorough and all vetting was in place to ensure staff were suitable to work in the home.

Staff understood their roles and responsibilities although reported they did not feel supported or valued.

There were insufficient numbers of care and ancillary staff to meet the needs of people and ensure the safe running of the home.

Many staff had undertaken regular mandatory training, but lacked knowledge of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

Medications were not effectively managed to ensure people received their medicine on time.

People did not enjoy their meals and the quality and presentation of the food was poor.

Staff were caring in their approach and they were well meaning in their intentions. However, people’s dignity was not always respected.

There were few activities for people to be engaged with in a meaningful way.

Audits and quality assurance systems within the home lacked rigour to ensure the quality of the provision and the safe care of the people living in the home.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

You can see what action we told the provider to take at the back of the full version of the report.