About the service:

Carrick House Nursing Home is a care home that provides personal and nursing care for up to 24 people, some of whom live with dementia. At the time of the inspection there were 23 people using the service. Accommodation was provided across two floors, with communal areas located on the ground floor.

People’s experience of using this service:

Since the previous inspection on 5 and 6 April 2018 the service had made improvements to the management and administration of medicines. This helped ensure that people received their prescribed medicines safely. However, there were occasions when there had been a delay in people receiving prescribed medicines. We also noted that there was a lack of detail and guidance in care plans about some aspects of people’s healthcare needs.

Improvements had also been made in the provision of activities so that people’s risk of social isolation was lessened.

Since the last inspection improvements to the décor of some communal areas and bedrooms had been made and an extension to the building was in the process of being completed. The registered manager and managing director told us they had plans to make further improvements to the premises once that extension had been finished.

Staff knew people well. People’s differences including cultural and religious needs were understood and respected by staff.

People told us they felt safe living in the home. Staff knew what their responsibilities were in relation to keeping people safe. Staff knew how to recognise and report any concerns they had about people's welfare.

Systems were in place to assess and monitor the safety of the environment. Risks to the health and wellbeing of people were regularly assessed. Guidance to minimise these risks and keep people safe was in place. Regular health and safety audits including fire safety checks were carried out.

The home was clean and safely maintained.

Engagement between staff and people using the service was caring and respectful. People’s relatives spoke positively about the care provided by staff.

People were supported to have the relationships that they wanted with family and friends.

People’s nutritional needs were assessed and monitored. The service provided people with a variety of meals that met their dietary needs and preferences.

People received the care and treatment that they needed and were supported to access healthcare services.

The provider recruited staff carefully to ensure that staff were suitable for their role. Staffing numbers and skill mix were flexible to ensure that people’s needs were met by the service.

Staff received the training and support they needed to carry out their roles and responsibilities in meeting people’s care needs.

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. Staff knew that when people were unable to make decisions about their care and support, the principles of the Mental Capacity Act (2005) needed to be followed.

Systems were in place to assess and monitor the quality and delivery of care to people and drive improvement.

During the past year the registered manager had worked hard to make improvements to the service. Staff had an awareness of how the changes had benefited the service for people.

More information is in the full report.

We identified one breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment and good governance. Details of action we have asked the provider to take can be found at the end of this report.

Rating at last inspection: Requires Improvement. The report was published in May 2018. Following this inspection, the rating remains as Requires Improvement.

Why we inspected: This was a scheduled planned comprehensive inspection based on the rating of the service at the last inspection.

Follow up

The comprehensive inspection of Carrick House Nursing Home took place on the 5 and 6 April 2018. The first day of the inspection was unannounced.

Carrick House Nursing Home is a ‘care home’ it provides nursing care and accommodation for a maximum of 24 people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission [CQC] regulates both the premises and the care provided, and both were looked at during this inspection. During our visit there were 21 people using the service, some of whom were living with dementia. People’s bedrooms are located on two floors. There is a passenger lift to assist people to access their bedrooms located on the upper floor. People have access to safe outdoor space and the home is located close to shops and public transport.

At the last inspection 27 June 2017 we rated the service requires improvement. We found improvements could be made in the quality monitoring systems, and we made two recommendations. One referred to reputable guidance about ways to decide appropriate staffing levels for the service and the second was about improving the environment to make it more suitable for meeting the needs of older people including those living with dementia.

Following the last inspection the provider informed us about the actions that they were taking to make the necessary improvements to the quality of the service. We found during this inspection that improvements to the service had been made and some were in the process of being achieved.

The service does not have a registered manager. A registered manager is a person who has registered with the 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. The manager has been in post since December 2017. She has started the process of registering with us.

Arrangements were in place to ensure that people received the medicines that they were prescribed. However, we found some shortfalls in the management of people’s medicines.

It was not evident that all the people using the service were supported to take part in a range of preferred and meaningful activities.

Some people were very dissatisfied with the meals that were provided by the service.

The service had clear procedures to support staff to recognise and respond to abuse and keep people safe. Staff had completed safeguarding adults training and knew about the whistleblowing procedure. They knew how to identify abuse and understood the safeguarding procedures they needed to follow to protect people from harm.

Risks assessments were carried out. These identified potential risks to people and strategies were in place to manage these risks to minimise the risk of people being harmed. Staff understood their responsibilities to deliver safe care and understood their duty to report all potential risks and other safety concerns so people were safe.

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. Staff gained people's consent before providing personal care.

Staff knew people well. People's care plans were up to date and included details about people’s individual preferences and other information that staff required to provide people with the care and support that met their individual needs.

People’s healthcare needs were assessed and monitored closely. The service worked with healthcare and social care agencies to ensure people’s needs were met.

Staff understood the importance of treating people with dignity and protecting people's privacy.

Staffing levels and skill mix provided people with the assistance and care that they needed. Appropriate recruitment

The unannounced inspection of Carrick House Nursing Home took place on the 27 June 2017. At our last inspection on 30 September 2015 the service met the regulations inspected.

Carrick House Nursing Home is a care home that provides accommodation, nursing and personal care for up to 24 older people some of who may have dementia, sensory impairment or physical disability. At the time of our inspection there were 22 people using the service. The service is owned and operated by MD Homes who run four other services. Public transport is located close to the home and a range of shops within walking distance.

The service has 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.

We saw mostly positive engagement between staff and people using the service. Staff were kind and respectful and showed an understanding of people’s varied needs.

The design and decoration of the premises was not beneficial in meeting people’s individual needs and there were some furnishings that were not clean.

People took part in some activities but there was a limited range of general and personalised activities to promote people’s well-being and minimise social isolation.

The staffing of the service was organised so people received the care and support they needed and to keep them safe. However, feedback from some people indicated that there were times when staffing was insufficient.

There were procedures for safeguarding people. Staff understood how to report possible abuse and knew how to raise any concerns about people’s safety so people were protected.

People’s individual needs and risks were identified and managed as part of their plan of care and support to minimise the likelihood of harm. We found systems were in place to manage and administer medicines safely. Accidents and incidents were addressed appropriately.

Staff were appropriately recruited. They underwent a range of pre-employment checks to ensure they were suitable to work in health and social care. Checks had also been undertaken to ensure that nurses who worked at the home had a current registration with the Nursing and Midwifery Council (NMC).

Staff had an understanding of the systems in place to protect people if they were unable to make one or more decisions about their care, treatment and other aspects of their lives. The registered manager knew about the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). DoLS were in place when it was necessary to restrict people’s freedom in some way.

Staff received appropriate training and support to enable them to be skilled and competent to carry out their roles and responsibilities.

People were supported to maintain good health. They had access to a wide range of appropriate healthcare services that monitored their health and provided people with appropriate support, treatment and specialist advice when needed.

There were some systems in place to assess, monitor and improve the quality of the services provided for people. Some areas of quality assurance were in the process of being developed and improved.

We have made two recommendations, that the service considered current guidance from a reputable source to determine appropriate staffing levels for the service, and guidance in relation to good practice regarding the design of environments that met the needs of older people including the specialist needs of people living with dementia.

The inspection took place on the 30 September 2015 and was unannounced.

Carrick House Nursing Home is a care home that provides accommodation, nursing and personal care for up to 24 older people who may have dementia. At the time of our inspection there were 23 people living at the service. Public transport is located close to the service and a range of shops are within walking distance.

At our last inspection on 29 August 2014 we found the provider was not meeting legal requirements in relation to the care and welfare of people. Some people did not have access to a call bell and told us they had to call out to staff when they needed assistance. People’s care plans did not indicate when people were unable to use a call bell or detail the action staff needed to take to ensure people received the care they needed at all times. Following that inspection we asked the provider to send us an action plan telling us the action they had taken to make the improvements needed. At this comprehensive inspection we found that the required improvements to the service had been made.

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.

There was a clear management structure in the home. People told us the home was well managed and the registered manager was accessible and approachable. People who used the service, staff and people’s relatives told us they felt able to speak to the registered manager and other staff when they had any concerns or other feedback about the service.

The atmosphere of the home was relaxed and welcoming. Throughout our visit we observed caring and supportive relationships between staff and people using the service. All staff interacted with people in a courteous manner. People told us they were happy with the service and had their privacy and dignity respected. However, we received some feedback that indicated there had been occasions when engagement with a member of staff had not always been positive.

Staff received a range of relevant training and were supported to develop their skills and gain relevant qualifications so they were competent to meet the needs of people they cared for. Staff told us they enjoyed working in the home, felt listened to and received the support they needed to carry out their roles and responsibilities. However, although staff had regular one-to-one and/or group supervision. It was not evident from records that formal staff supervision was meeting the needs of staff. We have made a recommendation about the provision of appropriate staff supervision which supports staff to carry out their duties.

People were protected, as far as possible by a robust staff recruitment system.

People had the opportunity to participate in some activities. However, the range of activities was limited and few were planned. People were provided with the support they needed to maintain links with their family and friends.

The interior of the home was ‘tired’ looking and there was little evidence of the environment being supportive for people who have dementia and or impaired sight. The service lacked signage in picture format and décor did not support people with their orientation or promote their well-being. We have made a recommendation that the service finds out more about how changes to the environment of the service could benefit people using the service.

Arrangements were in place to keep people safe. The risks people experienced had been assessed and there were plans in place to minimise the likelihood of harm. Staff understood how to safeguard the people they supported, and were familiar with people’s needs and their key risks.

People were given the support they needed with their medicines and were supported to maintain good health. Their health was monitored and referrals made to health professionals when this was needed.

People spoke in a positive manner about the food and were provided with a choice of food and drink which met their preferences and nutritional needs.

Staff had an understanding of the systems in place to protect people if they were unable to make one or more decisions about their care, treatment and other aspects of their lives. The registered manager knew about the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

There was an appropriate complaints procedure and people knew how to make a complaint.

There were effective systems in place to identify and manage risks and to monitor the care and welfare of people. Issues were addressed and improvements to the quality of the service were made when required.

Carrick House is a care home registered to provide nursing care for up to 24 older people. We were informed that, at the time of our visit, 24 people were accommodated. This inspection was carried out by one inspector.

We gathered evidence that helped 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 ten people using the service, two visiting relatives, ten staff supporting them including the registered manager and the operations manager. We also looked at a selection of records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

The communal areas and bedrooms that we looked at within the home were clean and tidy and maintained by domestic staff. A survey completed by a relative said “Good atmosphere, smaller unit size, not too institutionalised.”

Staff training included subjects specifically related to the safety of people, such as safeguarding, moving and handling, food hygiene, fire safety, first aid and infection control.

Care plans reviewed showed people had risk assessments in place for staff to follow. This ensured people were supported appropriately with their physical and mental health well-being.

Medicines were administered by appropriately trained staff. The provider had made suitable arrangements in relation to the obtaining, storing and disposing of medicines.

During our observations we found some people were unable to access their call bells which meant people could not summon help if they needed it. We found seven calls bells were placed out of reach and one call bell was unplugged. The manager informed us that in these cases the people would not be able to use the call bell system, however this was not clear in people’s care plans. The manager and operations manager told us it “was not acceptable” and it would be addressed “promptly” with the night staff. They also informed us that care plans and risk assessments would be updated to reflect this.

There were procedures in place to protect people from abuse and keep them free from harm. Referral procedures to external agencies were in place and staff spoken with were aware of whom to contact, both internally and externally, should they suspect someone had been the victim of abuse.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. On the day of our inspection we were advised no DoLS applications had been made. Relevant staff had been trained to understand when an application should be made to deprive someone of their liberty.

Is the service effective?

From speaking with staff and our observations we found that there was a good understanding of people's care and support needs. Staff we spoke with were clear about how best to support people while maintaining their independence and dignity. One person who used the service told us "They go over the top to help you.”

Care plans we examined included assessments and reviews of people's health and care needs. Care plans also included detailed information to ensure staff delivered care consistently to meet people's needs. All care and nursing staff we observed demonstrated they understood the care needs of people and how best to support them.

Is the service caring?

We observed staff interacting with people at different times during the day and saw breakfast and lunch being served as well as medicines being administered. People were supported by staff who displayed patience and kindness. The environment was relaxed and staff were calm. One person who used the service told us “I like it here very much, the staff are very caring.”

There was a celebration taking place on the day of our inspection and the chef had baked a cake for the occasion. The atmosphere was sociable and people told us they enjoyed the cake which was served. One person told us, “The food is good, it looks appetizing, and there is a good choice and plenty of it.” The same person told us “You can always ask for more as well.” We noticed at lunch time people were given time and were supported to enjoy their meal.

Is the service responsive?

We saw people’s health and social care needs were reviewed frequently with other professionals. We spoke with four people who used the service. They all told us they could speak to staff or family if they had any worries or concerns. One relative told us (referring to the manager) “X is very good, you can approach X about anything and be assured it will be dealt with.” A person who used the service said “It’s fine here, they look after you well.”

People were confident they would receive the support they needed quickly should their health needs change. Care staff and the manager were able to tell us how they would be able to recognise changes in people who were at risk of physical health deterioration. In such cases people were monitored closely and medical or emergency help arranged as necessary.

Is the service well led?

The registered manager was a health care professional and had been in post for over fifteen years. We spoke with the registered manager and operations manager who showed a good understanding of what was required to ensure staff were led by an effective management team.

The manager held regular staff meetings and used this to communicate issues related to the day to day running of the nursing home. Staff we spoke with felt supported by the manager and understood the philosophy of the home. One staff member told us “The best thing is we all work as a team here to support and look after people.”

Systems were in place to ensure that people were happy with the service they received. A relative commented in a survey “X, the home manager and nurse is the life blood and pulse of Carrick.” The same person also said “Continuity of staff and smooth running from day to day” was one of the best things about the home.

During the inspection we spoke with most of the people who used the service, five visitors, three care staff, a cleaner, a cook, the registered manager and the operations director. Some people were not able to tell us their views of the service but were able to respond to questions that we asked by gestures or by providing ‘yes’ or 'no' answers.

People who used the service told us that they were happy living in the home. They said the staff were kind and treated them well. People told us that they made decisions about their care and were asked for their consent prior to receiving care and treatment.

People who used the service had a plan of care that included up to date information about the individual support and care they needed. People’s health, safety and welfare were protected as they received the advice and treatment that they needed from a range of healthcare and social care professionals.

People told us they enjoyed the meals, which met their individual dietary needs.

The home was clean and there were systems in place to prevent the spread of infection.

Numbers and skill mix of staff were flexible to ensure people’s needs were met. Staff interacted with people who used the service in a respectful and sensitive manner. Comments from people included “It is very good here, there are nice people,” and “they ask what I want and I get it.”

People knew how to make a complaint. Complaints were responded to appropriately.

We carried out an unannounced inspection to check if the provider had complied with a compliance action that we had made in response to us having found some records had not been appropriately completed or were not in place at the time of our inspection that took place on the 11th February 2013. During this follow up inspection we spoke to some people using the service but on this occasion the focus was on talking to staff and checking records to make a judgement as to whether the provider was meeting Outcome 21 Records and was compliant with Regulation 20 (HSCA 2008 Regulated Activities) Regulations 2010.

At this inspection we found that the provider had taken proper steps to ensure that appropriate information and accurate records were in place so people were protected against the risks of unsafe or inappropriate care and treatment.

People told us that they felt safe and received the care they needed and wanted. People were positive about the staff who supported them. They told us that they were supported to make decisions about their lives, which included what they wanted to eat, and what they wanted to wear. Some people told us that they felt there was not enough to do

People’s health, safety and welfare were protected as they received the advice and treatment that they needed from a range of health and social care professionals. Staff knew about their roles and responsibilities in meeting the needs of people who use the service and they supported people in a friendly and respectful manner. People spoken with confirmed that they found that staff were generally very approachable and felt able to talk to them and to the manager if they had any concerns.

Each person had a plan of care that had been regularly reviewed and included information about the individual support and care that people using the service needed. However, some records were not fully completed, but the manager and operations director took prompt action during and following the inspection to ensure that there were systems in place to ensure the appropriate records were in place and monitored closely.

During our visit to Carrick House Nursing Home on the 7th January 2012, we spent most of the time talking to people using the service to gain their views about what it was like living in the home. Some people due to their varied health and communication needs had difficulty in speaking to us but they gestured, nodded or shook their head when they answered our questions. We also spoke to several visitors, nurses, care staff, the manager and the operations director.

People told us they liked their bedrooms, felt safe and knew who to talk to if they had any worries or concerns. People confirmed they were listened to, had their needs met, and were asked for their views of the service. They told us they were given the care and support they wanted and needed, and they received treatment and advice from health and social care professionals.

Records did not always tell us that people’s pressure care needs were being met and though people’s care plans were being reviewed regularly, it was not evident from records that people using the service were being included in this monthly review of their needs.

During our visit people showed signs of ‘well being’. People were well dressed; they smiled, laughed, talked with other people using the service and approached staff without hesitation. We observed staff supporting people in a friendly and professional way and saw that people were being offered choice with regard to menus and care preferences.

We saw that the home had systems in place to monitor the quality of the service provided to people. The registered manager responded promptly to issues found during our visit. It was evident from talking with the manager and from the action taken by her following our visit that she was motivated and keen to develop and make improvements to the service in response to feedback.

We received several very positive comments about the home from visitors.

Staff told us they enjoyed their job supporting and caring for people at Carrick House Nursing Home. They were able to give us examples of how they maintained peoples’ dignity, privacy, independence and how they offered choices to people on a daily basis. They confirmed there was good teamwork and they felt well supported by the manager and senior staff and received the training that they needed to carry out their role and responsibilities.