This inspection took place on 28 September 2018, and continued 1 October 2018.

Chestnut 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.

Chestnut House Nursing accommodates 85 people across three separate units, each of which has separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of our inspection the service was providing residential and nursing care to 28 older people some of whom were living with a dementia.

The home had not had a registered manager in post since November 2017. 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. An interim manager had been in position since May 2018. A new deputy manager was in position to support the interim manager. Although the interim manager informed us they would be applying to the Care Quality Commission to become the registered manager, concerns remained with regard to the stability of the management of the service.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At the last inspection in May 2018, we found continued risk in regards people safe care and treatment. We took enforcement action and asked the provider to continue to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well-led to at least a 'good'.

At this inspection although improvements have been made to the key questions, effective, caring and responsive to ‘good’. We found improvement are still required in the key questions, safe and well led. We will therefore continue with the imposed conditions and asked the provider to complete an action plan to show what they would do and by when to improve the key question safe and well led to at least ‘good’.

Quality monitoring systems were not fully effective or robust as they did not monitor whether tasks or actions had been completed. Information was not always shared with regards to risks, and systems and processes for keeping records up to date were not always effective.

Regular checks were made to ensure people were given sufficient to drink and eat. Fluid charts were in place for people at risk of dehydration. Systems to monitor whether people had enough to drink were not always effective, as records were not always maintained.

People were at risk because Personal Emergency Evacuation Plans [PEEP] were not up to date. These are a guide for staff on the most appropriate way to support people to get out of the home safely in the event of an emergency such as a fire or flooding.

People, relatives and professionals told us that they had experienced improvements in the home since the last inspection. Leadership was visible and promoted teamwork. Staff spoke positively about the management and had a clear understanding of their roles and responsibilities.

Lessons had been learnt when things went wrong. Incidents, accidents and safeguarding concerns were seen as a way to improve practice and action had been taken in a timely way when improvements had been identified. People were supported to remain safe. Improvements had been made to risk as

The inspection took place on the, 24, 25 and 31 May 2018 and the first day was unannounced. We last inspected this service in October 2017 where it was rated Inadequate in the safe and well led key questions and ‘Requires Improvement’ in the Caring, Responsive key questions. This meant the overall rating was inadequate.

Chestnut House is ‘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.

The service is registered to provide accommodation and residential and nursing care for up to 85 older people over three floors. At the time of our inspection the service was providing residential care to 34 older people some of whom were living with a dementia.

Following our inspection in October 2017 we imposed a condition on their registration. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well-led to at least a ‘good’.

At the inspection in October 2017 we found people were not safe as people did not consistently receive safe care and treatment, audits and quality assurance systems did not always identify shortfalls in the requirements of the regulations being met.

The provider’s reports had indicated that improvements were being made to address the issues identified at the previous inspection. We found that although action had been taken and some of the regulations were being met, improvements needed to continue to meet further breaches of regulations found at this inspection, which means the service will remain in special measures.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service did not demonstrated to us that improvements have been made and therefore is rated as inadequate overall. This service remains in Special Measures.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures. During this inspection, we identified a number of continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had not had a registered manager in post since October 2017. 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.

Risks remained to some people as they were not consistently assessed or managed to keep them safe. People particularly at risk were those people living with dementia, and those people with complex health needs and behaviours. People required staff to supervise them to keep them safe. We observed occasions when people were unsupervised. Records identified people were at risk of harm if left unsupervised.

We observed a number of good examples of risks to people being identified, reported, however we also identified instances where risks had not been adequately assessed or mitigated. People and staff were placed at risk of injury when moving and assisting. This was because the wrong equipment was used and staff had not received the correct training.

People and relatives spoke highly about some staff. Some staff were seen to be kind and caring. However not all interactions were seen to ensure people were treated with dignity and respect. Care was seen to be task led, and s

The inspection took place on the 12, 16 and 18 October 2017 and was unannounced.

The service is registered to provide accommodation and residential and nursing care for up to 85 older people. At the time of our inspection the service was providing residential care to 48 older people some of whom were living with a dementia.

There was a registered manager in post. 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.

At the last inspection, the service was rated Good overall. At this inspection we found seven breaches of the regulations.

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. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of Inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Prior to our inspection, we received information of concern about staffing levels in the home and standards of care.

People did not consistently receive safe care and treatment. Allegations of abuse were not always reported to the safeguarding authority as required. This was because the adult safeguarding procedures in place were not followed. This potentially placed people at risk of further harm or abuse.

Risks to some people were not consistently assessed or managed to keep them safe. People particularly at risk were those people living with dementia, those with specialist diets and those people with complex mental health needs and behaviours.

The deployment of staff was ineffective and was not always consistently safe to meet people’s needs and protect them from harm.

The management of medicines was not consistently safe as people did not always shave access to their prescribed medicines. There were gaps in the records of the administration of medicines and protocols for “when required” lacked detail of actions that staff needed to follow before administration.

People’s rights were not protected because staff had not acted in accordance with the Mental Capacity Act 2005 (MCA). Conditions of authorisations to deprive people of their liberty were not being met.

Staff did not receive training and support to carry out all aspects of their roles. Staff did not receive training to support people living with dementia that required positive behaviour support.

Improvements were required to support people to drink safely and to monitor people at risk of poor hydration.

People were supported to access healthcare services when needed.

People and relatives spoke highly about some staff. Some staff spent time with some people and treated people with kindness and compassion.

However not all people were treated with dignity, respect and care at times was task led. Some care provided was not

Chestnut House Nursing Home was last inspected on 24 October 2016. At that inspection the home was found not to be meeting all requirements in the areas inspected. We found that improvements were required with regards to people’s risk assessments and in the way management ensured the quality of care people received.. At this inspection we found that improvements had been made.

Chestnut House is a purpose built care home accommodating older people. The home is registered to provide accommodation for 85 people who require nursing or personal care. At the time of the inspection there were 78 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

There was a registered manager in place who had been in post for a number of years. 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 home had safe systems in place to protect people from the risks they faced. People’s individual care records evidenced that risks were recorded and action had been taken in accordance with the providers policies to minimise these risks.

Medicines were managed in accordance with best practice guidance. Medicines were stored, administered and recorded safely. People were supported to access external health professionals, when required, to maintain their health and wellbeing.

We observed that staff had developed an empathetic approach to the people they supported. We saw that people appeared comfortable in the company of staff. Staff knew people well and were able to tell us about the people they supported including their history, family, likes and dislikes. This demonstrated staff knew people well and listened to their preferences.

People were offered a varied choice of meals, where staff were concerned that people may be at risk of dehydration or malnutrition the provider had systems in place to address these risks.

People told us and we observed that people were supported by sufficient numbers of staff who had a clear knowledge and understanding of their individual support needs. People living at Chestnut House told us they were happy with the care and support provided. These comments were supported by the relatives we spoke with.

People were supported by staff who had received training with regards to their needs. Staff told us they were supported by the provider to train in areas that they wished to.

People’s social and emotional needs were met by a group of staff employed to provide activities and social stimulation. People told us there was plenty to do if you wished too. The home also enjoyed the support of volunteers and members of the wider community who supported fund raising and the provision of activities.

Some people who lived at the home were able to make decisions about what care or treatment they received. Where people lacked capacity to make some decisions, the staff were clear about their responsibilities to follow the principles of the Mental Capacity Act (MCA) when making decisions for people in their best interests.

The service was responsive to people’s individual needs. Care and support was personalised to each person which ensured they were able to make choices about their day to day lives.

When we last inspected the service on 13 January 2016 we had concerns about how people’s risks were managed and whether people were receiving foods which they could eat safely. We also had concerns about whether people’s care records were kept confidential and about how accidents and incidents were reported and how this information was used. There were breaches in two regulations and we asked the provider to take action about these concerns. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the identified breaches and told us that they would be compliant with the regulations by June 2016. At this inspection we found that they were no longer in breach, but that there were still areas for improvement.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chestnut House on our website at www.cqc.org.uk

Chestnut House is registered to provide accommodation and nursing or personal care for up to 85 people. At the time of the inspection there were 75 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

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.

There were not always clear risk assessments in place and although regular checks on people were made, areas of possible risk were not always identified.

Some people were at risk of developing sore skin, issues were highlighted promptly and treatment was appropriate and effective, however staff did not consistently record when people were being supported to move which meant that it was not clear that people were being protected from their skin becoming sore.

Audits were not always effective. There were some gaps in quality assurance audits which meant that some audits had not been completed as frequently as planned and there were some gaps in recording which had not been picked up by audits which had been completed.

People were supported by staff who were caring in their approach, however some language used by staff to describe people was not respectful.

There were systems in place to ensure people had enough to eat and drink. Where people needed particular diets or support to eat and drink safely this was in place.

People were protected from harm because staff knew how to identify and respond to abuse and said they would be confident to do so.

There were enough staff to support people and we observed that staff used equipment safely and reassured people when they were assisting them to move.

People were supported to received their medicines as prescribed by staff who had received training and undertaken competencies to manage medicines safely.

People and staff spoke positively about the management of the home and told us that the registered manager was approachable. Staff gave us examples of ideas and suggestions they had made which had been listened to and acted upon.

People and relatives, staff and other professionals were asked for their views twice yearly using a survey and there were forms in the reception area to encourage people to make suggestions about the service.

Staff were clear and confident about their roles and there were systems in place to ensure that information was handed over at each shift and that

Chestnut House Nursing Home was last inspected on 2013. The home was found to be meeting all requirements in the areas inspected.

Chestnut House is a purpose built care home accommodating older people. The home is registered to provide accommodation for 85 people who require nursing or personal care. At the time of the inspection there were 78 people living at the home. It comprises of two main areas; people with nursing care needs are resident on the ground floor; people with enduring mental health needs live on the two upper floors. The second floor is allocated for the care of females only.

There was a registered manager in place who had been in post for a number of years. 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 was meeting the some of the requirements of the Mental Capacity Act 2005 but further improvements could be made in the assessments of people’s mental capacity. People’s views or people important to them did not consistently have their comments recorded. Not all best interest decisions were complete. Staff understood some of the concepts of the Act, such as allowing people to make decisions for themselves. The staffs understanding of the act was consummate to their role

The risks people took were not consistently managed. Although risk assessment and plans had been put in place to minimise these risks changes in observational systems had had not considered these risk assessments and had put people at risk of harm. The registered manager was made aware of this and took steps to reintroduce the recordings of observations which had previously been in place instead of just visual observations without recordings being undertaken.

The provider had systems in place to ensure the quality of the service was regularly reviewed and improvements made but some of these processes need improvement. Medicines audits needed to be more robust to acknowledge all of the dispensing carried out by staff. Guidance to staff in relation to managing difficult behaviours was ambiguous and not fully understood by staff meaning that people and staff could be put at risk of harm.

The management at the home had developed an open culture through regular meetings with the people living there and people important to them. The staff told us they felt supported by the management and that their opinions were valued.

The staff knew people’s needs well but the care records did not always reflect their comments. One person told us, “I don’t want for too much, staff know what I need and how to help me, I don’t have any complaints”. Visiting relatives told us about how they considered their relatives were well cared for and how staff ensures their (relative) needs were met.

The staff demonstrated a caring and compassionate approach to people living at the home. People were offered choices at mealtimes such as where to sit and what to eat. The provider had a system to offer a choice of food during mealtimes.

People told us there were enough staff to meet their needs and our observations confirmed this, however, how they were deployed at key times of the day needed to be reconsidered in order to meet people’s needs.

The staff told us they worked well as a team and enjoyed working at the home. The home offered many activities such as a pub night in a purpose built bar area at the home. The provider was also using many initiatives to work with people with dementia such as ‘Namaste’ principles in use at the home. (Namaste Care is a program developed to offer meaningful activities to people living with dementia.)

The home was awarded accreditation with the Gold Standards Framework in Care Homes and achieved a beacon status. This is a nationall

We spoke with six people who were living on the ground floor of the home. They told us that staff looked after them well and consulted them to ensure that their needs were being met. We observed staff working with people. The interactions between staff and people living at the home were both compassionate and empathetic.

People were given the right medication at the right times. The provider had systems in place to ensure that medication was administered safely.

The home provided a safe and adequately maintained environment. Where some of the furniture was showing signs of wear the provider had an action plan in place to update these.

The records used by the home to ensure that people’s needs were assessed and met were accurate and updated where required.

This was a follow up inspection to assess if the home was now compliant with the outcomes that we had judged as non compliant at our previous inspection on 24 April 2012. A member of the public had also raised concerns with us that people were being neglected and left without assistance for long periods. They also felt that there was insufficient staff to meet people’s needs.

People that live on the ground floor have nursing needs and people who live on the first and second floors of Chestnut House have dementia care needs. Some people’s enduring mental illness meant that they could not articulate their views. In order to have an insight into their experiences we carried out a Short Observational Framework Inspection (SOFI) on the second floor during lunch time. SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We observed that staff interactions with people on the second floor were positive and empathetic. Two people who lived at the home told us that they were treated well and that staff were kind to them.

The staff told us they felt there was generally enough staff on duty. We observed that at some key times in the day people had to wait for periods of time to be assisted with their lunch. This meant that some people got up from the table and left the room requiring staff to also leave and assist them back.

The records gave staff clear and accurate guidance with which to meet the needs of those who lived at the home.

We were not always able to get direct comments from people living in the home because people with dementia are not always able to reliably tell us about their experiences. We were able to observe how people experienced care.

During an arts and crafts activity we saw staff chatting with people and engaging them in the activity. No one was ignored and we saw that people were enjoying themselves in a happy and comfortable atmosphere.

We spoke with people living on the ground floor, in the nursing unit and they told us that they enjoyed living at Chestnut House and that staff were kind and attentive.

Visitors to the home told us that they were all pleased with the service the home provided.