This was an unannounced inspection which took place on 21 February 2017.

Chestnut View Care Home provides nursing care and accommodation for a maximum of 60 older people who may be living with dementia and or a physical disability. They also provide respite care. Respite care is a service giving carers a break by providing short term care for a person with care needs. Accommodation is provided over three floors. The top floor is primarily for people with nursing needs, the first floor is for people living with dementia and nursing needs and the ground floor is primarily for people living with dementia. At the time of this inspection there were 55 people living at the home.

During our inspection the registered manager was present. 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.

Chestnut View Care Home was last inspected on 11 January 2016 when it was given an overall rating of ‘Requires Improvement’. No breaches of regulations were identified, however the manager at that time had only been in post for six weeks and her application to register as manager of the home had not been concluded. We made four recommendations that related to the deployment of staff, information about people who were living with dementia, record keeping and the environment. At this inspection we found that the recommendations had been acted upon.

Prior to our inspection concerns had been raised about staffing levels that we shared with Surrey County Council. When they visited the home they recommended that the staffing levels within the dementia unit be increased. The registered manager acted upon this immediately. At this inspection people’s views on staffing levels varied. However, we observed that there were sufficient staff on duty and that people received assistance and support when they needed it. Appropriate recruitment checks were undertaken before staff began work.

People said that they were treated with kindness and respect. The atmosphere in the home was calm, relaxed and friendly. People’s privacy was respected. An abundance of information was displayed around the home in different formats to help people understand choices about their care. Relatives were welcomed at the home. A dementia support group organised by the registered manager offered support to relatives of people who lived at the home.

Staff were skilled and experienced to care and support people to have a good quality of life. A training programme was in place that helped to ensure staff knowledge was current. Staff were confident about their role in keeping people safe from avoidable harm and abuse. They demonstrated that they knew what to do if they thought someone was at risk of abuse.

Risks to people’s safety were managed. Some people had been assessed as having high risk of developing pressure wounds and they had skin integrity assessments in place. We saw these people had specialist beds and pressure relieving equipment to prevent their skin becoming sore. Staff supported people to move safely from wheelchairs to armchairs using a hoist. Records were in place that confirmed that hoists and slings were checked on a regular basis along with a system to report if equipment was faulty. The registered manager had a good oversight over accidents and incidents within the home.

People said that they were happy with the medical care and attention they received and we found that people’s health and care needs were managed effectively. The medicine management in the home was safe. People said that they were happy with the choice of activities on offer. Trips out into the wider community were routinely planned for and enhanced people’s wellbeing.

The registered manager had taken appropriat

This was an unannounced inspection which took place on 11 January 2016.

Chestnut View Care Home provides nursing care and accommodation for a maximum of 60 older people who may be living with dementia and or a physical disability. They also provide respite care. (Respite care is a service giving carers a break by providing short term care for a person with care needs). Accommodation is provided over three floors. The top floor is primarily for people with nursing needs, the first floor is for people living with dementia and nursing needs and the ground floor is primarily for people living with dementia. At the time of this inspection there were 51 people living at the home.

During our inspection the manager was present. The manager had been in post since December 2015 and was in the process of submitting an application to us to be the 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.

Chestnut View Care Home was last inspected on 31 March 2015 when it was given an overall rating of ‘Requires Improvement’. Four breaches of Regulations 11,12, 17 and 18 were identified and requirement notices were issued. These related to medicines, consent to care, staff training and support and quality assurance systems. At this inspection we found that the requirement notices were met.

Although the manager had only been in post for six weeks prior to our inspection she was aware of the areas of the service that needed to improve and had started to take action to address these. Everyone that we spoke with said that the manager was a good role model and that she was implementing and driving positive changes at the home. There had been an increase in staff meetings and people were now being encouraged to be actively involved in making decisions about the service provided. Residents and relatives meetings had also been reinstated. Quality assurance systems had been reviewed and more robust monitoring of actions needed to be taken introduced in the form of a continuous improvement plan.

People said that they felt safe and we observed that they appeared happy and at ease in the presence of staff. In the main, potential risks to people were assessed and information was available for staff which helped keep people safe. We did note that for people who lived with dementia physical and emotional risks were not always linked. We have made a recommendation about this in the main body of our report.

Robust recruitment checks were completed to ensure permanent staff were safe to support people. However, this was not the case for agency staff. We raised this with the manager and the Nominated Individual who informed us that the staff from the recruitment agency would cease to be used with immediate effect. People told us that there were, on the whole, enough staff on duty to support them at the times they wanted or needed and we observed this to be the case for the majority of our inspection. We did note that people who lived with dementia did not always receive assistance at mealtimes. We have made a recommendation about this in the main body of our report.

People said that they were happy with the medical care and attention they received and we found that people’s health and care needs were managed effectively. Medicines were managed safely at Chestnut View Care Home. People’s needs were assessed and care and treatment was planned and delivered to reflect their individual care plan. The manager showed us life story books she and the activities coordinator had been working on to reflect people’s journey so far who lived with dementia and their likes and choices. This was a work in progress and had not been shared with the wider team at the tim

This inspection was carried out on the 31 March 2015. Chestnut View Care Home is a service that is registered to provide accommodation and nursing care for 60 older people some of who are living with dementia. They also provide respite care. (Respite care is a service giving carers a break by providing short term care for a person with care needs). The registered provider is St. Cloud Care Limited. Accommodation is provided over three floors. The top floor is primarily for people with nursing needs, the first floor is for people living with dementia and nursing needs and the ground floor is primarily for people living with dementia. On the day of our visit 48 people lived at the service.

There was 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.

Policies for staff in relation to people’s medicines were not always up to date. This meant that staff would not be aware of the most up to date guidance. Peoples’ medicine charts were not always completed clearly and accurately. Medicines were stored appropriately and audits of all medicines took place. Staff did not always have the most up to date guidance in relation to their role. Training which the service considered mandatory had not been completed by all of the staff and nurses were not up to date with their clinical knowledge.

One to one meetings were not regularly undertaken with staff and their manager and appraisals had not taken place for all staff. There were mixed reviews about the competencies of staff from health care professionals. One told us that staff did not always have the right knowledge or confidence to deal with clinical concerns.

There were sufficient numbers of staff on duty to meet people’s needs. People and relatives said they felt their family members were safe. One person said “I am very comfortable here and would speak to management if I was concerned.”

Staff understood what it meant to safeguard people from abuse and how to report any concerns.Risk assessments for people were up to date and detailed. Each risk assessment gave staff information on how to reduce the risk. These included risks of poor nutrition, choking and falls. Staff had a good understanding of people’s risks.

There were complete pre-employment checks for all staff. This included full employment history and reasons why they had left previous employment. This meant as far as possible only suitable staff were employed.

Staff had knowledge of their responsibilities under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). However the registered manager had not always submitted DoLS applications to the local authority where it was appropriate to do so. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw that where ‘Do Not Attempt Resuscitation’ (DNAR) forms had been completed for people who lacked capacity there was no evidence that capacity assessments had been completed for this or other decisions that needed to be made.

Staff gave examples of when and why they would ask people for consent in relation to providing personal care. We saw several instances of this happening during the day.

People and relatives said that the food was good. People were encouraged to make their own decisions about the food they wanted. We saw that there was a wide variety of fresh food and drinks available for people. Those people who needed support to eat were given it. One person said “ Food is good, there is a lot of choice.”

People had access to health care professionals as and when they required it. We saw several examples of visits from health care professionals on the day of our visit.

People and relatives felt that staff were kind and considerate. One person said “Staff are kind - I like the night nurse who puts me to bed and talks kindly.” People were treated with kindness and compassion by staff throughout the inspection. Staff acknowledged people warmly and sat talking with people. Where people were anxious staff responded in a caring and reassuring way.

Staff knew what was important to people. We saw that staff knew and understood people’s needs. People and relatives had the opportunity to be involved in the running of the service. Residents and relatives meetings were held and the minutes showed discussions about the activities and the refurbishment of the building.

People were treated with dignity and respect. Staff knocked on people’s doors and waited for a response before entering and personal care was given in the privacy of people’s own rooms or bathrooms.

The provider did not supply any evidence of complaints however there was a complaints policy which people and relatives had knowledge of.

People’s personal history, individual preferences, interests and aspirations were all considered in their care planning. Plans provided staff with information so they could respond positively, and provide the person with the support they needed in the way they preferred.

Care plans were reviewed every month to help ensure they were kept up to date and reflected each individual’s current needs. We found instances where a change had occurred and care was changed to reflect this. Staff responded to people’s needs as and when they needed it.

There was a programme of activities in place and an activities coordinator who worked part time at the service. Activities included entertainment, trips out to the local café, arts and crafts, and reminiscence sessions.People were also supported to access the outside community.

Audits of systems and practices carried out where not always effective. Where concerns had been identified these were not always addressed. Incidents and accidents were recorded but there was no analysis of these.

Staff said they felt supported or motivated in their jobs. Regular staff meetings took place and staff contributed to how the service ran. Meetings were minuted and made available to all staff. Relatives meetings were organised where discussions took place around events and work being done in the service.

Annual surveys were sent to the relatives and responses had been received which were very complimentary of the service.

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

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

We carried out this inspection to check whether action had been taken to improve the service since the previous inspection in June 2014.

We spoke with three people who used the service, four visiting relatives and six members of staff including the acting manager. We spent time observing the interactions between staff and people because not everyone who used the service was able to directly answer our questions.

We found that action had been taken and as a result people's care and safety had improved.

People or their representative’s consent had been sought and recorded regarding their care and treatment.

Care had been assessed, planned and delivered appropriately according to people’s needs. People we spoke with told us the staff met their needs. One person said, “The staff are really lovely here and they do everything that I need”. Another person said, "The staff are kind and they always help me". Relatives agreed with these positive views. One relative said, “The staff are superb, they know X really well and look after them well. I am very happy with the care”. Another relative said, “It is over and above what we expected”.

People had been protected against abuse or harm.

Staff had been safely recruited using a system which had ensured that all the appropriate checks had been completed.

There were enough staff to meet people’s needs and the way staff worked had been changed and improved. People were having their needs met by enough qualified and experienced staff.

Staff were being supported, supervised and trained to carry out their roles to the expected standards and to meet people’s needs.

There was a system for assessing and monitoring the quality of the service. Peoples’ views were listened to and acted on. People who used the service, their relatives and the staff said they felt the acting manager was approachable and had made positive changes to the service.

There is no registered manager in place which is a requirement of the Health and Social Care Act 2008 (registration regulations 2009). The acting manager has applied to register with the commission.

At this inspection we spoke with six people who use the service and four relatives. They all spoke positively about the home and the care and support provided to them. People told us they were happy with the care and support they received. They told us that they received care in the way they had expected.

One person said, "I am really well cared for. I can't think of anything that concerns me".

Another person told us that they were happy with how their personal care needs were met. They told us that they felt very reassured with how the care staff provided support. They said, "The staff do a really good job. They are gentle and kind and I am very happy".

We also spent time observing the interactions between staff and people who use the service in the main home and in the reminiscence unit. We found this to be positive, friendly and caring.

We spoke with staff who told us that they were very happy working in the home. They felt supported in their work, had good training and felt the management was open and supportive.

We found that the provider had taken steps to address the compliance actions set at our last inspection of the service. We found that the care planning, training and provision of safe staffing levels had all been addressed at this inspection. However, the provider could not demonstrate that appropriate steps were taken to obtain the consent of people or their representatives to care and treatment.

Some people that we spoke to said that they felt that the care and support they received at the home was good and that they felt safe. They said that the staff were friendly and helpful and the standard of cleanliness in the service was good.

People said they thought there were enough staff to meet their needs yet some thought their care could be better as they would like to have people to talk to and some staff were better than others.

The summary is based on our observations during the inspection, speaking with people who used the service and their relatives, the staff who supported them and from looking at records.

If you wish to see the detailed evidence supporting our summary please read our full report.

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Is the service safe?

People were not protected from the risk of inappropriate or unsafe care. This was because the provider did not have effective systems in place to assess, plan, review and monitor the care and support provided to people who used the service. In addition the procedures to identify, assess and manage risks to the health, safety and welfare of people and care workers in relation to activities had not been used effectively.

During the two days we visited to inspect this home we spoke with four people who were directly able to answer our questions, three relatives and nine members of staff. We also spoke with the acting manager and the provider's representative. We spent time observing the care people received because the majority of people who use this service are living with dementia.

Relatives of people who used the service were confident about people’s safety being maintained by the provider. One relative told us “I have never been concerned that X has been mistreated." People told us they felt safe in the service. One person said, “They do look after me here."

Staff did understand how to manage in the event of an emergency and they had the guidance they required to protect people in emergency situations.

Is the service effective?

People’s care needs had not been assessed or planned for effectively. The staff were not always aware of people's assessed needs and this led to examples where inappropriate care was delivered.

All staff had received training to meet the needs of the people who use the service. Examples of training included infection control, the safeguarding of vulnerable adults (SOVA), safe moving and handling, and fire safety.

The staff were not always aware of people's health needs including what support people needed in relation to their oral health. The information staff required to deliver appropriate care had not been recorded for their guidance.

People told us they were able to see a doctor when they needed to. We spoke to a doctor who visited the service at least weekly and they told us that people's health needs were met. They told us that it was not clear who had responsibility for making important decisions relating to their treatment.

Is the service caring?

People were supported by kind staff. We observed kind and caring interactions between staff and people who use the service. However, we also saw staff who were assisting people with their meals who did not interact or engage people in conversation.

Relatives told us they thought the staff were excellent and tried their very best to provide a caring home.

Three members of staff said they enjoyed working at the home. Six other staff said they were fond of the people who live at the home and they knew how to provide caring ,compassionate support but they did not feel supported in their roles.

There were systems in place to ensure relatives could provide feedback to the provider about the quality of the service they received. The systems for staff to inform the provider about the quality of the service had not been used effectively.

Is the service responsive?

The service was not responsive to people's needs because the number of staff was inadequate to meet people's needs at all times. This meant that staff were still responding to people's personal care needs close to lunch time as they told us they did not have time earlier in the day.

Is the service well-led?

At the time of this inspection there was no registered manager in post. The acting manager had been employed for four months and had submitted an application to register which was being considered. Shortly after this inspection we were informed by the provider that alternative management arrangements.

Quality monitoring procedures were not effectively assessing or monitoring the quality or safety of the service.

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